Day 3: Outcomes

3

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.

Impact of intramedullary instrumentation versus damage control for femoral fractures on immunoinflammatory parameters: prospective randomized analysis by the EPOFF Study Group.

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)
  • immunosuppression

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.

Emergence of Imipenem-Resistant Gram-Negative Bacilli in Intestinal Flora of Intensive Care Patients

Prophylactic antibiotics for penetrating abdominal trauma

Antibiotic prophylaxis for surgery for proximal femoral and other closed long bone fractures

Antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures

Systematic review and meta-analysis of the additional benefit of local prophylactic antibiotic therapy for infection rates in open tibia fractures treated with intramedullary nailing

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

Thromboelastography as a better indicator of hypercoagulable state after injury than prothrombin time or activated partial thromboplastin time

Study – Comparison of low dose heparin and LMWH heparin in trauma pts

Study – Dalteparin vs enoxaparin for VTE prophylaxis in acute spinal cord injury and major orthopaedic trauma: DETECT trial

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

Strategies

  • 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

Management of cyanide poisoning (review)

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.

Systemic and pulmonary hemodynamic changes accompanying thermal injury.

A protocol for resuscitation of severe burn patients guided by transpulmonary thermodilution and lactate levels: a 3-year prospective cohort study

Prevent hypothermia.

Risk factors for hypothermia in EMS-treated burn patients.

Consider escharotomies (chest and limbs) actively. If limb pressures > 30mmHG = escharotomy

Ten tips for managing critically ill burn patients: follow the RASTAFARI!

 

PROGNOSIS AND LONG-TERM OUTCOME ANTERO FERNANDES / DANIEL DE BACKER

Prognostication in traumatic brain and spinal cord injury (Geert Meyfroidt)

NOT BIOMARKERS.

Clinical predictors of recovery after blunt spinal cord trauma: systematic review.

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
  • combination

Early prognosis in traumatic brain injury: from prophecies to predictions.

IMPACT-TBI Score – http://www.tbi-impact.org/?p=impact/calc

CRASH Head Injury Prognosthttp://crash2.lshtm.ac.uk/Risk%20calculator/index.html

Determination of neurologic prognosis and clinical decision making in adult patients with severe traumatic brain injury: a survey of Canadian intensivists, neurosurgeons, and neurologists

Self-fulfilling prophecies through withdrawal of care: do they exist in traumatic brain injury, too?

Recommendations for the Critical Care Management of Devastating Brain Injury: Prognostication,

Novel methods to predict increased intracranial pressure during intensive care and long-term neurologic outcome after traumatic brain injury: development and validation in a multicenter dataset

Psychosocial, and Ethical Management : A Position Statement for Healthcare Professionals from the Neurocritical Care Society

 

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.

Stroke

  • Mortality causes
    • Week 1: 90% due to direct infarct
    • Week 2-4: PE
    • Week 8-12: Infection
  • Importance of secondary prevention

TBI

  • Increased risk of seizures
  • Association with Alzheimers dementia and Parkinsons (especially moderate-severe TBI)
  • Other associations – dementia purgulistica, MS

Long-term outcomes of patients with aneurysmal subarachnoid haemorrhage.

  • 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

Attitudes of European physicians, nurses, patients, and families regarding end-of-life decisions: the ETHICATT study

Dying with dignity on the ICU – http://www.nejm.org/doi/full/10.1056/NEJMra1208795

UK Code of practice and diagnosis of death

 

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

Systematic review of early exercise in intensive care: A qualitative approach

Early mobilization of mechanically ventilated patients: a 1-day point-prevalence study in Germany

The power of the mind: the cortex as a critical determinant of muscle strength/weakness

Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit.

Comfort and patient-centred care without excessive sedation: the eCASH concept

 

Post Traumatic Stress Disorder syndrome prevention: ICU strategies for prevention (Diederik van Dijk)

How to measure PTSD?

  • Goal standard – psychiatric interview
  • Questionnaires

Prevalence varies depending on tool but approximately 20% (5-63%)

PTSD in critical illness survivors

Medications to prevent post-traumatic stress disorder (PTSD): a review of the evidence

Risk factors

  • female gender
  • younger age
  • pre-existing psych illness

Prevention of PTSD

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.

That is all we have. Hope you have enjoyed and found the signposts useful. @avkwong and @drjimday