Michael Avant, M.D.
The Children’s Hospital of GHS
OVERVIEW
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ER to ICU Transition
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Early Management Priorities – the First 48 hours
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Organ System Support
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Complications
THE FIRST 48 HOURS
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Communication
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Damage Control Surgery
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Ongoing Resuscitation
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Organ System Support
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Missed Injuries
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Manage/Prevent Complications
Communication: Yes, It’s really
that important !
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Joint Commission says:
 10% of trauma fatalities preventable
 67% of these due to communication errors
 Patient handoff critical
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The Handoff (Miami data)
 24% had missing injuries in ICU record
 50% had discrepancies in documentation
Communication: ER to ICU Handoff
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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
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General
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Neurologic
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Respiratory
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Cardiovascular
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Hematologic
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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
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ICU Trauma Care: Respiratory
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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
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ICU Trauma Care : Sedation
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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
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Longer duration
 Lorazepam
 Morphine
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0.1 mg/kg
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
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 Hypoxia, hypotension, ischemia
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Avoidance of secondary injury – Critical!
 First 24 – 48 hours
 Single episode of hypotension doubles mortality
 4x risk of poor neurologic outcome
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Goals
 > 90% O2 sat or PaO2 > 60 mmHg
 Systolic BP > 75th %
 PaCO2 30 – 40 mmHg
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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
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Neurologic : Seizure Prophylaxis
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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
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Benzodiazepines
Keppra (levetiracetam)
Fosphenytoin
barbituates
Neurologic : ICP Control
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ICP Monitoring
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GCS < 8
Abnormal head CT
Abnormal neuro exam
Sedation
Maintain ICP < 20 cm H20
Osmolar therapy
Sedation /analgesia/NMB
CPP management
Induced hypothermia ( 32 – 35 Co)
Consider reimaging
Decompressive craniectomy
ICP Control : Osmolar Therapy
Mannitol
Hypertonic Saline (3%)
Long history of use
Recent clinical use
Little clinical data
Substantial recent data
Rapid onset
Sustained response
0.25 – 1 grm/kg
3 – 5 cc/kg and/or 0.1-1 cc/kg/hr
Diuresis & hypovolemia
Hyperchloremic acidosis,
thrombosis if Na+ >170
Follow serum Osm
Follow serum Na+ (< 170)
Out of favor (except emergent)
Currently recommended
Hemodynamic Support
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Avoid hypotension !!
Lactate and/or base deficit monitoring
 Superior to BP & UOP monitoring
 Keep lactate < 1.5 & BD > -2
 High mortality if acidosis remains > 48 hours
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CPP Management (CPP =MAP – ICP)
 Adults
 6 – 17 yo
 0 – 5 yo
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50 – 60 mmHg
> 50 mm Hg
> 40 mm Hg
Consider blunt cardiac injury
 Arrhythmia
 Unresponsive hemodynamics
ICU Trauma Care: Hematologic
Aggressive use of blood products
 Minimize crystalloid
 Massive transfusion protocol
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 1:1:1 PRBC:FFP:Platelets
 PT/PTT vs. TEG/ROTEM monitoring
New data on fibrinolysis
 Alternative therapies
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 Tranexamic acid
 rFVIIa
 Fibrinogen concentrate
Fibrinolysis
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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
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Fractures – facial, extremity
Spinal
Vascular
Abdominal
Risk
 Altered mental status or sedation
 Lack of early symptoms
 Unresponsive to resuscitation
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Tertiary survey
Family communication
ICU Trauma Care: Complications
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Hypothermia – coagulopathy
Transfusion Related Acute Lung
Injury(TRALI)
Transfusion Associated Circulatory
Overload (TACO)
Rhabdomyolysis
Hyper/ Hypo – kalemia
Hypocalcemia
Intra-abdominal hypertension
 Bladder pressure monitoring
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Infection
FROM ER TO ICU – SUMMARY
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Communication
Monitor need for ongoing resuscitation
 Lactate/Base deficit
 Minimize crystalloid
 1:1:1 Transfusion ratio
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Lung protective strategy
Avoid hypotension, hypoxia, ischemia
Hypertonic saline recommended over Mannitol
Be aware of fibrinolysis
ICP control guidelines
Tertiary survey
Family communication