section name header

Information

  1. Traumatic Brain Injury (TBI): For the critically ill TBI patient, a checklist approach to physiologic management goals may improve outcomes. Care is oriented at managing intracranial hypertension to prevent herniation. Current recommendations include the early placement of cerebrospinal fluid (CSF) drainage systems to lower intracranial pressure (ICP) in patients with an initial GCS less than 6 and utilizing ICP monitoring to reduce in-hospital and 2-week postinjury mortality in patients with severe TBI. ICP greater than 22 mm Hg should be treated because values above this level are associated with increased mortality, and recommended target cerebral perfusion pressure (CPP) is between 60 and 70 mm Hg. See Chapter 10 for a thorough review of critical care of the neurologic patient. The latest Brain Trauma Foundation guidelines can be found at www.braintrauma.org.
  2. Blunt Cerebrovascular Injury (BCVI): Severe acceleration/deceleration or flexion/extension forces can injure the intima of the carotid or vertebral vessels, resulting in thrombus formation and risk of emboli/stroke. Finding this injury requires a high index of suspicion because there are usually no clinical signs or symptoms until an often catastrophic stroke has occurred. The Eastern Association for the Surgery of Trauma (EAST) guidelines recommend using a screening protocol, such as the Denver or Memphis criteria, to detect BCVI in blunt polytrauma patients. Among patients with cervical spine injuries, screening CT angiography is recommended to detect BCVI. Antithrombotic therapy should be utilized in patients diagnosed with BCVI.
  3. Pneumothorax
    1. As previously stated, a patient with absent breath sounds and hypotension or respiratory distress should have a chest tube placed without waiting for imaging.
    2. Occult pneumothorax: An “occult” pneumothorax is one that is found on CT but not seen on plain radiography. Previously, it was thought that any patient requiring positive pressure ventilation with a pneumothorax required tube thoracostomy. Randomized controlled trials have shown that positive pressure ventilation does not influence the progression of occult pneumothoraces. We no longer routinely place chest tubes for stable patients with occult pneumothoraces who will undergo positive pressure ventilation, but caregivers must be alert for progression, and we typically monitor these patients with serial chest x-rays.
  4. Hemothorax: Posttraumatic hemothorax comes from the chest wall, lung, or intrathoracic vessels. Drainage allows for lung reexpansion and assessment of bleeding severity. Surgical intervention should be considered when the initial output is greater than 1500 mL, is greater than 200 mL/h over the first 4 hours, or there is hemodynamic instability because this degree of bleeding is less likely to stop spontaneously. If bleeding stops and chest x-ray shows persistent effusion, chest CT is useful to evaluate for retained hemothorax, which may be treated with intrapleural thrombolytics or thoracoscopic evacuation.
  5. Rib Fracture: The presence of rib fractures should alert the intensivist to the potential for associated injuries including pneumothorax, hemothorax, pulmonary contusion, liver or spleen laceration, and diaphragmatic injury. Adequate pain control and pulmonary toilet are the cornerstones of rib fracture management. This can be accomplished with epidural, paravertebral, or intercostal nerve blocks, opioids, nonsteroidal anti-inflammatory medication, or combinations of these and other adjuncts. The goals should be normal tidal volumes, normal mobility, an effective cough, and secretion clearance. Patients with flail chest (two or more consecutive ribs fractured in two or more places) and respiratory failure or severe chest wall deformity may benefit from open reduction and internal fixation of rib fractures.
  6. Pulmonary Contusion: This is more commonly seen associated with blunt traumatic injury to the chest wall. Unlike most sequelae of trauma, pulmonary contusions usually take 24 to 48 hours to “bloom” and fully manifest. Management includes minimizing fluid resuscitation, but even with careful fluid management, many patients will require intubation. Colloid resuscitation does not improve outcomes compared with crystalloid. Pulmonary contusion rarely presents as an isolated injury and is often associated with rib, diaphragm, and extrathoracic injuries.
  7. Aortic Injury: This is usually related to a significant deceleration injury (fall from height or motor vehicle collision) resulting in a contained rupture of the aorta, most commonly immediately distal to the origin of the left subclavian artery. It is most often diagnosed by chest CT with intravenous contrast. Surgical control of a contained rupture is nonemergent if there are other pressing injuries, but tight “impulse control” of heart rate and blood pressure should be maintained until repair, which can usually be accomplished with an endovascular stent.
  8. Blunt Cardiac Injury: This injury is associated with significant chest wall trauma and manifests as hypotension and/or new arrhythmias. More significant, time-sensitive injuries such as cardiac tamponade or tension pneumothorax must be ruled out before hypotension is attributed to blunt cardiac injury. Suspected blunt cardiac injury should be evaluated with an ECG and a serum troponin measurement. If both are normal, no blunt cardiac injury exists. If either an elevated troponin or a new arrhythmia is found, the patient should be admitted to a monitored bed for 24 hours. If either exists with hypotension or significant arrhythmias, the patient should be admitted to the ICU and undergo a transthoracic echocardiogram to look for a traumatic valvular lesion, tamponade, or segmental wall motion abnormality. Occasionally, inotropic support is required until the myocardium recovers.
  9. Abdominal Solid Organ Injury: The spleen, liver, and kidneys are susceptible to injury (laceration, contusion, hematoma), particularly in blunt trauma. In the absence of hemodynamic instability or peritonitis, these injuries can be managed with serial abdominal exams and serial measurement of hematocrit. Large-bore intravenous lines and reversal of coagulopathy are important in managing these injuries. If there are signs of continued bleeding, these injuries can be managed by angioembolization or by surgery. There are no absolute values for minimum hematocrit, or number of units of transfused blood, or hemodynamic parameters to guide the decision to intervene on these injuries. Rather, the clinician must evaluate the entire patient and how the solid organ injury affects management.
  10. Pelvic Fracture: These can cause significant bleeding and rapid decompensation, and management should focus on large-bore intravenous access and reversal of any coagulopathy. There are three modalities for managing severe bleeding from pelvic fractures: pelvic fixation, extraperitoneal pelvic packing, and bilateral internal iliac artery angioembolization. In unstable patients, they are often employed simultaneously. Patients with extraperitoneal packing will require reoperation for pack removal. Because angioembolization is typically done with absorbable gelatin foam, a small percentage of patients with recurrent bleeding will require repeat angioembolization.
  11. Extremity Compartment Syndrome: This secondary injury is related to swelling, crush injury, or periods of ischemia with reperfusion (tourniquet application, vascular injury, long bone fracture with or without vascular injury). Clinically, compartment syndrome will present as a tense compartment The 6 Ps—pain, pallor, paresthesia, pulselessness, poikilothermia, and/or paralysis—in an awake, sober, and cooperative patient should raise your suspicion for a possible compartment syndrome. In patients with a decreased level of consciousness, the index of suspicion should remain high.
    1. If there is any doubt about the diagnosis, compartment pressures can be measured directly with commercially available devices or with a transducer and large-bore needle. Although different thresholds have been proposed, urgent surgical decompression is usually required when compartment pressures reach 25 to 30 mm Hg and should be performed urgently.
  12. Cervical Spine Injury: Most blunt trauma patients requiring ICU admission will have had a high-energy mechanism of injury, such that the possibility of cervical spine injury must be considered. Many patients will arrive to the ICU with a hard cervical collar in place to provide in-line stabilization. For patients who are clinically evaluable (not intoxicated, no distracting injury), the cervical spine can be cleared by physical exam alone. If there is no posterior midline tenderness or no pain or paresthesia with axial loading, flexion, extension, or rotation, there is no need for further evaluation. Patients who cannot be clinically cleared by exam should undergo CT of the cervical spine. When injuries are found, they can be treated appropriately (either with immobilization or surgery). When no injuries are found on CT, in-line stabilization is typically maintained until a clinical evaluation can be performed to assess for possible ligamentous injury. If patients are likely to be clinically evaluable shortly after CT is performed, it is appropriate to wait for the opportunity to examine them. If not, or if the physical exam is abnormal despite a normal CT scan finding, cervical spine magnetic resonance imaging (MRI) should be performed to evaluate for ligamentous injury. It should be performed as soon as feasible because prolonged cervical collar application is associated with a number of complications from pressure ulceration to ventilator-associated pneumonia.