FEATURE TRAUMA SURGERY
INTRODUCTION Poly-trauma patients are challenging because of several organ damage, consequences of the hemorrhagic shock and late complications like sepsis and multi organ failure. Many patients need several and recurrent surgical procedures with increasing morbidities and mortality. In the ICU, organ directed therapy is the mainstay strategy for management of this group of patients. The concept of Damage Control Surgery (DCS) is employed because application of the skills used for elective surgery failed to obtain satisfactory results in the treatment of severely injured patients who have different physiology and anatomy. DCS is indicated in patients if they have one or more of the following; hemorrhagic shock, signs of ongoing bleeding, coagulopathy, acidosis, hypothermia, inaccessible major anatomical injury, need for time-consuming procedures and major injury outside the abdomen e.g. traumatic brain injury (TBI). DCS has three components; first an abbreviated resuscitative surgery for control of bleeding and/or contamination. Second, ICU management to optimize the physiological and metabolic status and lastly the definitive surgical repair. All patients with severe poly-trauma
need a secured airway to protect the lungs and to optimize the oxygenation. Intubation of this group of patients is very challenging because of the urgency, hemodynamic instability, compromised respiration, possible cervical spines injury, full stomach, associated TBI and possible maxilla-facial trauma. Currently, the lung protective strategy is the role for any ventilated patient by using a low tidal volume and peak airway pressure less than 30 cmH2
O.
CHALLENGES During the initial resuscitative phase, the main goals of fluids therapy are; restoration of effective blood volume, optimization of tissue perfusion and limitation of ischemia-reperfusion injury. Usually combinations of colloids, crystalloids, red blood cells and vasopressors are used to obtain predetermined end points e.g. mean arterial blood pressure (MAP) more than 60 mmHg, urine output more than 0.5 ml/ kg/hour and clearance of excessive serum
Arab Health Issue 3 2011 31
«All patients with severe poly-trauma need a secured airway to protect the lungs and to optimize the oxygenation»
lactate within 24 hours. In patients with TBI, all efforts should
be directed to prevent and to treat the factors that may result in secondary brain injury. Secondary brain injury may result from hypotension, hypovolaemia, hypoxia, hypercapnia, anemia, acidosis, hypo- or hyperglycemia, seizures and hyperthermia. Coagulopathy is a common
complication of the severely injured patients. The optimal use of blood and blood products guided with clinical and laboratory assessment can overcome this problem. Factors that aggravate coagulopathy e.g. acidosis, hypocalcaemia and hypothermia should be treated aggressively. Pharmacological agents like tranexamic acid and recombinant activated factor VII may help the haemostatic process. Renal failure is not uncommon in
poly-trauma patients and may result from inadequate resuscitation, prolonged shock, rhabdomyolysis and sepsis. Once renal failure has occurred, renal replacement therapy should be commenced.
Immunological changes following
multiple traumas are another ICU challenge. Poly-trauma is associated with a multilevel complex involving neuro- hormonal, cellular and hemodynamic factors. This may resultant in a state of immunopralysis and severe post- traumatic complications such as Systemic inflammatory response syndrome, acute respiratory dysfunction syndrome and multiple organ dysfunction syndrome. Abdominal Compartment Syndrome
(ACS) is frequently seen in patients sustaining multiple trauma, massive hemorrhage, massive fluids resuscitation, abdominal packing and bowel distension. ACS causes multi-organ failure by reduction the perfusion of abdominal viscera, impairment of ventilation and by decreasing cardiac output. If ACS is not treated by abdominal decompression, the mortality rate is 100%. Other therapies include adequate
antibiotic therapy, electrolytes homeostasis, good control of blood glucose, prophylaxis against deep vein thrombosis and stress ulceration. Early enteral alimentation helps to preserve intestinal function and limit infectious complications. In summary, traumatic injury to a wide variety of organ systems and consequences of severe hemorrhage can complicate the diagnosis, management and delivery of necessary care. ■
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