|EVIDENCE BASED DATA
|Year : 2008 | Volume
| Issue : 3 | Page : 340-341
Trauma and Intensive Care
Senior Prof. & Head, Department of Anaesthesiology, R.N.T.Medical College, Udaipur (Raj.), India
|Date of Web Publication||19-Mar-2010|
25, Polo Ground, Udaipur (Raj.)
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Bajaj P. Trauma and Intensive Care. Indian J Anaesth 2008;52:340-1
Trauma patients who are admitted to an intensive care unit are among the most complex and labour-intensive patients, and they have prompted many of the advances in critical care  .
The practice of performing a CT scan of the chest to map atelectatic, recruitable and nonrecruitable zones has become more widespread, although there is still no consensus on the evaluation of optimal PEEP.
The incidence and the mortality from ARDS have probably declined  .
However, other than avoidance of barotrauma and volutrauma, and some improvement by prone positioning of gas exchange, no particular technology seems to have shown a clear decrease in mortality, which suggests that a combination of factors must be involved.
Careful attention to limiting antibiotic resistance by administering shorter and more focused courses might help with infection control. Eradication of infection and haemodynamic resuscitation has recently been flanked by new strategies on immunomodulation for better resistance to sepsis. Only activated protein C seems to have any clinical advantage at present, however, and only in patients with very severe sepsis.
The use of low doses of corticosteroid in most forms of shock seems to be replacing the initial aversion to this.
Haemodynamic monitoring has become less invasive, but probably more widespread for this very reason, and it centres around cardiac output monitoring and evaluation of the mixed venous oxygen saturation, both of which are measured by Edwards Medical Life Science Systems: the Flo Trac Vigileo measures the cardiac output through a standard arterial line, with no need for frequent intervention, and incorporates realtime cardiac output and systemic vascular resistance displays. The other measures the ScVO 2 , a good surrogate for the SVO 2 , and one of the preferred assessments of Early Goal-Directed Therapy, but its value has not been conclusively demonstrated in trauma , .
Cardiopulmonary resuscitation has recently seen some changes and improvements, such as the preference for amiodarone for treatment of ventricular arrhythmias, the use of vasopressin in combination with adrenaline during CPR, and mild hypothermia in the first 24 hours after resuscitation.
In neurosurgery, while intracranial pressure monitoring has become more widespread, more information can now be obtained through tissue oxygen monitoring or microdialysis techniques, while again some hypothermia may be protective to ischaemic brains.
Strict sugar control, steroids and vasopressin in septic shock are becoming better understood and regulated.
Leucodepleted blood, and blood components, judicious use of albumin, greater care with dialysis and diuretics, introduction of protocols and the concept of closed ICDs seem to have had an impact on mortality. Advantages may be derived from the concept of critical care without walls, and from outreach.
Large national studies have defined the roles of prone ventilation, supranormal oxygen delivery, transfusion requirements, ulcer prophylaxis and dopamine, etc.
| Developments in massive blood transfusion|| |
One of the aims of this research has been to limit the need for massive blood transfusions, since these lead to coagulopathy, acidosis and acute lung injury  . In particular, patients receiving older blood had a significantly longer ICU stay, although this did not translate into higher mortality  . Massive blood transfusions should therefore be avoided as far as possible; this means that the development of better haemostatic agents and devices to control blood loss must be considered a priority for major trauma.
The new technologies aimed at haemorrhage treatment fall into four groups:
- Optimal resuscitation fluids
- Alternative oxygen carrier,
- Direct chemical haemostats
- Activated blood coagulation factor VII
| Prone Ventilation For Severe Lung Confusion|| |
The advantages of prone ventilation as an early, prophylactic technique in the management of severe lung contusion and consolidation have recently been widely recognised. Until recently, prone position ventilation was recognised as one mode of ventilation that could improve ventilation, but not affect mortality, in patients with early acute respiratory distress syndrome (ARDS) and acute lung injury (ALI).
Recently, studies on the distribution of ventilation in the prone and the supine position have also made it an attractive option in other conditions than ARDS. It has been used successfully in patients with severe bronchitis  , for severe hypoxaemia in COPD patients  and for early acute lung contusion and aspiration  .
Guerin  recently analysed the reason for the discrepancy between the beneficial effects of the prone position and proven benefits on patient outcome. He found that the prone position could do the following:
Voggenreiter et al.  , in a prospective randomised trial on the effect of prone positioning on the duration of mechanical ventilation in polytrauma patients, showed that while the duration of ventilation did not differ significantly the prevalences of ARDS and pneumonia were significantly decreased, while one patient in the prone and three patients in the supine group died of multi-organ failure.
- Abolish tidal expiratory flow limitation
- Improve oxygenation of localised infiltrates
- Allow for reducing positive end-expiratory pressure level
- Reduce lung stress and strain
The significance of the above studies is all the more dramatic because alveolar recruitment is not thought to be as useful in primary as in secondary ARDS, while on the other hand prone ventilatiort seems to be effective particularly in case of chest CT-proven direct lung injury.
Paediatric and adult ventilation are quite different, but there are studies demonstrating improved gas exchange and oxygenation, and also reduction in mean airway pressure if utilised in the first few hours of ventilation  .
The prevention of atelectasis itself has been shown to decrease the incidence of ventilator-induced lung injury, by minimising distal airway injury away from the atelectatic regions  .
In animal studies, Valenza et al.  have demonstrated that prone positioning delays the progression of ventilator induced lung injury through a more homogeneous distribution of strain.
The fact that prone positioning itself helps with alveolar recruitment has been highlighted by studies showing the greatest advantage of recruitment after the patients had been prone for 6 hours  .
Very importantly, Gattinoni et al.  showed that patients who responded to prone positioning by decreasing their PaCO 2 had better survival at 28 days.
Current advances in trauma care have revolved mainly around saving valuable lives at all cost, in a scientifically valid but pragmatic fashion.
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