Fonseca’s Oral Surgery 3rd Ed

Volume 2, Chapter 4
Initial Assessment and ICU Care of the Trauma
Patient
Matt Dawley
April 6th, 2020
Chapter 4 Outline (part 1)
INITIAL ASSESSMENT OF THE
INJURED PATIENT

Primary Survey

ABCDE

Adjuncts to Primary Survey

Secondary Survey

Adjuncts to Secondary Survey

Penetrating injuries
Pneumothorax
Tension Pneumothorax
Penetrating injuries - General
Stab wounds an impalements

Cause local injury

Generally should not be removed in ED

GSWs

Potential to damage organs far from

entry wound

Not uncommon to involve multiple

body cavities
Penetrating injuries -Head

Often fatal

ICP can evevate rapidly

Brain injuries frequently

associated with coagulopathy

Give appropriate coagulation

factors as needed
Penetrating injuries - Neck
Zones I & III

Not amenable to surgical exploration

Require special diagnostic and

radiographic studies to exclude injury

Zone II

More amenable to surgical exploration

Historically mandated surgical

exploration
Penetrating injuries - Chest
Should not be explored

Mediastinal box - cardiac injury

Tamponade

Tension pneumothorax

Massive hemothorax

>1500 mL or 200 mL/hr

surgical exploration
Penetrating injuries - Abdomen
Anterior abdominal wall

Can be exposed under LA

Violation of of muscle fascia

increases likelihood of peritoneal
injury

Posterior abdomen and flank

More musculature

Less likely intraperitoneal injury

Penetrating injuries - Toracoabdominal

Can cause damage to both

thorax and abdomen

Need to eval for both

Anterior - below nipple

Posterior - below tip of scapula

Penetrating injuries - Extremities
Examine peripheral pulses

GSWs can cause secondary

blast injuries to vascularature

Fractures

Reduce

If open - antibiotics and tetanus

Chapter 4 Outline (part 2)
Reasons for ICU admission

Respiratory insufficiency

Potential loss of airway

Hemodynamic instability

Decreased level of consciousness

Respiratory - Intubation
Indications

Difficulty breathing

Reduced GCS score (<8)

O2 Sat (<90%)

Respiratory Acidosis pH <7.25)

Hypercapnea (Paco2 >50 mm Hg)

Semi-elective intubation is always preferred

Respiratory - Ventilation
2 Main Goals:

Adequate oxygenation

O2 Sat > 92%

Increase FiO2 or PEEP

Adequate ventilation

Normal pH (PaCO2)

↑ minute ventilation: ↓PaCO2: ↑ pH

↓ minute ventilation: ↑PaCO2: ↓ pH

Respiratory - Liberation from vent
Adequate ventilatory and oxygenation?

Trial of unassisted breathing

Rapid shallow breathing index (RSBI)

RSBI = RR(breaths/min)/TV(L)

RSBI < 80 may be able to liberate

Mental status to protect airway

Underlying condition resolved?

Respiratory - ARDS
Acute Respiratory Distress Syndrome Clinical findings

inflammatory state in the lungs Decreased oxygenation

alveolar capillary leak Infiltrates on chest xray

accumulation of exudate in alveoli Require ventilation

Cardiovascular - Shock
Cellular and tissue hypoxia leading to end
organ damage

4 Types

Hypovolemic

Cardiogenic

Neurologic

Septic

Trauma patients may have more than one

category
Cardiovascular - SIRS and MODS
Systemic Inflammatory Response Syndrome (SIRS)

Exuberant pro-inflammatory response

Multiple Organ Dysfunction Syndrome (MODS)

SIRS + organ dysfunction

1 system = 40% mortality, 4 systems = 80% mortality

Cardiovascular - Afib
Propensity for dysrhythmia may be unmasked by

Catecholamine release

Electrolyte and fluid levels

Loss of atrial kick well tolerated

May be a problem with non-compliant LV (HTN)

Afib with Rapid Ventricular Response (RVR)

Atrial rate approaching 300 bpm

2:1 or 3:1 block = ventricular rate 150 or 100 bpm

Pharmacological tx for rate control (CCBs, Beta

Blockers, amiodorone, digoxin)
Gastrointestinal - Adynamic Ileus

Inadequate peristalsis

May require IV or transdermal

medication and nutrient delivery
Gastrointestinal - Acalculous
Cholecystitis
High mortality

Fever, emesis, RUQ pain

Ultrasound or CT

Cholecystectomy or
Cholecystotomy
Gastrointestinal - Abdominal
Compartment Syndrome
Abdominal Compartment Syndrome (ACS)

Increased intrabdominal pressure

↓Urine output

Hypotension

↑ Airway pressure

24-48 hrs s/p trauma and resuscitation

Decompressive laparotomy
Hematologic
Issues due to acute blood loss

Acute anemia

Exacerbates tissue hypoxia

RBC transfusion

Coagulopathy

Loss of platelets and clotting factors

Transfusion of FFP, cryoprecipitate,

platelets
Acute Renal Failure - Prerenal

Decreased perfusion of glomeruli

Usually due to hypovolemia

Acute Renal Failure - Intrinsic

Insult to renal parenchyma

Acute tubular necrosis

Myoglobin

IV contrast dyes

“muddy brown casts”

Acute Renal Failure - Postrenal

Obstruction of the urinary outflow

tract

Damage to ureters and/or

urethera
Endocrine - Acute Adrenal
Insufficiency
Inadequate response of the
hypothalamic-pituitary-adrenal
axis to acute stress

Should suspect if patient does not

respond to volume resuscitation
and vasoactive agents

ACTH stimulation test

Treat with replacement therapy

Endocrine - Intensive insulin therapy

Goal is to maintain glucose

80-110 mg/dL

Hyperglycemia correlated to
increased mortality and infections

Hyperglycemia can be due to

diabetes or metabolic stress
Fluids, electrolytes, nutrition
Monitor electrolytes at least daily

Nutrition

Basal energy expenditure (BEE)

BEE (kcal/day) = 25 × weight in

kg

Protein requirements may

double to 2g/kg/day
Infectious disease - Fever
5 “Ws”

Wind (pulmonary conditions)

Water (urinary tract infection)

Wound (infections at the surgical

site)

Walk (DVT, PE)

Wonder drugs (drug-related fever)

Infectious disease - Pneumonia
Ventilator-associated pneumonia

Directly related to intubation

time

Bronchoscopy with
bronchoalveolar lavage

Use specific antibiotics when

possible
Infectious disease - wound infection

Primary therapy is opening,

draining, and aggressive
debridement

Antibiotic therapy is considered

as an adjunct
Pain control
IV fentanyl is drug of choice

Rapid onset

Short half-five

Sedation - anxiolytic

Benzodiazepines

Propofol - intubated pt only

Tubes and lines - General
“Less plastic is better”

Foley

ET tube

ICP monitors

A lines

IV line
Tubes and lines - Arterial lines
Invasive arterial line

Radial, axillary, or femoral

Allow frequent blood gas

Real time BP

Placed under LA at bedside

Rarely a source of sepsis

Tubes and lines - invasive venous
access
internal jugular, subclavian, or
common femoral veins

Triple lumen catheter

Frequent blood draws, drug

infusion, and central venous
blood pressure
Prophylaxis
GI - Stress ulcers

cytoprotective agent sucralfate

H2-receptor antagonist

DVT

Heparin

Compression