Category Archives: Trauma

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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NEXT Day – HOT TOPICS 2015

Multimodal monitoring (Oddo)

Monitoring devices does not replace clinical examination

ICP can be elevated despite absent mass lesion on CT brain

No possible to have continuous neuroimaging as monitor

Sedation interruption among TBI with intracranial hypertension is not recommended

ICP and CPP monitoring are recommended as part of a protocol-guided, individualised care

References

Consensus statement on multimodal monitoring on neurocritical care

NEJM ICP trial 2012

Monitoring the brain and systemic oxygenation in neurocritical care patients

Multimodal neuromonitoring to detect brain hypoxia in TBI

Continue reading NEXT Day – HOT TOPICS 2015

Critical Care Refresher Course: Trauma and Surgery

Polytrauma Patient (Duranteau)

Early mortality is usually due to uncontrolled haemorrhage. Late mortality and disability is due to brain injury and multiorgan failure

Control of haemorrhage

  • Low volume volume resuscitation – SAP 80-90mmHg until bleeding stopped; MAP > 80mmHG in TBI. vaopressor may have role (animal models)
  • Trauma-induced coagulopathy: multifactorial, complex and dynamic. Use TEG
  • Euro recommends plasma:red cell ratio of at least 1:2
  • Plts > 50 ( >100 if ongoing bleeding or TBI)
  • Fibrinogen target of between 1.5-2g/L
  • Early transexamic acid (1g load, followed by 1gm over 8)

 

References

European guidelines of major trauma

Damage control haematology

Trauma-Associated Severe Haemorrhage (TASH) Score

PROPPR Trial

CRASH-2 Trial

 

Perioperative Intensive Care Medicine  (Hiesmayr)

Post op issues on the ICU

  • Volume instability
  • Bleeding – surgical and anaesthetics (lines)
  • Fever
  • Residual anaesthetic drugs
  • Delirium

Know the patient (premorbid state) and know the surgery

Types of surgery and specific problems

  • Vascular – comorbidities, bleeding, ischaemia
  • Ortho – fat embolism, bone-cement cardiac event
  • Solid organ transplant – infection, graft failure, vascular complications
  • Neurosurgery – brain oedema, vascular spasm, hydrocephalus, CNS disturbances e.g. DI
  • Cardiac – hear failure, stiff heart, pulmonary complications, cerebral complications

Consider post-op checklist

References

Post-operative hypoxia

Transplantation and Immunosuppression (Meyfroidt)

HLA; class 1 on all nucleated cells, class 2 on antigen presenting cells

Immunosuppresant drugs

  • Glucocorticoids
  • Calcineurin-inhibitors; cyclosporine, tacrolimus
  • DNA-synthesis inhibitors; AZT, mycophenolate
  • Antibodies; depleting or non-depleting
  • mTOR inhibitors; sirolimus, everolimus

Rejection

  • Hyperacute rejection
  • Cellular rejection
  • Humoral rejection

Kidney transplant complications

  • Surgical complications; vascular, ureter
  • Delayed graft function – living donor 5%, DBD 30%, DCD 50%

Liver transplant complications

  • Monitor liver function
  • Bleeding
  • Arterial complications: ultrasound – early/late hepatic arterial thrombosis

Heart transplant complications

  • Bleeding
  • Rhythm – denervated
  • RV failure – inotropes, iNO
  • LV dysfunction/failure – inotropes, mechanical assist
  • Renal dysfunction – calcineurin inhibitors

Lung transplant complications

  • Respiratory – protective ventilation, assess structures with bronchoscopy, chest tubes, phrenic nerve injury, ischaemia/reperfusion, difficult weaning (anxious/pain)
  • AF
  • Cystic fibrosis: other manifestation e.g. liver GI
  • Infections

Infections – bacterial, viral, fungal, protozoal

References

Review of immunosuppresant drugs