Category Archives: Trauma

#EuAsia18 Keynote: Caring for the Injured Brain

Mauro Oddo

Championing individualised neurointensive care

  • Neurological examination
  • Imaging
  • Monitoring

The RCTs of therapies in Neuro ICU have shown no effect on pt prognosis

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EUROTHERM Study

A Trial of Intracranial-Pressure Monitoring in Traumatic Brain Injury

So what do you do??

Evidence for Health Decision Making — Beyond Randomized, Controlled Trials

Severe traumatic brain injury: targeted management in the intensive care unit.

Fluid therapy in neurointensive care patients: ESICM consensus and clinical practice recommendations.

 

But it may be that we are not finding the solution/therapy due to the heterogeneity of TBI

Diverse effects of hypothermia therapy in patients with severe traumatic brain injury based on the computed tomography classification of the traumatic coma data bank.

A response to the Chestnut trial –

A Method of Managing Severe Traumatic Brain Injury in the Absence of Intracranial Pressure Monitoring: The Imaging and Clinical Examination Protocol.

 

There is therefore an unsurprising degree of variation in how TBIs are managed.

Variation in monitoring and treatment policies for intracranial hypertension in traumatic brain injury: a survey in 66 neurotrauma centers participating in the CENTER-TBI study.

  • Outcome was more favourable in pts treated in aggressive centres

 

Multi Modal Monitoring (MMM)

Multimodal monitoring approach improves ability to detect hypoperfusion in the injured brain

Accuracy of brain multimodal monitoring to detect cerebral hypoperfusion after traumatic brain injury.

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New paradigm – quantitative brain function monitoring

Electroencephalography as a Prognostic Tool after Cardiac Arrest.

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Summary

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ESICM LIVES 2017 NEXT Day – ECMO #LIVES2017

ECMO Course

Session 1 – Antonio Pesenti, Refractory Hypoxaemia Therapuetic Strategies

Before deciding on support, first need to know what targets. One might be PaO2? If you climb up a mountain it’s low? Is this important – not according to Grocott in NEJM 2009 where low levels were compensated for by higher Hb.

Rx hypoxia broadly divided as follows

  1. Treat cause – antibiotics, thrombolysis, etc, etc
  2. Increase FiO2
  3. Reduced atelectasis – PEEP
  4. Increase pulmonary blood flow
  5. Reduce venous admixture – ECMO

Reabsorption atelectasis complicates high FiO2 administration.

PEEP prevents collapse = recruitment manoeuvres are needed to open collapsed lung. Indeed main difference between traditional IPPV & HFOV/APRV is high airway pressure – theory being more recruitment AND retention.

Don’t forget effects of heart + shunt upon O2 but iNO doesn’t work.

The benefits of proning extend beyond its effects on PaO2 – failure to improve this variable does not mean you should stop doing it.

Longer term, hypoxemia is a risk factor for long-term neuropsychological impairment but HYPEROXIA IS BAD.

 

Session 2 – Jan Bakker, Haemodynamic effects upon ECMO

Very variable! Limited prospective scores – ENCOURAGE might be useful for VA, or clearing fluid balance on day three but in essence little evidence.

When considering you need to ask:

  • What other support have you got?
  • What configuration are you using?

Peripheral VA-ECMO can significantly increase after load – first consider dilators, then increase forward flow whilst remember to treat acidodsis/anaemia. If that doesn’t work, add an IABP.

With VV-ECMO, RV afterload will fall with PVR effect because of beneficial effects upon CO2/PAO2.

 

Session 3 – Weaning from ECMO Giacomo Grasselli

No science to this – lack of definite criteria, indications from guidelines and local protocol and personal experience

Four scenarios

  1. wean ECMO, then vent
  2. Emergency discontinuation, e.g. bleed
  3. First wean vent, then ECMO
  4. Withdraw

Weaning from VV is weaning gas flow – you don/t need to reduce flow

Weaning GF increases muscle effort and needs vent support 

ELSO guidelines

You need haemodynamic stability as well as respiratory improvement. Measure oxygen delivery – the target is tissue oxygenation NOT PaO2.

How long do you keep the gas off? – Karolinska say 4 hours

Some authors propose leaving cannulae in place for put to 48 hours flushed with heparinised solution – practice VARIABLE

How to decannulate VV?

  • Stop/reduce heparin
  • Put purse string around insertion cannula
  • Clamp lines
  • Stop pump
  • Remove pipe allowing small amount of leakage to red air embolism
  • Manual compression 20 min for venous and 30 min for arterial.
  • Close monitoring distal perfusion for arterial and consider  vascular ultrasound in both as high incidence of clot or injury

 

Keynote – Michael QUINTEL, 50 years of ECMO

ECLS first developed by John Gibbon and Mali in 1936 in response to sudden death young patient with PE and first used in ORD for ASD repair May 1953

First trials negative – but badly done – so perhaps can be better interpreted as even if you do ECMO badly, you don’t kill everyone…

CESAR trial goo.gl/T6tdEL

First oxygenators bubble before developed hollow fibre oxygenator

The development of heparin-coated circuits allowing limiting APTT was one the major steps in reducing morbidity and mortality

Single centres such as Michigan have led the way – now more adult/paed, less neonates

Then H1N1 prompted exploration http://ja.ma/2xp301Q

H1N1 make worldwide excessive use of the technology but there is no new real data.

Reasonable data about risk/benefit ratio does not exist. Cerebral micro emboli are universal. 85% get DVT.

Is informed consent even possible?

 

Pro: Is ECMO always an Option? Steffen Weber-Carstens

UK evidence summarised by @CochraneUK in 2015

Similar International Consensus Position Paper by Coombes and colleagues on what defines an ECMO centre

Triage essentially as duration IPPV significant risk factor of deaths.

Con: Giacomo Bellani 

In one series, 87% of referrals had at least one relative contraindication

25% of patients in CESAR didn’t get it

EOLIA trial has not reported and is ongoing – we are in the infancy of what we know

16% rates of head bleed

20% nosocomial infection

Why use more resources when you can achieve the same thing with less? LungSafe shows we still don’t get optimium PEEP, NMBA, fluid balance and supportive care in ARDS.

 

EuAsia 2017 Day 3: Trauma

Initial trauma care (J Duranteau)

STOP THE BLEEDING – requires multidisciplinary task force

Communication vital

A major trauma centre is a specialty hospital not a hospital of specialties.

Damage control surgery and resuscitation should be emphasised by the team

Minimise time between arrival and operation

Aim for systolic BP 80-90mmHg (if TBI MAP 80mmHg)

  • Duranteau – if no response after 1l fluids, start vasopressors

Correct coagulopathy

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References

A major trauma centre is a specialty hospital not a hospital of specialties.

The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition

 

Ultrasound in trauma: what you need to know (A Wong)

 

Can trauma care be improved with simulation (HY So)

Simulation – strategy to mirror, anticipate or amplify the real situation

Learning process amongst professional is complicated

Debrief structure phase

  • Introduction
  • Reaction – emotion before cognition, go where the heat is
  • Debrief with good judgement

Simulation advantages

  • deliberate practice with feedback
  • uncommon events
  • reproducibility
  • ability to range the difficulty levels
  • absence of risk to patients

Hurdles

  • learners do not ‘buy in’
  • fidelity problematic
  • threatened – psychological safety crucial
  • confidentiality

Training the trainer is important

I hear and I forget. I see and I remember. I do and I understand. Confucius

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