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ICU monitoring; Critically ill trauma patient

ICU trauma

Tri Modal Distribution of Trauma Death

First peak


Second peak Golden hours

30% (hemorrhage)

(Central nervous systems)


Third peak 24 10-20%

pulmonary embolism multi-organ failure


Patho: Critically ill Trauma Patients

(Gebhard & Huber-Lang, 2008)

Critically ill Trauma Patients

(Gebhard & Huber-Lang, 2008)

Hypoperfusion

TBI IICP

Blunt abd. FIND

Chest inj. ICD

Shock SI

TM monitoring RASS,PAIN

Traumatic brain injury

ICP ICP

CPP CPP

CBF CBF

Ischemia

Ischemia

Edema

Edema

Tissue pressure

Tissue pressure

Secondary Brain injury

Primary Brain injury

Goal is to stop

2nd injury

CPP=MAP-ICP

CPP=Cerebral Perfusion Pressure CBF = cerebral blood flow

Factor:2nd TBI Hypotension hypoxia

Factor:2nd TBI Hypotension hypoxia


Goal of treatments

(American college of surgeons,2015)


How to stop 2nd brain injury

Step 1. Management of intracranial pressure

Head of bed 30 degrees

Sedation and analgesia (recommend propofol,midazolam,fentanyl)

Continuous ventricular drainage

If ICP >20-25 mmHg. Next steps?



Step 2. hyperosmolar therapy (mannital,3%NSS)

Keep CPP > 50 mmHg. ICP

Neuromuscular blocking

Suction clear airway (15sec,80 mmHg., SjvO2>50%

If ICP >20-25 mmHg. Next step?



Step 3. decompresive hemi-craniectomy adequate sedation : goal paralysis propofol hypotension

SBP>100 mmHg. #### Propofol

phebitis### Hypothermia ( 4mm.

90%


Blunt Abdominal injury

F Fast track (trauma)

I Intra abdominal pressure

Keep

F: Fast track (Trauma)

Indication : Vascular injury, penetrating injury, Hypovolemic shock, cardiac arrest

Management:

1.notify staff trauma

2.Door to OR 30 (team : Ward + Blood Bank+lab+Anesth.)

3.Post-OP care in ICU

I:intra-abdominal pressure

Infuse 50-100 mL saline into an empty bladder, measureing at the level of the symphysis pubis

I:intra-abdominal pressure

D: drainage

Suction abdominal drainage < 40 mmHg.

Record content drainage per hour. Keep

ICU TM KKH.

trauma triad of death

HEMORRHAGE TRUAMA Classification of shock

Resuscitate goal

SvO2 >70%

Goals of damage control in the severely Injured Patient

1. Stable airway and oxygenation

2. Effective analgesia and sedation (MO,fentanyl,midazolam)

3. Hemostasis-control of life-threatening hemorraghe (EL, Thoracotomy,ligation, Temporary closure etc.)

4. Appropriated blood compossition (RBC,Plt.,Clotting factors,Ca+,glucose,K,CL)

Predicting Fluid Responsiveness

SVV keep 9-13%

Leg raising test

CVP keep 8-15 mmHg.

Hemodynamic monitoring

Leg raising

: A-line , flow-track, VIGILIO

CVP:Central venous pressure

the Frank-Starling curves

46

Fluid Challenge Test

Initial CVP 15 cm H2O

PAOP 16 mm Hg

Volume & Rate 200 mL/10 min 100 mL/10 min 50 mL/10 min

During infusion, CVP rises >5 cm H2O

or PAOP rises >7 mm Hg

Yes No

Stop challenge Complete the volume

Wait 10 min Wait 10 min

CVP change >5 3-5

Secondary care: set zero Complication

TM Pt

IHT

Delirium

CAUTI

VAP

CLABSI

malnutrition

IHT:Intrahospital Transfer

Cardiac arrest

Respiratory problem

SBP 20%

cardiac arrest Management

Respiratory problem

Management

shock Management

Agitation Agitation Management

1. 2. 3.

1. 2. 3.

Delilium

Risk factors for delirium ( daily alcohol, smoke,intubation,Isolation, no visible daylight)

the Confusion Assessment Method for the ICU (CAM-ICU) the Intensive Care Delirium Screening Checklist (ICDSC)

Sedate critical care clients carefuly; monitor sedation, analgesia, and delirium scores

Holiday sedate sedate 1-2

The bloomsbury sedation scale Sedation Score

3 Agitation and restless

2 Awake and comfortable

1 Aware but calm

0 Roused by voice

-1 Roused by touch

-2 Roused by painful stimuli

-3 Unrousable

A Natural sleep

P Paralysed

Richmond Agitation-Sedation Scale

CAUTI:catheter associated urinary tract infection

1.

2. 2

3.

4.

VAP:Ventilator associated pneumonia

CPIS score

30

mouth care q 2 hr. (chlorhexidine, special mouth wash)

Suction prn. 1-2

Check cuff pressure keep 20-30 cmH2O

Prevention central line-associated bloodsteam infection(CLABSI)

C-line

2 tegaderm

triple lumen/duble lumen 7

septicemia Hemo culture

Change heparin every day

Malnutrition

The subjective global assessment (SGA),IJEE

Early feeding 24-48 hr.

Continous feeding

20 cc/hr. Check content 4 hr. keep

Biffl et al,2002)

Biffl, W. L., Moore, E. E., & Haenel, J. B. (2002). Nutrition support of the trauma patient. Nutrition, 18(11), 960-965.

Ely, E. W., Truman, B., Shintani, A., Thomason, J. W., Wheeler, A. P., Gordon, S., ... & Sessler, C. N. (2003). Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS). Jama, 289(22), 2983-2991.

Curtis N. Sessler, Mark S. Gosnell, Mary Jo Grap, Gretchen M. Brophy, Pam V. O'Neal, Kimberly A. Keane, Eljim P. Tesoro, and R. K. Elswick "The Richmond AgitationSedation Scale", American Journal of Respiratory and Critical Care Medicine, Vol. 166, No. 10 (2002), pp. 1338-1344.

http://www.edwards.com/eu/products/pages/cceducationmap.aspx Truman, B., Stephens, R., & Ely, E. W. (2003). Critical care nurses'

perspectives on delirium in the ICU.(Poster Abstracts). American Journal of Critical Care, 12(3), 284-285.

Ghajar, J. (2000). Traumatic brain injury. The Lancet, 356(9233), 923-929. Spahn, D. R., Bouillon, B., Cerny, V., Coats, T. J., Duranteau, J., Fernndez-

Mondjar, E., ... & Neugebauer, E. (2013). Management of bleeding and coagulopathy following major trauma: an updated European guideline. Crit Care, 17(2), R76.

Rowe, K., & Fletcher, S. (2008). Sedation in the intensive care unit. Continuing Education in Anaesthesia, Critical Care & Pain, 8(2), 50-55.

Kusek, L. (2012). Preventing central line-associated bloodstream infections. Journal of nursing care quality, 27(4), 283-287.

Thank you

Keep warm

How to Keeping Pt. warm

Warm blood products/IV

Blanket warmer

Warm operating room

Clinical differences between TIC and DIC

TIC DIC

Early bleeding Late bleeding

Hypothermia Normo-/hyperthermia

Hypovolemia Euvolemia

Systemic anticoagulation Systemic hypercoagulation

Hyperfibrinolysis Hypofibrinolysis(occasionally: hyper)

Microthrombi rare Microthrombi

TIC Trauma-induced intravascular coagulopathy, DIC disseminated intravascular coagulopathy

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