HAEMORRHAGE CONTROL RICARDO MATOS / ANNE WEAVER
Haemorrhage control: When to go to the operation room? (Luke Leenen)
Trauma is dynamic and constant evaluation with decision-making are the norms. You need to check, check and check the patient again.
Physiology is key. Imaging only aids this.
The role of damage control surgery is NOT to restore anatomy.
Phase 1 – damage control (abbreviated surgery), life saving only. Control haemorrhage/contamination, pack, temporary closure. Physiology leads the decision making in theatre.
Phase 2 – restoration of physiology on ICU; temperature, acidosis, coagulopathy
Phase 3 – definitive surgery. When not to go when hypothermic and uncorrected coagulopathy.
Phase 4 – reconstructive surgery (can be months later)
Haemorrhage control: When to go to the angiography suite? (Sophie Hamada)
Damage control radiology – http://bja.oxfordjournals.org/content/113/2/250.abstract
Management of penetrating trauma (Pierre Carli)
MARCHE – Massive bleeding control, airway, respiration, circulation, head, evacuation
Triad of death – coagulopathy, acidosis and hypothermia
Damage control resuscitation – ncbi.nlm.nih.gov/pmc/articles/P…
Transfusion strategies in severe trauma (Anne Weaver)
Bart’s and the London NHS Trust (Home of London Air Ambulance) Trauma Transfusion Protocols:
These are the a selection of papers of trials/studies that have guided current practice and some more underway to guide future therapies.
Karim Brohi on TXA – http://intensivecarenetwork.com/karim-brohi-on-tranexamic-acid-in-trauma/
Early fibrinogen trial – http://efit1trial.co.uk/
Stopping trauma-induced coagulopathy (Dietmar Fries)
Haemorrhage associated with direct/novel oral anticoagulants (Giuseppe Citero)
There is very little published data and working clinical knowledge of NOACs in trauma
INTERACTIVE SESSION LUCIANO GATTINONI
Radiology quiz (Sophie Hamada)
Transcranial Doppler after traumatic brain injury: is there a role? ncbi.nlm.nih.gov/pubmed/2453165
Transcranial Doppler pulsatility index: what it is and what it isn’t – http://www.ncbi.nlm.nih.gov/pubmed/22311229
U/S of ONSD for detection of raised intracranial pressure: a systematic review and meta-analysis – ncbi.nlm.nih.gov/pubmed/21505900
The effectiveness of prophylactic inferior vena cava filters in trauma patients: a systematic review and meta-analysis – http://www.ncbi.nlm.nih.gov/pubmed/24195920
ICU MANAGEMENT OF SEVERE TRAUMA JOÃO GOUVEIA / JACQUES DURANTEAU
Severe traumatic brain injury (Giuseppe Citerio)
The GCS is still being used to classify TBI BUT it is a very heterogenous group of conditions. Reducing GCS at scene correlates very well with mortality
TBI severity ratio of hospitalised pts is changing – 90% are mild
Causes of TBI have also changed – rising car crashes in Asia and India. UK/US/Australia has reducing numbers of car crashes causing TBI and falls increasing numbers.
Older pts being admitted – changing TBI population median age has increased by a decade in last 10-15 years.
Recommendations on the use of EEG monitoring in critically ill patients: consensus statement from the neurointensive care section of the ESICM –http://icmjournal.esicm.org/journals/abstract.html?v=39&j=134&i=8&a=2938_10.1007_s00134-013-2938-4&doi
Consensus summary statement of the International Multidisciplinary Consensus Conference on Multimodality Monitoring in Neurocritical Care –http://www.esicm.org/admin/lib/ckfinder/userfiles/files/NCC_Consensus_ICM_09_2014.pdf
Spinal cord injury (Geert Meyfroidt)
Early versus Delayed Decompression for Traumatic Cervical Spinal Cord Injury: Results of the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS) – http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0032037
Cochrane review – Steroids for acute spinal cord injury
- Early surgery and decompression
- Steroids not recommended original trials flawed (NASCIS 2 and 3 trials)
- Supportive therapy according to level
Severe chest trauma (John Laffey)
Surgical intervention rarely needed in chest trauma (besides chest tube)
Role of surgical fixation for flail segments – poor evidence
Pulmonary contusion – common
Indication to fix ribs is uncertain unless thoracotomy for other reasons.
RibScore: A novel radiographic score based on fracture pattern that predicts pneumonia, RF, & trachy – ncbi.nlm.nih.gov/pubmed/26683395
NIV may have a role but only used in 5% of patients- Safety and efficacy of noninvasive ventilation in patients with blunt chest trauma: a systematic review
ECMO in trauma patients (Dirk Donker)
First survivor of VA ECMO was in 1972 and was a trauma patient.
Traumatic lung injury treated by extracorporeal membrane oxygenation (ECMO) – http://www.ncbi.nlm.nih.gov/pubmed/16243331
Prevalence of Venous Thrombosis Following Venovenous Extracorporeal Membrane Oxygenation in Patients With Severe Respiratory Failure – http://journals.lww.com/ccmjournal/Citation/2015/12000/Prevalence_of_Venous_Thrombosis_Following.40.aspx
Prolonged heparin-free extracorporeal membrane oxygenation in multiple injured acute respiratory distress syndrome patients with traumatic brain injury – http://www.ncbi.nlm.nih.gov/pubmed/22673280
Venovenous extracorporeal life support improves survival in adult trauma patients with acute hypoxemic respiratory failure: a multicenter retrospective cohort study – http://www.ncbi.nlm.nih.gov/pubmed/24747460
- Limited heparinisation is relatively safe (not a big problem in the first week)
- Evidence is scarce
- Respiratory failure in trauma is different from non-trauma
- ECMO in trauma is challenging and complex, patients are complex
ICU MANAGEMENT OF SEVERE TRAUMA ANTÓNIO MARQUES / JOZEF KESECIOGLU
Managing combined injuries (Luciano Gattinoni)
Acute brain and lung injuries – contrasting needs. Trying to balance O2, CO2, TV, fluids etc
If lungs are very compliant, ventilation is not going to be a problem.
- Intracheal gas insufflation
- High frequency oscillation
- VV extracorporeal CO2 removal
High Pleural pressure and PCO2 strategies
- Protective lung ventilation
- Prone (care with position of the head)
- Abdominal pressure considerations
Conservative management of abdominal trauma (Luke Leenen)
Non-operative management of abdominal trauma is increasingly utilised. Non operative management of liver trauma was routinely used from the 1980s
Puritanism/Free air/Abdominal gunshot still reasons to go to OR.
Abdominal trauma can result in bleeding but also CONTAMINATION
Increase in non operative management goes hand in hand with improvements in imaging
Sonography as the primary screening method in evaluating blunt abdominal trauma – ncbi.nlm.nih.gov/pubmed/15856519
Delayed splenic rupture – no evidence for bedrest. Success of non operative management is not predicted by grade of injury or size of haematoma.
Adjuncts to non-operative management
- CT guided drainage
Pitfalls are small bowel, pancreas and diaphragmatic injuries not readily seen on CT.
Compartment syndromes (Jacques Duranteau)
Abdominal and compartment syndrome of the extremitis requires timely diagnosis
Primary abdo compartment syndrome develops in patients with abdominal injuries.
Secondary abdo compartment syndrome develops in pts needing large volumes of transfusion/fluids for other injuries
Abdominal Compartment Syndrome: pathophysiology and definitions – http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2654860/
Secondary abdominal compartment syndrome after severe extremity injury: are early, aggressive fluid resuscitation strategies to blame? – http://www.ncbi.nlm.nih.gov/pubmed/18301187
Diagnosis and treatment of acute extremity compartment syndrome – thelancet.com/pdfs/journals/…