Page 1601 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

1120 PART 10: The Surgical Patient

The hallmark of CNS injury is a change in the level of consciousness. Until adequate radiologic assessment is complete, these patients should
Therefore, it is essential that the level of consciousness be determined be moved with caution by log-rolling, and any rotation, flexion, or
early so that repeated assessment will detect any changes over time. extension of the thoracolumbar spine should be avoided. Spine boards
The mini neurologic assessment consisting of the Glasgow Coma Scale should be used only for transporting the patient and prolonged position-
score, the pupillary response and any lateralizing signs documents the ing of the patient on the spine board should be avoided because of the
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initial level of consciousness. Deterioration from this base line level of risks of decubitus ulcers. 35
consciousness signifies the need for further intervention including CT All multiply injured patients should have (1) large-bore intravenous
imaging and possible craniotomy. access, (2) a gastric tube to decompress the stomach and monitor for
The brain is very sensitive to hypoxia and hypoperfusion, and one of evidence of upper gastrointestinal hemorrhage, and (3) a transurethral
the most common causes of a depressed level of consciousness in the Foley catheter for monitoring urine output, unless contraindicated
multiply injured patient is uncorrected hypovolemia resulting in hypo- by the presence of a urethral injury. Patients in whom urethral injury
perfusion and cerebral hypoxia. Therefore, overall resuscitative mea- may be present include those with a major pelvic fracture, perineal and
sures aimed at maintaining vascular volume and arterial oxygenation are scrotal ecchymosis, or bleeding through the urethral meatus, and those
of prime importance in the treatment of a patient with a possible head in whom a high-riding, boggy prostate is found on rectal examination.
injury. 28,29 Volume restriction as a primary goal, with the aim of decreas- If these signs are present, a urethrogram should be performed; only if
ing intracranial pressure and cerebral edema, is inappropriate in the the results are normal should the Foley catheter be inserted per urethra.
hypovolemic head-injured patient. In fact, this approach is more likely to Suspicion of a basal skull fracture (CSF rhinorrhea or otorrhea, Battle
aggravate the head injury and increase cerebral edema and intracranial sign, hemotympanum or “raccoon” eyes) is a contraindication to inser-
pressure. The key features of initial assessment and resuscitation of the tion of a gastric tube 36,37 through the nasal route. Gastric decompression
brain-injured patient are to prevent secondary brain injury due to hypo- in this situation should be achieved by orogastric intubation.
perfusion and hypoxemia, control of cerebral edema, and identification If a rectal examination has not already been conducted to rule out
and evacuation of significant mass lesions based on careful clinical and a urethral injury prior to the insertion of a urethral catheter, it should
CT scan assessment under the guidance of a qualified neurosurgeon. be done as part of the complete assessment. Although the utility of the
■ FRACTURE STABILIZATION rectal examination in the trauma patient has been questioned, it not
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only assesses the integrity of the rectum, but provides information on the
Although the most dramatic injury in the multiply injured patient is presence of blood in the gastrointestinal tract, the possibility of extrar-
frequently the mangled limb resulting from major fractures, fractures as ectal pelvic injury (bony as well as soft tissue, eg, injury of the prostatic
such do not pose an immediate threat to life, and therefore are gener- urethra), and the status of rectal sphincter tone, which may be abnormal
ally lower in our list of management priorities. However, the second- in patients with spinal cord injury. During this phase of the assessment,
ary effects of fractures may have high priority. For instance, massive potentially life-threatening injuries or injuries that are likely to produce
hemorrhage associated with a fracture will require direct control of the morbidity and require correction on a nonurgent basis are detected. If
hemorrhage where possible, aggressive early fluid resuscitation, reduc- the techniques of inspection, percussion, palpation, and auscultation are
tion of the fracture, and in the case of massive hemorrhage from pelvic used appropriately, injuries such as simple pneumothoraces, uncompli-
fractures, the use of such techniques as external fixation. If the source of cated fractures, and soft tissue wounds are detected and managed.
the shock is suspected to be the pelvic fracture, with failure to improve Reduction and stabilization of uncomplicated fractures are conducted
after fluid infusion and external fixation, consideration must be given to once the life-threatening injuries have been treated. The tetanus immu-
retroperitoneal packing or angiography with a view to possible angio- nization status of the patient should be determined, and appropriate
embolization of identified bleeding from pelvic vessels. 30-32 prophylactic measures instituted. The trauma flow sheet should be
Time is also of the essence in the management of fractures when completed, and the use of agents such as tetanus toxoid should be clearly
there is interference with the blood supply to the limb, as from spasm documented and must be available for continued reference during the
of the blood vessels or direct injury to the blood vessels adjacent to the patient’s stay in the ICU. It is at this point that subspecialty services such
fracture. Early assessment of neurovascular integrity and the correc- as plastic surgery and otolaryngology may be consulted.
to ensure limb salvage and to prevent rhabdomyolysis and compart- ■ REEVALUATION AND MONITORING THE PATIENT
tion of any abnormality are essential in the management of fractures
ment syndrome. Limb ischemia associated with the fracture should be Repeated examination of the trauma patient is important so that
initially treated by reduction of the fracture and immobilization. If this injuries that are not obvious at presentation may be diagnosed and
maneuver fails to restore perfusion, early surgical exploration with or treated appropriately. The mechanism of the injury should be carefully
without angiographic assessment should be considered. To improve the noted in the history, and a high index of suspicion is required so that
chances of saving the limb, the period of limb ischemia should be less occult injuries are not missed. Patients who are relatively stable but
than 4 to 6 hours. Therefore all efforts should be made to obtain an early who have been involved in a collision in which there is an associated
diagnosis and definitive repair of the vascular injury associated with a fatality must be monitored very carefully in an ICU setting, since it
fracture. The possibility of compartment syndrome should be kept in must be assumed that they were exposed to the same force and energy
mind, particularly after perfusion has been reestablished to a previously transfer as the dead victim. Such patients may have temporarily con-
ischemic limb. 33,34 tained hematomas in the spleen, liver, or retroperitoneum or around
■ DETAILED SYSTEMATIC ASSESSMENT AND DEFINITIVE CARE major vascular structures. These patients can decompensate abruptly
with sudden spontaneous hemorrhage. Slowly progressive tachycardia,
Once the initial rapid assessment and resuscitation of the patient has hypotension, a fall in hemoglobin concentration, or any worsening
been completed, an anatomic systematic in-depth assessment is con- of abdominal findings, such as increasing pain or signs of peritoneal
ducted, beginning with the head and ending with the lower extremities. irritation, should warrant aggressive investigation and consideration
The multiply injured patient must be completely undressed to allow a of intervention, including surgical exploration. For these high-risk
complete physical examination. This includes assessment of the back patients, approximately 4 to 6 U of blood should be available at all times
and requires careful log-rolling of the patient to visualize the back while in the early phase of treatment. An unexplainable fall in hemoglobin
protecting the spinal column. Imaging of the thoracolumbar spine concentration must be considered a sign of continued hemorrhage, and
should be considered in unconscious patients or those with major torso any sudden increase in heart rate or decrease in blood pressure must be
trauma with or without neurologic deficit, and in those in whom the considered signs of major hemorrhage. The source of this hemorrhage
mechanism of injury suggests the possibility of spinal column injury. should be identified promptly and treated appropriately. A more subtle

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