SPECIAL CONSIDERATIONS: RICARDO MATOS/MARTIN DÜNSER
The immunologic response to severe trauma (Jean-Daniel Chiche)
Inflammation is part of the immune response to trauma and its mechanisms are very similar to that for other causes of inflammation
The systemic immune response to trauma: an overview of pathophysiology and treatment – http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)60687-5/abstract
The danger model: a renewed sense of self – ncbi.nlm.nih.gov/pubmed/11951032
Trauma alarmins as activators of damage-induced inflammation – http://www.ncbi.nlm.nih.gov/pubmed/22441851
A genomic storm in critically injured humans – http://jem.rupress.org/content/208/13/2581.long
The difference in individual immunogenomics may explain some of the difference in pt outcomes to same injury.
Uncontrolled systemic inflammation causes MOF
When is the right time to go back to the OR for secondary surgeries? (Luke Leenen)
A second hit from secondary surgeries is evident but the clinical implications of timing of secondary operations however is undetermined.
When should we go back to the OR?
- As soon as possible
- Hemodynamically stable
- Respiration not deteriorating
- Temperature controlled
- Coagulation corrected
Doing too much, too early will cause problems for the pt
Therapy will be adapted to the individual immune response of the patient.
New techniques being developed based on neutrophil capabilities to evaluate immunological competence.
Antibiotic prophylaxis and infectious complications (José Artur Paiva)
Antibiotics are important but is only one element in the management of infection in the trauma pt
Judicious use of antibiotics with stewardship programme is needed
Trauma leads to
- bacterial burden
- broken physical barriers (as does ICU)
The collateral damage of antimicrobial resistance is very seldom considered both clinically and in research
Antibiotic prophylaxis would ideally be at the time of innoculation i.e. at time of trauma but what is the second best thing to do?
Most important action is to reduce bacterial burden by wound debridement and disinfection
antibiotic choice is balance between efficacy and limiting collateral damage
Speakers review of literature
- Basilar skull fractures do not require antimicrobial prophylaxis (even if there is CSF leak)
- No role of abx for facial fractures except mandibular fracture
- Short courses of antibiotics (24hrs) for penetrating abdominal trauma
- Single dose antibiotic for closed fracture repair
- For open fracture, there are conflicting recommendations – short course (24hrs) of 1st generation cephalosporins combined with prompt wound management as long course (5 days). Bacterial pathogens have changed over time from gram positive to mostly gram negative.
Localised therapy may be the answer compared to systemic administration.
Post traumatic thromboembolism: Risk factors and prevention (Dietmar Fries)
80% of lethal PE have no previous clinical signs (Epidemiology and risk factors for venous thrombosis)
Frequency of DVT in trauma pts with no prophylaxis is between 40-80%
Monitoring using traditional coagulation test e.g. PT, APTT are useless to help decide timing of DVT prophylaxis (do not present the balance between pro and anti-coagulatory system)
TEG detected hypercoagulable state which was not proved by plasma PT or APTT
Heparin resistance is an underestimated problem
No IVC filter!
Start mechanical devices ASAP
The elderly trauma patient (Rui Paulo Moreno)
70% of falls in elderly pts occur whilst they are attempting to perform activities of daily living
Following a single fall, 65% will fall again with significant injury
Increased risk of dementia in pts with TBI
- Preventive measures
- Screen for history of brain injury
- Strategies to support e.g. memory and orientation checklist
- Resource and referral as rehabilitation works
Caring for the burn patient during the first 24 hours (Matthieu Legrand)
Caution with concomitant alcohol intoxication, poisoning (e.g. cyanide) and inhalation injury
Burns to the face is not an indication for tracheal intubation in itself but may become difficult if it is required later
Legrand uses balance solution e.g. Ringers Lactate. Amount – Parklands formula (rough estimate)
Burn injury is a changing haemodynamic profile: early low output, high resistance state to high flow, low resistance state. Hence, haemodynamic monitoring recommended.
Consider escharotomies (chest and limbs) actively. If limb pressures > 30mmHG = escharotomy
PROGNOSIS AND LONG-TERM OUTCOME ANTERO FERNANDES / DANIEL DE BACKER
Prognostication in traumatic brain and spinal cord injury (Geert Meyfroidt)
MRI most important prognostic tool in traumatic SCI (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3143391/)
3 possible patterns for SCI
- haemorrhage of cord
- oedema of the cord
IMPACT-TBI Score – http://www.tbi-impact.org/?p=impact/calc
CRASH Head Injury Prognosthttp://crash2.lshtm.ac.uk/Risk%20calculator/index.html
Long-term outcome of traumatic brain injury and severe trauma (Rui Paulo Moreno)
Mortality after hospital discharge following trauma mirrors that of the general public.
- Mortality causes
- Week 1: 90% due to direct infarct
- Week 2-4: PE
- Week 8-12: Infection
- Importance of secondary prevention
- Increased risk of seizures
- Association with Alzheimers dementia and Parkinsons (especially moderate-severe TBI)
- Other associations – dementia purgulistica, MS
- 2/3 survivors regain functional independence but half have cognitive impairment
- 1/3 will resume the same work as before
Ethical considerations in neurotrauma patients (Paulo Maia)
Prospective important – balance of expectations and reality
Dying with dignity on the ICU – http://www.nejm.org/doi/full/10.1056/NEJMra1208795
Early rehabilitation: What can we do in the ICU? (Matthieu Legrand)
Functional disability after ICU is common
- physical weakness
- cognitive impairment
Barriers – CVS instability and deep sedation
Post Traumatic Stress Disorder syndrome prevention: ICU strategies for prevention (Diederik van Dijk)
How to measure PTSD?
- Goal standard – psychiatric interview
Prevalence varies depending on tool but approximately 20% (5-63%)
- female gender
- younger age
- pre-existing psych illness
Prevention of PTSD
- avoid benzodiazepines
- treat pain
- other pharmacological therapies
- music (Effects of Patient-Directed Music Intervention on Anxiety and Sedative Exposure in Critically Ill Patients Receiving Mechanical Ventilatory Support A Randomized Clinical Trial)
- patient diary (Intensive care diaries reduce new onset post traumatic stress disorder following critical illness: a randomised, controlled trial)
Treatment of PTSD
- ICU diary
- ICU follow-up clinic DID NOT help with PTSD
- Self-help rehabilitation manual
- Eye Movement Desensitisation and Reprocessing (EMDR)
There is some evidence that steroids may prevent occurrence and aid in treatment of PTSD- Medications to prevent post-traumatic stress disorder (PTSD): a review of the evidence
This was not shown in this study- The Effect of Dexamethasone on Symptoms of Posttraumatic Stress Disorder and Depression After Cardiac Surgery and Intensive Care Admission: Longitudinal Follow-Up of a Randomized Controlled Trial.