Chapter 53: Posttrauma Care

KEY POINTS

1. Survival outcomes in trauma patients over the last 30 years have largely resulted from the adoption of the damage-control strategy than from all other improvements in trauma care combined.

2. Damage-control strategy involves an abbreviated laparotomy, surgical control of arterial bleeding, temporary control of enteric spillage, stabilization of long bone fractures, abdominal packing to control venous bleeding, and temporary wound closures to accommodate swelling and to avoid compartment syndrome.

3. In severely injured trauma patients, the initial hypotension is a consequence of uncontrolled bleeding. Oxygen-carrying capacity must be maintained with red blood cells, the coagulation system must be supported with plasma and platelets, and after meeting those 2 objectives, any remaining hypovolemia can be corrected with balanced crystalloid.

4. Endpoints of resuscitation can monitor regional organ-specific function (eg, urine output, ST-segment abnormalities, and mental status), or global perfusion (lactate, base deficit).

5. An acute traumatic coagulopathy can be observed within 30 minutes postinjury. Thromboelastography-guided resuscitation, using targeted platelets, plasma, cryoprecipitate, or other directed therapy may be the optimal strategy once the surgical bleeding has been addressed.

6. Abdominal compartment syndrome is important to recognize in the resuscitation of the trauma patient. Definitive treatment is surgical decompression of the abdominal fascia. Intraperitoneal dialysis with a hypertonic glucose solution is a promising intervention to optimize bowel wall perfusion, minimize inflammation, and more rapidly decrease edema.

7. Traumatic brain injury frequently accompanies major blunt trauma. Managing elevated intracranial pressure (ICP) in the setting of severe bleeding, hypovolemia, and shock is particularly challenging. In the presence of elevated ICP, optimizing cerebral perfusion pressure becomes the priority.

8. Corticosteroids for spinal cord injury are no longer recommended.

9. Pulmonary contusion is unique to trauma and can occur directly from blunt injury or indirectly from the blast effect and pressure wave created by a projectile passing through the tissue.

10. Blunt cardiac injury following thoracic trauma is a potentially lethal syndrome. In extreme cases, it can lead to cardiac rupture, valvular dysfunction, or coronary occlusion. Mortality is typically from malignant arrhythmias.

11. Mechanical limb compression, prolonged ischemia, blast effect, and vascular insufficiency are all factors which can contribute to delayed myonecrosis.

12. Damage-control laparotomy with an open abdomen is not necessarily a contraindication to enteral nutrition.

13. Trauma patients are at elevated risk for posttraumatic stress disorder, and early screening and treatment can begin during their ICU stay.

14. Physical and occupational therapy availability for trauma patients in the ICU enhances their recovery, and eases the transition to their next phase of care.