Intensive care unit management of the trauma patient

Intensive care unit management of the trauma patient

Author
C Crawford Mechem, MD, FACEP
Section Editor
Rosemary Kozar, MD
Deputy Editor
Kathryn A Collins, MD, PhD, FACS
Last literature review version 18.2: May 2010 | This topic last updated: December 31, 2009 (More)

INTRODUCTION — The intensive care unit (ICU) management of patients with traumatic injuries presents a variety ofchallenges. Patients usually have been evaluated by an emergency clinician and/or a general or trauma surgeon prior to transfer to the ICU. However, patients remain at risk for deterioration due to unrecognized injuries, iatrogenic complications of initial diagnostic studies and therapy, and general complications of critical care.

Management of traumatically injured patients who have been admittedto the ICU is reviewed here. Evaluation and treatment prior to ICU admission are discussed separately.

INITIAL ASSESSMENT — Initial and ongoing assessment are critical to appropriate ICU care of trauma patients. This is especially true in patients who have undergone damage control surgery or whose injuries are being managed non-operatively. Damage control surgery has become common in the pastdecade. It involves surgical correction of immediately life-threatening injuries followed by transfer to the ICU for ongoing resuscitation. Acidosis, hypothermia, and coagulopathy are corrected. The patient is then taken back to the operating room for definitive surgery.

While damage control surgery has been shown to save lives, it also results in sicker patients being cared for by intensivecare specialists [1-3]. Non-operative management of hemodynamically stable victims of both penetrating and blunt abdominal trauma has also become more common in recent years. This practice is associated with shorter ICU stays and improved outcome. However, it also requires a greater commitment to ongoing patient assessment and monitoring [4-6]

The trauma patient transferred to the ICU from theemergency department or operating room warrants full reassessment by the receiving medical personnel in accordance with advanced trauma life support (ATLS) guidelines. Immediate attention should be given to the airway, breathing, and circulation [7,8].

* Breath sounds should be evaluated, and, if the patient is intubated, the position of the endotracheal tube should be assessed to insure thatit has not become dislodged during transport.
* The patient's cardiovascular status should be evaluated, the patency of peripheral and central intravascular catheters confirmed, and the total volume of intravenous fluids administered since presentation established.
* The patient's neurologic status should be fully documented.
* The patient should be completely exposed, at leastbriefly, to evaluate external injuries. The value of this tertiary survey cannot be overstated; it is crucial to exclude any occult or iatrogenic injuries immediately to prevent excess morbidity and mortality.

Past medical history — Patients with serious traumatic injuries often are unable to give details of their past medical history upon presentation to the emergency department, and collateralsources of information (eg, family or friends) may not have been available at that point. It may therefore become incumbent upon the ICU clinician to obtain additional information about past medical history, outpatient medications, allergies, and any history of drug or alcohol use.

Ongoing drug or alcohol dependence is present in over 30 percent of patients admitted for complications of trauma[9]. These individuals have an increased risk of complications during hospitalization, particularly those related to pneumonia and other infections. They also are at risk for withdrawal syndromes, which may be difficult to recognize in the setting of ongoing blood loss or closed-head injury [10,11]. The possibility of an intentional drug overdose prior to injury should also be considered....