Michael Avant, M.D. The Children’s Hospital of GHS

OVERVIEW  ER to ICU Transition  Early Management Priorities – the First 48 hours  Organ System Support  Complications

THE FIRST 48 HOURS  Communication  Damage Control Surgery  Ongoing Resuscitation  Organ System Support  Missed Injuries  Manage/Prevent Complications

Communication: Yes, It’s really that important !  Joint Commission says: 10% of trauma fatalities preventable 67% of these due to communication errors Patient handoff critical  The Handoff (Miami data) 24% had missing injuries in ICU record 50% had discrepancies in documentation

Communication: ER to ICU Handoff  No standardization  Poorly defined responsibilities  Many distractions  Differing clinical priorities among services  Novice trainees  Medical hierarchy  Solutions Flattening of medical hierarchy Pilot/Co-Pilot model Trauma checklist

ICU TRAUMA CARE  General  Neurologic  Respiratory  Cardiovascular  Hematologic  Orthopedic

ICU Trauma Care : General  Hyperglycemia  Early enteral nutrition  Surgical timing  Infection surveillance – fever, wounds  Tertiary survey  Family communication  Ongoing monitoring  Prevention of complications & secondary injury

ICU Trauma Care: Respiratory  Lung protective strategy 6 – 8 ml/kg tidal volume Higher PEEP  Avoid hyperventilation in TBI  Avoid hypoxia  Pulmonary contusion  Consider TRALI & TACO  Sedation of mechanically ventilated pt

ICU Trauma Care : Sedation  Rapid acting, Short duration Propofol 2-3 mg/kg bolus followed by 75 – 200 mcg/kg/min infusion Midazolam 0.1 – 0.2 mg/kg Fentanyl 2 – 3 mcg/kg Ketamine 1 – 2 mg/kg  Longer duration Lorazepam 0.1 mg/kg Morphine 0.05 – 0.1 mg/kg  Infusions – propofol, midazolam, fentanyl  Neuromuscular blockade

ICU Trauma Care: Neurologic  Traumatic brain injury (TBI) most common cause of pediatric mortality  Primary vs. secondary injury Hypoxia, hypotension, ischemia  Avoidance of secondary injury – Critical! First 24 – 48 hours Single episode of hypotension doubles mortality 4x risk of poor neurologic outcome  Goals > 90% O 2 sat or PaO 2 > 60 mmHg Systolic BP > 75 th % PaCO 2 30 – 40 mmHg  Consider abusive head trauma

GOALS OF NEUROLOGIC SUPPORT  Avoid secondary injury  Mitigate cerebral edema & control ICP  Seizure control  Avoid hyperventilation  Support hemodynamics (CPP)  Avoid/Tx hyperthermia  Treat hyperglycemia

Neurologic : Seizure Prophylaxis  Seizure Risks – young age, pre-hospital hypoxia, non-accidental trauma, depressed skull fracture, penetrating injury, subdural hemorrhage  70% occur within first 24 hours  Non-convulsive seizures common in peds  Consider EEG monitoring  Treatment Benzodiazepines Keppra (levetiracetam) Fosphenytoin barbituates

Neurologic : ICP Control  ICP Monitoring GCS < 8 Abnormal head CT Abnormal neuro exam Sedation  Maintain ICP < 20 cm H 2 0  Osmolar therapy  Sedation /analgesia/NMB  CPP management  Induced hypothermia ( 32 – 35 C o )  Consider reimaging  Decompressive craniectomy

ICP Control : Osmolar Therapy MannitolHypertonic Saline (3%) Long history of useRecent clinical use Little clinical dataSubstantial recent data Rapid onsetSustained response 0.25 – 1 grm/kg3 – 5 cc/kg and/or cc/kg/hr Diuresis & hypovolemiaHyperchloremic acidosis, thrombosis if Na + >170 Follow serum OsmFollow serum Na + (< 170) Out of favor (except emergent)Currently recommended

Hemodynamic Support  Avoid hypotension !!  Lactate and/or base deficit monitoring Superior to BP & UOP monitoring Keep lactate -2 High mortality if acidosis remains > 48 hours  CPP Management (CPP =MAP – ICP) Adults 50 – 60 mmHg 6 – 17 yo> 50 mm Hg 0 – 5 yo> 40 mm Hg  Consider blunt cardiac injury Arrhythmia Unresponsive hemodynamics

ICU Trauma Care: Hematologic  Aggressive use of blood products  Minimize crystalloid  Massive transfusion protocol 1:1:1 PRBC:FFP:Platelets PT/PTT vs. TEG/ROTEM monitoring  New data on fibrinolysis  Alternative therapies Tranexamic acid rFVIIa Fibrinogen concentrate

Fibrinolysis  Definition: Process that restores flow to injured areas by dissolving fibrin clots formed by the coagulation cascade  Plasmin degrades Fibrin which worsens coagulopathy  Common early in severe trauma  CRASH-2 Study : Tranexamic acid should be given within 3 hours of injury  Tranexamic acid – inhibits fibrinolysis by blocking plasminogen(prevents degfradation of existing clots)  TEG monitoring ????

MISSED INJURIES  6.5% of all trauma deaths due to undiagnosed injuries  Types of missed injuries Fractures – facial, extremity Spinal Vascular Abdominal  Risk Altered mental status or sedation Lack of early symptoms Unresponsive to resuscitation  Tertiary survey  Family communication

ICU Trauma Care: Complications  Hypothermia – coagulopathy  Transfusion Related Acute Lung Injury(TRALI)  Transfusion Associated Circulatory Overload (TACO)  Rhabdomyolysis  Hyper/ Hypo – kalemia  Hypocalcemia  Intra-abdominal hypertension Bladder pressure monitoring  Infection

FROM ER TO ICU – SUMMARY  Communication  Monitor need for ongoing resuscitation Lactate/Base deficit Minimize crystalloid 1:1:1 Transfusion ratio  Lung protective strategy  Avoid hypotension, hypoxia, ischemia  Hypertonic saline recommended over Mannitol  Be aware of fibrinolysis  ICP control guidelines  Tertiary survey  Family communication