ICU
and post-injury care
Divided
into first 24 hours, 1-7 days and then 8+ days
First 24
hours (stabilization and secondary survey)
Resuscitation
(First 24
hours)
Duration
and degree of shock is a risk factor for subsequent organ
dysfunction and
infection.
Goals:
fluid resuscitation and maintaining oxygenation; Identify occult
injuries
through tertiary survey.
Goal-directed
therapy
·
U/O –
30ml/Kg/hr
·
Hb 12-15
·
HR 100
·
SBP 120
·
CVP
12-15
·
DO2:
500ml O2/min/m2
·
CI: 4l/min/m2
·
Central venous
O2 saturation
>70%
·
The more
invasive
monitoring and goal-directed therapy has not been shown to
improve outcome over
measurement and correction to parameters that can be measured
with a IDC,
arterial line and Central Venous catheter. However patients who
achieve
supra-normal goals have a better outcome.
Hypothermia
·
Thermoregulation
is compromised
in trauma and heat is continually lost through convection,
conduction,
radiation and evaporation
·
Minimizing
heat loss is
much easier than correcting hypothermia: warmed room, foil
blanket,
warned/humidified ventilator circuit, warmed fluids, warming
blanket.
·
Treatment
for
hypothermia can relay on passive warming (heat generated by
oxygen consumption
through metabolism) or active warming (radiant warmer, body
cavity warming,
CPBP, continious arteiovenous rewarming.
·
Active
rewarming is
required when temp <34.5
·
Extra-corporeal
warming
is the most effective but radiant heat is an alternative
Coagulopathy
·
Massive
transfusion/dilution
from crystalloid, hypothermia , acidosis
·
Consumption
of clotting
factors – especially from tissue thromboplastins released from
damaged tissues
can produce marked reductions in fibrinogen
·
Combinations
of
paltelts, FFP and cyroprecipiate are required.
Start massive Tx
protocol based on clinical
coagulopathy or transfusion of >6-10 PRC.
One FFP and
Platelet unit for every unit PRC
once 6u PRC exceeded.
Aim for PT<16s,
Platetlts >50000 and
fibrinogen >100mg/dl.
·
Treatment
does not
require laboratory confirmation and coagulopathic bleeding
mandates empiric
treatment
·
Recombinant
factor VIIa
binds to tissue factor at exposed sites and stimulates
coagulation – may be
useful in patients already treated with platelets, FFP and
cryoprecipitate.
TBI
·
Any
clinical
deterioration or rise in ICP warrants repeat CT scan
·
Hypotension
increase
the risk of death and should be avoided
·
Post-traumatic
seizures
should be treated prophylactically with phenytoin
·
Maintain
normocapnia
Mechanical
ventilation
·
Acute
hypoxia in the
first 24 hours is probably different from ARDS.
·
High
peak pressures may
be required at this stage, although the approach will change
once the patient
has been successfully resuscitated.
Abdominal
compartment syndrome
·
An intra-abdominal pressure >20mmHg
(with or without
APP <60mmHg) in association with new organ dysfunction or
failure
·
Abdominal perfusion pressure = MAP-IAP
·
Cause of raised IAP
Intra-abdominal
and
retroperitoneal haemorrhage
Massive
fluid
resuscitation with bowel and tissue oedema
Tissue
oedema
due to sepsis or ischaemia
Paralytic
ileus
or pseudo-obstruction
·
Clinical features: Tense abdomen,
increased
end-inspiratory pressures, oliguria, reduced CO, increased SVR.
How
do you measure bladder pressure?
·
I ensure the patient is supine
·
I disconnect the bladder from collection
bag
·
I palce a T piece on the end of the
catheter and
reconnect one limb to the drainage bag and clamp
·
I connect the other end to the
electronic pressure
transducer
·
I instill 50ml saline through the other
end of the T
piece and zero the system.
·
The normal pressure is less than 12mmHg
at end of expiration
with variations of 5-10mmHg with respiration.
·
If the pressure is very high it is
probably blocked.
·
I flush the catheter
·
An alternative is to instill 50ml into
bladder and
elevate the tubing and measure the height. 1mmHg = 1.3cm water.
Management
principles
·
Frequent re-measurement
·
Optimizing systemic perfusion and organ
function
·
Look for reversible factors – stop
haemorrhage, treat
pseudo-obstrcution
·
Decompressive laparotomy
–intra-abdominal pressure
elevation in absence of physiological derangement is not
indication:
· Origuria or persistent shock
with raised intra-abdominal pressure despite resuscitation
· A laparotomy with temporaru
abdominal closure technique is used
Full
length
laparotomy is recommended
Days 1-7
·
Extubate the patient as early as
possible – SOAAP
S- Secretions:
minimal
O- Oxygenatio good
A – Alert
A – Airway without
injury
P – Pressures and
parameters satisfactory.
·
Consider tracheostomy in patients
unlikely to be
weanable
·
ARDS defined by diffuse bilateral
pulmonary infiltrates
on CXR, cardiogenic pulmonary oedema excluded, PaO2/FiO2
<200mmHg
·
High airways pressures and repeated
alveolar collapse
(lack of PEEP) contribute to ARDS.
·
Moderate PEEP and restricted tidal
volume (6ml/Kg) and
moderate FiO2 all reduce the extent of lung injury.
Nutrition
· Should be enteral
whenever possible.
· Commencing enteral
nutrition is possible once shock has resolved. Tolerated within
12 hours of
being resuscitated by 80% of patients.
· Calorie requirement
can be estimated using the Harris-Benedict equation based on
sex, age, weight
and height.
· Typical calorie
requirement is 30kcal/Kg/day.
· Depending on the
severity of injury the basal energy requirement is multiplied by
a stress
factor usually about 1.3-1.4. eg 35-40 kcal/kg/day
Fluid
Maintenance water is 25 - 35 ml/kg per day
Electrolytes
Electrolyte Amount required (mmol/kg/day)
Sodium 1.5
Potassium 1
Chloride 1.5
Magnesium 0.2
Phosphate 1
Energy and protein
Generic
— Glucose:fat 50:50
— 35-40 kcal/kg/day
·Protein
— 1g/kg/day
Nitrogen requirement
300 mg/kg/day
Essential fatty acids
· 15g each of linoleic and arachidonic acids
are required per week.
— (given as Liposyn 500ml via peripheral
line once per week)
· Extra fat given to provide extra calories
when dextrose not enough,
— but no more than 3g/kg/day.
Trace elements & vitamins
Given as 10ml of multivitamin mixture daily
In depleted or stressed patients;
— Folate 10mg daily for 3 days followed by
5mg per day
— Zinc 10mg daily for the first week
Vitamin B12 given IM 1000 ug/month
·Vitamin K given IM 20 mg/week
Specific TPN
composition
· 50%
glucose
— Max rate » 15g/hr
otherwise XS
CO2 and XS fat production
— Min rate » 2g/kg/day
to
prevent gluconeogenesis
· 30%
lipid
· 20%
protein
Stress
ulceration
· Noscomial
pneumonia is increased in patients receiving H2-antagonist
· Sucrasulfate
reduces the incidence of gastric ulceration without causing
gastric acid
neutralization.
Pain relief
Adequate relief of pain.
Thoracic epidural
results in fewer nosocomial pneumonia and fewer days of
ventilator days
DVT/PE
Occur at any time after the
first 48 hours.
Spinal cord and lower
extremity are
particularly high risk
LMWH are more effective than
UFH, but the
risk of bleeding is greater and therefore should be avoided in
intracranial
haemorrhage or ongoing extra-cranial haemorrhage.
After first week
Nosocomial pneumonia
Other infections