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Year : 2008  |  Volume : 52  |  Issue : 3  |  Page : 340-341 Table of Contents     

Trauma and Intensive Care

Senior Prof. & Head, Department of Anaesthesiology, R.N.T.Medical College, Udaipur (Raj.), India

Date of Web Publication19-Mar-2010

Correspondence Address:
Pramila Bajaj
25, Polo Ground, Udaipur (Raj.)
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Source of Support: None, Conflict of Interest: None

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How to cite this article:
Bajaj P. Trauma and Intensive Care. Indian J Anaesth 2008;52:340-1

How to cite this URL:
Bajaj P. Trauma and Intensive Care. Indian J Anaesth [serial online] 2008 [cited 2020 Sep 22];52:340-1. Available from: http://www.ijaweb.org/text.asp?2008/52/3/340/60648

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 [1] .

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 [2] .

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 [3],[4] .

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 Top

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 [5] . In particular, patients receiving older blood had a sig­nificantly longer ICU stay, although this did not trans­late into higher mortality [6] . 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:

  1. Optimal resuscitation fluids
  2. Alternative oxygen carrier,
  3. Direct chemical haemostats
  4. Activated blood coagulation factor VII

   Prone Ventilation For Severe Lung Confusion Top

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 [7] , for severe hypoxaemia in COPD patients [8] and for early acute lung contusion and aspiration [9] .

Guerin [10] 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:

  • Abolish tidal expiratory flow limitation
  • Improve oxygenation of localised infiltrates
  • Allow for reducing positive end-expiratory pressure level
  • Reduce lung stress and strain
Voggenreiter et al. [11] , 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.

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 [12] .

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 [13] .

In animal studies, Valenza et al. [14] 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 [15] .

Very importantly, Gattinoni et al. [16] 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.

   References Top

1.Vincent JL, Marini JJ, Pinsky MR. Intensive care and emergency medicine: progress over the past 25 years. Chest 2006;129:1061-1068.  Back to cited text no. 1      
2.Martin M, Demetriades D, Rhee P. The decreasing inci­dence and mortality of ARDS after injury: a 5-year obser­vational study. J Trauma 2005;59:1107-1113.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]  
3.Coimbra R. ICU Technology: what works? what does not? In: Mattox K (ed) Trauma and critical care, Las Vegas Course manual 2006:317-324.  Back to cited text no. 3      
4.Rivers E, Anders DS, Powell D. Central venous oxygen saturation monitoring in the critically ill patients. Curr Opin Crit Care 2003;7:204-211.  Back to cited text no. 4      
5.Hess JR, Zimrin AB. Massive blood transfusion for trauma. Curr Opin Hematol 2005; 12:488-492.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]  
6.Murrell Z, Klein SR. The effect of older blood on mortal­ity, need for ICU care and the length of ICU stay after major trauma. Am Surg 2005;71:781-785.  Back to cited text no. 6  [PUBMED]    
7.Mentzelopoulos SD, Zakynthinos SG. Static pressure volume curves and body posture in severe chronic bron­chitis. Eur Respir J 2006;28:165-174.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]  
8.Reignier J, Lejeune O, Renard B, et al. Short-term effects of prone position in chronic obstructive pulmona'ry dis­ease patients with severe acute hypoxemic and hyper­capnic respiratory failure. Intensive Care Med 2005;31:1128-1131.   Back to cited text no. 8  [PUBMED]  [FULLTEXT]  
9.Easby J, Bonner SM. Prone ventilation following wit­nessed pulmonary aspiration: the effect on oxygenation. Intensive Care Med 2003;29:2303-2306.  Back to cited text no. 9      
10.Guerin C. Ventilation in the prone position in patients with acute lung injury/acute respiratory distress syn­drome. Curr Opin Crit Care 2006;12:50-54.  Back to cited text no. 10      
11.Voggenreiter G, Aufmkolk M, Nast-Kolb D. Prone posi­tioning improves oxygenation in post-traumatic lung in­jury. J Trauma 2005;59:333-341.  Back to cited text no. 11  [PUBMED]  [FULLTEXT]  
12.Sawhney A, Kumar N. Prone versus supine position in mechanically ventilated children: a pilot study. Med Sci Monit 2005;11:235-240.  Back to cited text no. 12      
13.Tsuchida S, Kavanagh BP. Atelectasis causes alveolar injury in non-atelectatic lung regions. Am J Respir Crit Care Med 2006;174:279-289.  Back to cited text no. 13  [PUBMED]  [FULLTEXT]  
14.Valenza F, Gattinoni L. Prone position delays the pro­gression of ventilator-in duced lung injury in rats: does lung strain distribution playa role? Crit Care Med 2005;33:361-367.  Back to cited text no. 14  [PUBMED]  [FULLTEXT]  
15.Oczenski W, Hormann C, Keller C. Recruitment manoeuvres during prone positioning in patients with acute respiratory distress syndrome. Crit Care Med 2005;33:54-61.  Back to cited text no. 15      
16.Gattinoni L, Pesenti A. Decrease in PaC02 with prone position is predictive of improved outcome in ARDS Crit Care Med 2003;31:2727-2733.  Back to cited text no. 16      


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