Polytrauma
Polytrauma
Shock
Shock
Alimentation
Alimentation
Rhabdomyolysis
Rhabdomyolysis
Comp
. Syndr
. u.
Comp.
Syndr.
u. ACS
ACS
Traumatic
Traumatic brain
brain injury
injury
Polytrauma
Syndrome of multiple injuries exceeding a
defined severity (ISS 17), with
consecutive systemic reactions which may
lead to dysfunction or failure of remote,
primarily not injured, organs or vital
systems.
Polytrauma
Surgical
Surgical systemic
systemic disease
disease
pathophysiological understanding
complete resuscitation
correct triage
negotiated titration of care
Pathophysiology
Wound = inflammatory focus
Hypoxic zone
Dead
Tissue
Endocrine organ
Release of mediators
Systemic reaction
Polytrauma
Systemic
Systemic reactions
reactions
Neuro-endocrine responses
Stimulation neuro-immune axis
Metabolic responses
SIRS
Shock
I/R injury
Trauma
Systemic Inflammatory
Response Syndrome
(SIRS)
physiologic
reversible
Damage healing
Death
pathophysiologic
irreversible
Systemic Inflammatory
Response Syndrome (SIRS)
Temperature >38C or <36C
Heart beat >90/min.
Respiration >20/min. or PaCO2 <4,3 kPa or ventilated
Leukocytes >12000 cells/mm2 or <4000 cells/mm2 or
>10% juvenile Granulocytes
Society of Critical Care Medicine Consensus Conference 1992
SIRS - Definition
2 or more of the following 4 criteria:
Temperature:
>38.8C or <36.0C
Heart rate:
>90/min
>12.000/l or
<4000/l or
>10% juvenile PMNL
Hypoxia
Shock
Infection
Sepsis
SIRS Trauma
Hypotension
Burn
Injury
Second
Second
Hit
Hit
First
First
Hit
Hit
Late
Late
MOF
MOF
vulnerable
Tissue inury
+ shock
SIRS
Recovery
Recovery
Early
Early
MOF
MOF
Primary objectives:
Survival
Normal cognitive functions
Avoid sepsis
Best available function
Killer
Exsanguinating hemorrhage
Tentorial herniation
Hypoxia
Sepsis
Primary survey
ATLS
Resuscitation
oxygenation, perfusion
Evaluation
vital functions?
Response ?
?
secondary survey
Life saving
surgery
Damage control
Bailout surgery
Scoring
ICU
Damage control
The term Damage control is coined by
the US Navy and refers to keeping
afloat a badly damaged ship by
procedures to limit flooding, stabilize
the vessel, isolate fires and explosions
and avoid their spreading. These
measures permit damage assessment and
gain time to establish plans for
definitive salvage.
Rationale
Saving life by deferring
repair of anatomical
lesions and focussing on
restoring physiology.
Definition
Rapid abbreviated laparotomy to
stop hemorrhage and peritoneal
soiling and staged sequential repair
after ongoing resuscitation and
recovery from hypothermia,
coagulopathy, and acidosis.
10
11
Damage control
BailoutBailout-procedure
procedure::
Aborted termination of surgery in a
patient at imminent risk of death.
Preemptive intervention:
intervention:
Calculated early decision to
accomplish definitive correction of
injuries in staged sequential
procedures.
12
13
Damage
control
Control of
Damage
done by lazy,
lingering-surgeons !
14
15
Contamination control:
Ligation, suture or stapling of
bowels
Resection of damaged segments
with clips, clamps, or staples
Anastomoses and stomas have to
be deferred
16
Stage 3 Physiological
restoration in the ICU
Rewarming
Correction of coagulation
Correction of acidosis
Optimisation of oxygen delivery
Monitoring and avoidance of an
Abdominal Compartment Syndrome
17
Stage 5 Reconstruction of
abdominal wall
Direct closure only without gut
distension
After fascial retraction subsequent
gradual vacuum-assisted closure
Mesh repair
In an hostile abdomen: gauze packing,
secondary granulation and skin grafting
Secondary plastic reconstruction
18
VACVAC
-Therapy and polytraumatized patients
19
Control of Hemorrhage
Packing
Source control
Dbridement
External fixator
V.A.C.- Vacuum Sealing
20
True pelvis
Paracolic gutters
Ethizip + second look
21
Rationale of Packing
Main source of bleeding:
venous plexus !
Stable pelvic ring:
Abutment for tamponade !
Packing pelvis and paracolic gutters
Abdominal wall remains open
Monitoring ACS
22
Trauma
Abdomen 204
penetr.
71
blunt
133
Pelvis
Abdomen
+ Pelvis
Isolated /
Packing
Multiple
ACS
Survival
39/32
21/112
17 %
16 %
3%
5%
90 %
76 %
63
7/56
19 %
6%
80 %
44
0/44
25 %
9%
57 %
DC Injured Limbs
Dbridement, Fasciotomies
External fixator
Temporary intraluminal vascular shunts
Epigard, Vacuum-Sealing
23
"Damage control"
Hyper-inflammation
"Window of
opportunity"
Immunosuppression
No surgery!
Recovery
Secondary reconstructive
surgery
Day 1
Day 2-3
Day 5-10
Week 3
24
Shock
Definition
Reduced tissue perfusion leading to
generalized cellular hypoxia with a
persistent discrepancy between
delivery and consumption of oxygen.
25
Oxygen delivery
Intracellular ATP
Cell dysfunction
Cell death
reversible
irreversible
Traumatic-Hemorrhagic
Traumatic-Hemorrhagic shock
shock
26
Pathophysiological
alterations
Loss of fluid
Pump failure
Decreased vascular
resistance
Hemorrhagic shock
Symptoms
Symptoms
Tachycardia
Late symptoms in
young patients !!
Hypotension
Central venous pressure
Hemoglobin
27
TraumaticHemorrhagic shock
Blood
Blood loss
loss
<10%
complete compensation
10% - 25%
cardiac output
>25%
Trauma-Cardiogenic
shock
Tension pneumothorax
Myocardial contusion
Cardiac tamponade
Vena caval obstruction
28
Cardiogenic shock
Symptoms
Symptoms
Hypotension
Tachycardia
Arrhythmia
Central venous pressure
Paradoxic pulse
Spinal shock
Symptoms
Symptoms
Hypotension
Pulse normal or decreased
Pulse feels strong
Skin dry and warm
29
Emergency treatment
Correction of oxygen availability
Fluid
Fluid replacement
replacement
Ventilation
Ventilation therapy
therapy
Vasoconstrictive
Vasoconstrictive and
and
cardiotropic
cardiotropic agents
agents
(g%)
1000 = 5.250 x 95
x 15
x 1.34
300 = 3.500 x 64
x 10
x 1.34
Oxygen debt !
Nunn JF, FreemanJ. Anaesthesia 1964;19:206
30
Alimentation
31
Disease Process
Change in
Metabolic
Activity (%)
100
50
50% Burn
20% Burn,
Infection,
Multiple Trauma
Long Bone Fracture
Normal
Postoperative
Flow phase
The body tries
to maximize gluconeogenesis
from all available sources !
32
Glucose the
sole source for energy
PMNL
RBC
Renal medulla
Bone marrow
RES
Neurons
Fat
Fat
Source
Source
Triglyceride
Ketosis
Ketosis
Liver
Liver
Ketone
Bodies
Nonpreferred
Nonpreferred
Glucose
Glucose
Users
Users
(eg.
(eg. kidney,
kidney,
heart,
heart,
muscle
muscle
Glycogen
Glycogen
Glycerol
Lean
Lean Body
Body
Mass
Mass
Amino
Amino Acid
Acid
Stores
Stores
Amino
Acids
GluconeoGluconeogenesis
genesis
Urinary
Nitrogen
Lactate
Lactate
Glucose
Preferred
Preferred
Glucose
Glucose
Users
Users
(eg.
(eg. Brain,
Brain,
RBC)
RBC)
33
Muscle catabolism
Aminoacids:
substrate for gluconeogenesis
in the liver
Byproduct urea:
increased level of urinary urea
nitrogen
34
Rhabdomyolysis
Rhabdomyolysis
Metabolic disturbances
acute renal failure (ARF)
35
Muscle injury
Trauma-mechanical/thermal
I/R-injury
Crush
Seizure
Drug abuse
Malignant hyperthermia
Symptoms
Cramping pain
Progressive weakness
(calves / lower back)
Discoloration of urine
36
Release
Purines (uric acid)
Sulfur-containing protein+hydrogen
(anion gap acidosis)
Creatine (creatinine+BUN)
Myglobine
Release
Aldolase
LDH
sGOT
Creatine-Kinase (CK)
CK-MB (7%)
37
Myoglobine
Not highly protein bound
Filtered at the glomeruli
50 g/L color visible in water
>100 mg/L color visible in urine
Serum concentrations >>>25 mg/L
>25 mg/L hemolysis
Myoglobine converted to
ferrihemate
toxic and precipitation
38
sodium + calcium
fluid
potassium + phosphate
Electrolyte
Electrolyte ++ fluid
fluid shifts
shifts
Severe
Severe hypovolemia
hypovolemia
Rhabdomyolysis
>>>ARF in 30 %
Hypovolemia
Free oxygen radicals
Plugging of renal rubuli
39
Therapy
Fluid resuscitation
Bicarbonate
(urine pH 8.0, serum pH 7.45)
Compartment
Compartment Syndrome
Syndrome
and
and
Abdominal
Abdominal Compartment
Compartment
Syndrome
Syndrome
40
Compartment Syndrome
Raised pressure
Within a closed space
Causing damage to its
contents
Due to decreased capillary
blood flow
Precondition
Ischemia-Reperfusion-Injury
Posttraumatic edema
Low MAP
41
Clinical Diagnosis
Unrelenting pain
Swollen, tense compartment
Painful muscle stretch
Sensory deficit
Muscle weakness
BUT:
BUT: Palpable
Palpable pulses
pulses !!
42
I
S
C
H
M
E
I
A
ATP
Edema
Microvascular
Injury
ATP-break-down
Xanthine
Dehydrogenase
OH-.
Fe2+
Conversion
Hypoxanthine
Xanthine
Xanthine
Oxidase
H2O2
O2-.
O2
Uric Acid
REPERFUSION
Trauma
Ischemia
Histamine
C3a / C5a
X.D.
Reperfusion
Hypoxanthine
Xanthine
O2
Xanthine Oxidase
Uric
Acid
O2.OH-.
Microvascular
Injury
43
Intraabdominal pressure
44
Pathophysiology of increased
abdominal pressure
Cardiopulmonary:
Thoracic pressure
Venous reflow
Preload
Systemic afterload
Cardiac output
Cardiac index
Diagnosis of ACS
Ventilation pressure >35mbar and
Horowitz-quotient
(PaO2/FIO2 )
>20kPa
45
Therapy
Decompression !
Ethizip
Secondary abdominal closure
Summary
Abdominal
Abdominal Compartment
Compartment Syndrome
Syndrome after
after
severe
severe abdominal
abdominal and
and pelvic
pelvic trauma:
trauma:
Incidence: 4.4 %
After tamponade: 8%
Organ failure: spleen 100%,
hemodynamics: 86%
Therapy: emergency decompression
Complications: intestinal ischemia
46
Conclusion
Monitoring of bladder pressure
Monitoring of organ functions
Secondary abdominal closure after
emergency laparotomy with
tamponade
47
Hypotension
Hypotension // hypoxemia
hypoxemia
Evacuation
Evacuation of
of intracerebral
intracerebral hemmorrhage
hemmorrhage
Early
Early fracture
fracture fixation
fixation
Fracture reconstruction: Window of opportunity
5-4
2-1
307
64
17
Early
30
40
47
Late
117
20
66
39
15
77
No hypotension
GOS %
48
2.
CNS assessment
Evacuation of EDH / SDH
ICP / pti O2 monitoring
Brain protection
3.
Stress
Stress
Fear
Fear
Pain
Pain
Endotoxin
Endotoxin
Temperature
Temperature
Cortex
Cortex
Hypothalamus
Hypothalamus
Pituitary
Pituitary
Blood
Blood volume
volume
Fluid
shifts
Fluid shifts
Hypoxemia
Hypoxemia
Hypercapnia
Hypercapnia
Acidosis
Acidosis
Receptors
Receptors
Brain
Brain stem
stem
Autonomic
Autonomic
centers
centers
Tissue
Tissue injury
injury
49
ICP - therapy
CBV
BWC
CSF
steal
50
Klassifikation SHT
Wach
Somnolent
Sopors
Komats
Symptomatik
1)
1) Psychopathologisches
Psychopathologisches Syndrom
Syndrom
Vigilanzstrung
Somnolenz
Sopor
Bewusstlosigkeit (Koma)
akustisch weckbar
Abwehr auf Schmerz
unerweckbar
cave: Abwehr auf Sz
kann erhalten sein
Orientierungsstrung
Gedchtnisstrung
Durchgangssyndrom
51
Symptomatik
2)
2) Neurologische
Neurologische Ausflle
Ausflle
Pupillenstrung (Weite und Lichtreaktion)
Reflexstatus
Motorik
Sensibilitt
Muskeltonus
Symptomatik
3)
3) Vegetatives
Vegetatives Syndrom
Syndrom
Schwindel
Brechreiz
Kreislaufinstabilitt
Strung der Wrmeregulation
52