Welcome to Critical Care Congress 2024. I am Julie Valenzuela. I'm an assistant professor of surgery at University of Miami. I work as a trauma acute care and surgical critical care surgeon at Jackson Memorial Hospital, Rider Trauma Center in Miami, Florida. And I'll be discussing the management of trauma patients in the ICU. I have no disclosures. Our learning objectives are to review the priorities of ICU management for trauma patients. We're going to discuss the phases of care. And part of managing trauma patients is to understand the principles of damage control resuscitation and surgery. We'll discuss the endpoints of resuscitation and the pitfalls. So despite the systematic improvements in all phases of care for injured patients from pre-hospital care to the emergency room in the ICU, trauma remains a leading cause of death worldwide with early deaths primarily due to devastating central nervous system injuries like traumatic brain injuries and hemorrhage. The most common cause of preventable death is still exsanguination, which also contributes to the morbidity of CNS injuries. So I want to give you some case examples and a typical call night at our trauma center. I've got a young male with multiple gunshot wounds who has multiple ballistic wounds to the torso. He's hypotensive, tachycardic, peritonitic with a positive FAST. Oh, and by the way, EMS also tells you that he's had pulsatile bleeding from the thigh and they placed a tourniquet on. And you do notice that he's got a ballistic wound to the mid anterior thigh and posterior thigh. Massive transfusion is initiated and the patient's taken to the operating room where he's found to have several enterotomies, injuries to the spleen and kidney. He undergoes bowel resections. He's left in discontinuity. He has a spleen and kidney taken out. Then the leg is explored and the severed femoral vein is ligated and the femoral artery is shunted. Then we have an elderly female who's a restrained passenger involved in a motor vehicle accident. Her imaging reveals that she has multiple refractors, a small right hemothorax, a grade three, four liver laceration and a pelvic hematoma without active extravasation along with a pelvic fracture. She's on a blood thinner for atrial fibrillation on two antihypertensive medications and has baseline chronic kidney disease. Her systolic have been in the 100s. The call night continues because it's still early. 56 year old who's a known cirrhotic and is struck by a vehicle and comes in with a depressed UCSF8. He's hemodynamically stable, gets intubated and scanned and found to have a traumatic brain injury, a high grade cellular organ injury and a spleen and liver without active extravasation. Lastly, I have an unhelmeted motorcyclist who comes in with concerns for TBI due to blood from the ears and mid face injuries and scalp contusion, but due to ongoing hypotension and a positive fast, he's taken to the operating room and found to have a complex liver laceration, bucket handle injury and undergoes segmental bowel resection and left in discontinuity. There's also a right zone two hematoma but not expanding in the OR. So he's packed and brought to the ICU. I present these to show the complexity of cases in regards to mechanism of injury, whether blunt versus penetrating, sometimes both. Sometimes I get the patients who were shot then hit by a car and they can present in stable or unstable fashion. They may be coming to you after some intervention or you may have to be prepared to provide critical intervention, whether it's getting them to the operating room, getting them to IR or bringing the surgeon and OR to the bedside. Let's talk about the initial evaluation and management. We always start with the ATLS principles. The Advanced Trauma Life Support Program emphasizes the systematic ABCD approach to perform the primary survey for the initial evaluation. The main causes of early deaths in trauma patients are typically due to airway obstruction, respiratory failure, massive hemorrhage and brain injuries. So the initial assessment focuses on identifying and treating immediate life-threatening injuries and prompt identification of shock and its source. For airway, you want to ensure there's a patent airway and provide a definitive airway quickly if the patient is unable to maintain or protect his or her own airway, which typically means endotracheal intubation. For breathing, ensure there's adequate minute ventilation and oxygenation because inadequate oxygen delivery results in worsened tissue perfusion and this can lead to secondary insult to CNS injuries. Life-threatening tension pneumothoracies should be identified and decompressed by needle decompression, finger thoracostomy or tube thoracostomy. For circulation, the primary goal is to identify shock and its source. In trauma, shock is commonly due to uncontrolled hemorrhage and the model for unstable patients is it's bleeding, bleeding, bleeding until proven otherwise. Volume loading is a mainstay of circulatory support. Restoring blood volume and obtaining hemorrhage control are mandatory in order to improve outcomes. Establishing large-bore IVs is critical. Other potential causes for shock could be cardiac tamponade and tension pneumothorax. This is when adjuncts are particularly helpful to triage the cavities quickly and to identify these life-threatening conditions at the bedside. For hypotensive patients, I typically start with an eFAST followed by a chest X-ray and pelvic X-ray. Important adjuncts for hemorrhage control are pelvic binder, tourniquets, wound packing, hemostatic wound packing like combat gauze and some centers using Roboa. Disability is focused on identifying central nervous system injuries like traumatic brain injuries or spinal cord injuries. So you wanna calculate a Glasgow Coma Scale and perform a neurologic exam. Your resuscitation strategy may change if you identify CNS injuries as we'll discuss later. You want to expose a trauma patient in order to identify all potential sources of bleeding. Now the secondary survey repeats this ABCD approach but now in a systematic head-to-toe evaluation to ensure all remaining injuries and medical conditions are identified. An important question I'm asking myself in the trauma bay is where do I need to be next? Does this patient need OR, IR or ICU? And I ask the same question when I am the intensivist receiving patients into the ICU. I need to have an idea of the potential need for OR, IR or some other intervention. I am going to emphasize this again. 40% of trauma related deaths are still due to exsanguination. The depth and duration of shock leads to cumulative oxygen debt that can lead to refractory shock if resuscitation is delayed or inadequate. If I have an unstable patient in the trauma bay with obvious hemorrhagic shock, I do my best not to delay operative intervention and focus on just getting a type in cross and mobilizing to the OR. I prefer establishing large IVs in the trauma bay but if a patient is so intravascularly depleted that no one is able to get an IV, I will just place bilateral IOs which is much faster than placing a central line and start resuscitation with blood. I'll do this also in preparation for intubation and while pre-oxygenating. This allows some volume loading prior to giving intubation medications which I asked for in reduced dosages in order to avoid cardiovascular collapse. And after a couple of units, getting central access or large IVs is much easier. I'm pleased, large IVs. The amount of times I've had to throw triple lumen catheters out of my resident's hands. Cortis, RIC, MAC, even a dialysis catheter. However, two large bore IVs suffice and I have actually done supra massive transfusions with just two large bore peripheral IVs. Now, many intensivists are typically not present for the initial response to the trauma patient and you may even be at home but having to lead a team who directly manages the patient. Furthermore, you may work in a mixed med surg ICU and if that's the case, it's even more imperative you and especially your mid-level providers and nurses understand the ATLS approach and management principles. I encourage you and especially your mid-level providers and nurses to take the ATLS course or trauma courses geared towards nurses in order to become familiar with the terminology concepts and this initial approach. And think of the trauma patient examples I gave. A patient may be admitted with polytraumatic injuries who is initially stable, but then decompensates in the ICU at which point then you and your ICU team is responsible for essentially redoing their primary and secondary survey. ATLS and the adjuncts are part of critical resuscitation maneuvers. Resuscitation is a concept, not a place. So in your ICU, there should still always be an ultrasound readily available, tourniquets, combat gauze, pelvic binder, chest tubes, and scalpels. These are not items that should only exist in the trauma bay or emergency room. Be ready to mobilize the patient quickly if need be. Again, does the patient need to be in the operating room or IR or need bedside exploration? You should know the numbers to get your surgeon or interventional radiologist quickly. If you plan on IR intervention, I recommend that you still inform the surgeons in case the patient decompensates further and can't manage to even make it to the IR suite in time. Or if IR attempt fails, if you end up having to start MTP in the ICU, then you should be informing your surgeon. Once the initial primary and hopefully secondary survey has been completed and hemorrhagic shock is identified, then the goals of this early phase of intensive care focuses on resuscitation. You want to restore blood volume, optimize tissue perfusion, correct coagulopathy while you're managing life or limb-threatening injuries as the patient's moving from the trauma bay to the operating room, angiography suite, or ICU. Now, the wider adoption of massive transfusion protocols and damage control resuscitation strategies makes this initial phase dynamic and poses some challenges for the intensivist. In order for you to provide seamless care from the trauma bay to the OR to the ICU, you need to be familiar with the principles of damage control resuscitation and adjunct so you can anticipate the needs of the patient. Let's talk about massive transfusion. What is massive transfusion? Well, like many things in medicine, there's not one definition. The literature typically uses massive transfusion as more than 10 to 20 units of blood in 24 hours, which approximates replacement of an individual's blood volume. But that's not very helpful to identify someone who needs massive transfusion when someone is in front of you. The one that is clinically meaningful is a patient who receives more than three units of blood in one hour with ongoing need for products. But how did massive transfusion and massive transfusion protocols even come about? Like, how do we know when we should activate massive transfusion protocol or MTP? Well, the concept of the lethal triad was actually pretty well recognized, but our initial understanding of this coagulopathy really depicts the late consequences of poor resuscitation strategy. We used to flood our patients with crystalloids, and so the worsening coagulopathy was thought to be related to clot disruption, dilution of clotting factors, and caused hypothermia, and that the hypothermia and acidosis impaired the enzyme function, which resulted in dysfunctional coagulation proteases. Now, the lethal triad still certainly holds true, but we began to understand in the early 90s that trauma patients became coagulopathic well before we even gave any fluids, and that severe trauma causing shock, hyperperfusion, and vascular damage set off an entire cascade at the time of injury. This is what we now know as acute coagulopathy of trauma, and it's far more complex than our initial understanding. This acute coagulopathy of trauma is an independent risk factor for death. It's associated with longer ICU stays, and more likely to develop acute kidney injuries and multi-organ failure. As our understanding of coagulopathy was growing, the military was gaining experience with what we now call damage control surgery and resuscitation. Now, the military has long taught sailors how to perform damage control maneuvers for damaged ships. Even when I was in the Navy, I did the same exercise. They basically flood a ship and have you make critical repairs only to temporize the situation with the goal of getting back to shore safely for definitive repairs. So just like damage control in a ship, the military was starting to limit the extent of their surgeries. And you can see here that the military would do the critical surgical intervention downrange, would write down all the findings and surgeries done on the body. And once a patient was transferred to higher level of care, the next team of surgeons completed the surgeries. The other critical maneuver the military was doing was giving blood sooner. They started seeing better survival and suggested that a one-to-one-to-one ratio of blood products was best. And they posited that it most closely resembled whole blood. Well, everyone said your findings are all retrospective, they're survival bias. So the idea wasn't readily adopted initially. This led to the PROMED study, which was a prospective observational study looking at the ratio of blood components and found that patients with higher ratios within the first six hours had improved outcomes. So the takeaway was give blood products earlier and in higher ratios. Well, the next question was what's the better ratio which led to the proper study? Now, there was no statistical difference for 24-hour or 30-day mortality between the groups, whether it was one-to-one-to-one or one-to-one-to-two. However, there was a trend towards improved outcome for those receiving the higher ratio and a greater proportion of those had quicker hemostasis. So we still don't know the ideal ratio, but earlier administration of products with higher ratios are associated with improved survival. And as one of my mentors said, one-to-one-to-one ratio is also a lot easier to remember and keep track of when a patient is exsanguinating. So this led to a wider adoption of giving blood sooner, now that we understood that resuscitation of the severely injured patient in hemorrhagic shock necessitated massive transfusion in order to restore blood volume quickly for circulatory support. But traumas are unplanned. And so hospitals began to develop massive transfusion protocols, or MTP, to allow for a well-coordinated, rapid delivery of large amounts of blood products over a sustained period of time. The goal is to provide and send a balanced ratio of blood components without having to keep asking. Once activated, the blood should keep coming until you deactivate it. When it comes to MTP, only 3% of civilian trauma patients receive massive transfusion. But those patients end up consuming 70% of all blood transfused at a trauma center. Wherever you go, you should know your own institutional massive transfusion protocol. I guarantee you that every hospital has one by now. Though MTP development came from the world of trauma, it is now widely adopted and used for GI bleed, OB bleeding, and other surgical bleeding. The American College of Surgeons has a MTP best practice guideline that is free, and it goes through the basics of MTP creation and implementation. Massive transfusion protocols have been shown to improve outcomes, and it actually reduces the wastage of existing blood products. An important part of MTP is knowing when to activate the protocol. So what are the triggers? The ACST group recommends these as triggers. If you have someone with ongoing instability, still has bleeding that requires surgical or interventional radiology for hemorrhage control, ongoing transfusion requirement, and the ABC score. This is the assessment of blood consumption score. It's a simple scoring system that can be done at the bedside. You get a point if it's penetrating mechanism, if the patient has a systolic, blood pressure less than 90, an elevated heart rate, a positive FAST, and the score greater than two is likely to require MTP. Now, the original study by Dr. Nunez showed a sensitivity of 75% with the ABC score with 86% specificity. Some newer studies show less sensitivity. Another commonly used scoring system is the shock index, which is found to be highly sensitive in predicting the need for MTP. There are other scoring systems like the TASH score, but they require lab values and are more cumbersome. These two are quite easy to calculate at the bedside. Other clinical conditions you want to consider for activation of MTP is presence of a pelvic fracture and long bone fractures. We had to compare the scoring systems to Gestalt, and one of the more cumbersome scoring systems did better than Gestalt alone. But again, if you need to wait for lab values, then you're likely going to end up activating MTP too late. It turns out that the ABC score did not fare better than Gestalt and can actually overestimate the need for massive transfusion. However, another study showed that the ABC score would have initiated blood transfusion sooner to those who really needed it. Furthermore, another study showed that every minute delay from time of MTP activation to first transfusion resulted in a 5% increased odds of mortality. So using both clinical judgment and a scoring system is recommended, and it's better to err on the side of early transfusion. I would rather trigger early and be wrong and deactivate MTP quickly rather than get behind on resuscitation. So we've identified someone in shock and started our initial resuscitation of volume loading, and then it's time for damage control surgery. It's really two things. Find what's bleeding and stop it, and stop any contamination. For contamination control, we do whatever is fastest and easiest to control gastric content, succus, or stool from spilling out. Usually means just over-sewing the holes or taking a stapler and removing sections without putting things back together. Hence the term discontinuous. And the primary goal of stopping the bleeding is hopefully a simple found the vessel and I get to ligate it. But sometimes it's not that simple. It's not uncommon for us to find massive liver injury that we manage by packing and then asking for intraoperative IR consultation. Or in many places, this means another trip to the IR suite with a critically ill patient with MTP that may still be required. This may mean placing temporary vascular shunts, a roboa, or maintaining the tourniquet if you're dealing with multiple sources of life-threatening bleeding. There's no absolute evidence-based prediction models of who would benefit from damage control, but it should be initiated in severely injured patients with multisystem trauma, and especially those in shock. So people who are acidotic, coagulopathic, hypothermic, if they require massive transfusion, if they're needing internal packing for hemorrhage control, if they got multi-organ injuries, and especially if the surgical time for definitive repair is going to take more than 90 minutes. Once we control contamination and hemorrhage, we end up typically just doing skin closure or there are commercial products that are available, just covering the abdomen with a bag. It is possible to leave the abdomen, chest, wounds open, and again, provision of vascular shunts that are temporary. The outside will typically look something like this, where the skin is just closed, or there's a bag that's provided over the bowels. The middle is a commercial product that's available, and then the far right is the same effect, but using products that are just available in the operating room. The top two left shows vascular shunts that are in place, that are temporary. And the next top right, it's hard to tell, but it's actually an open chest where someone's had a clam shell thoracotomy and a plastic bag that's just covering the open chest. And again, the commercial product that may be used to provide temporary coverage of the chest. I've certainly, unfortunately, had to leave chest and abdomens open or bring the patient back to the ICU with a roboa and a pelvic binder still in place until I can get better hemorrhage control with interventional radiology. Damage control resuscitation and surgery is not one technique, but really a group of strategies. And the strategies are really to address that lethal triad. So we've discussed the early initiation of blood and giving a balance ratio. The other important strategies to implement are to limit crystalloids and to allow for permissive hypotension. This has been shown to improve mortality and also believed to prevent dislodging of existing clot and preventing further blood loss. Now, we don't know what the optimal arterial blood pressure target is, but typically we recommend systolic 70s. But I will shoot for greater than 100 if I know I have a brain injury or have concerns for brain injury. If it's clearly penetrating to the torso in a young, healthy male, I really ask for pressures no greater than systolic of 90 until I can actually get surgical control. Remember, without getting surgical control or IR control of hemorrhage, that cycle of the lethal triad is not going to stop. Now, I'm not going to go into detail about the adjuncts because my colleague is covering this in his fantastic talk and discussion on hemostatic resuscitation. But in regards to TXA, which is an antifibrinolytic, this medication got a lot of attention after the CRASH-2 and MATTER study. There still remains a lot of questions about the medication and its utility in trauma, but I really like Dr. Napolitano's review of TXA and how best to use it with the available data that we do have. This paper suggests that people who may benefit most are patients in severe hemorrhagic shock with systolic blood pressure less than 75, those with known predictors of fibrinolysis or with known tag reading for fibrinolysis. And to give it within three hours from injury. So I mentioned TEG, which stands for thromboelastography. And so there's a lot of emerging data about the use of viscoelastic testing, especially since our understanding of coagulopathy and trauma has expanded. Now, EAST is one of our main trauma societies and they did a nice review of all the available literature regarding the use of viscoelastic testing. And it highlights the strengths and weaknesses of the studies. And they conclude that ultimately they conditionally recommend the use of TEG. This is the most recent study comparing VET or viscoelastic testing to traditional coagulation tests. It's a European multi-center randomized controlled trial. Now, both arms received empirical treatment of a balanced ratio blood products, such as MTP with viscoelastic testing and traditional clotting tests that was taken at every fourth red cell unit that's given. And the viscoelastic testing was used to guide additional administration of fibrinogen, platelets, plasma, or TXA. Now, the primary outcome was patients alive and free of massive transfusion at 24 hour mark. And the secondary outcomes looking at the typical mortality at 24 hours, 28 days, time to hemostasis, thrombotic events, ICU days, vent days, and hospital length of stay. Now, they did not find a difference in mortality or overall outcomes. And this is a pretty good study, but it turns out that very few of these patients had baseline coagulopathy. And so maybe the viscoelastic testing wouldn't have benefited these patients anyway. The ultimate takeaway is use it if it's available. The existing studies have mixed outcomes and varying resuscitation strategies being used. One study showed that mortality was improved in penetrating trauma when using TAG-guided resuscitation. I think for people with ongoing coagulopathy and especially in the ICU, when you're trying to stop MTP and the surgical bleed is controlled, then it's a helpful adjunct. There are reversal strategies depending on the severity of bleeding, how quickly you need to reverse and the available reversal agents depending on the anticoagulant the patient is taking. The real controversy is the use of prothrombin complex concentrate, or PCC, for patients receiving MTP who are not on anticoagulants. This recent trial was a double-blind, multicenter, randomized trial in France. And they used PCC in patients at risk of MTP, which they defined as one unit of PRBC given pre-hospital or within one hour of arrival and an ABC score of two or clinical judgment. The patients were randomized to receive PCC within one hour of arrival versus saline. And the transfusion protocol was a balanced ratio and viscoelastic testing guided for fibrinogen. The primary question was whether PCC reduced blood product consumption, and it did not. When looking at mortality differences, they also did not find a difference at 24 or 48 hours. But there are still significant interest and ongoing studies looking at this medication. Realize that the primary outcome for the study was looking at 24-hour blood product utilization, which is not a patient-centered outcome. There are studies that are occurring now looking at the utility of PCC as an adjunct to MTP. Press's report was traditionally discouraged due to concerns that vasoconstriction would worsen organ perfusion and result in increased mortality and initial studies seem to suggest that, but this was well before MTP and damage control strategies were widely adopted. We also now know that traumatic shock is complex. It involves multiple neurohormonal interactions and that the hypotension from ongoing hemorrhagic shock is due to a sympathetic inhibition, depletion of AVP stores and vasopressin. Now this paper nicely reviews the complexity of vasodilatory shock and the evidence behind vasopressin support for hemorrhagic shock. Even though we still don't know the optimal pressure goals or which pressors work best for hemorrhage, there are certain clinical scenarios in which early vasopressor use with norepi or vasopressin is recommended. Those with severe brain injury to minimize the secondary insults and maintain adequate cerebral perfusion pressure. The trauma patient who's pericardiac arrest has not had surgical hemorrhage control yet and this would help maintain cardiac output. Those with persistent hypotension and who's no longer responsive to ongoing blood product administration. And those ICU patients where hemorrhage control is obtained but they're demonstrating early organ dysfunction from persistent vasodilatation, multi-organ dysfunction or persistent inflammation. So that's a lot going on before the patient even makes it to the ICU. There've been cases where I've gone from the trauma bay to the IR suite, back to the OR, sometimes with the scanner. But remember that the sequence events can be direct ICU admission for a patient who's initially a responder and then decompensates and you're in the position to initiate and do all the initial maneuvers we just discussed. When the patient does arrive, you need to reconfirm and reassess the primary and secondary survey. But this will need to be in the context of known or still unknown injuries. Don't assume the airway is secure. Don't assume that the chest tubes are in the right place and working properly. Don't assume that your IVs are fine. Don't assume that the drains are functioning okay. And most importantly, do not assume that all injuries have been found and dealt with sufficiently. You need to have a systematic approach to signing out these patients for these complex cases so you can have an understanding of the pre-ICU course, the operations, the resuscitation provided thus far, if MTP is still active and what things still have not been addressed. If your patient still has ongoing resuscitation needs, ensure to warm the patient with all the adjuncts and appropriate maneuvers while reviewing the pre-ICU course and awaiting for your initial labs to come back. The intensive care treatment, again, should focus on rewarming, correcting lactic acidosis and coagulopathy. One of the things you need to determine is where the patient is physiologically and be prepared to receive the patient at any point along the continuum of care. So is the patient coming back from the operating room in stable condition? Then you should be meeting your resuscitation endpoints pretty quickly. Is the patient coming back with MTP still running and coagulopathic? These are the ones you're trying to meet endpoints of resuscitation, but you have to consider need for re-exploration or another intervention if you don't think hemorrhage or contamination control has been adequately performed. Is the patient a transient responder and you're still having to provide active resuscitation while awaiting for IR or OR. Remember that shock is defined by the failure to meet metabolic demands of the body because of inadequate oxygen delivery or utilization. So how do we know when we adequately resuscitated a patient? How do we know when that oxygen debt is repaid? Well, the resuscitation endpoints can be divided into three groups. Hemodynamic, metabolic, and hemostatic. Because shock occurs due to inadequate tissue perfusion, therefore inadequate delivery of oxygen, our understanding of hemodynamic endpoints and resuscitation is based on the Fick principle, that in order to improve oxygen delivery, we need to optimize preload and cardiac output. Now, normalization of heart rate, blood pressure, and urine output are the traditional endpoints. These basic vital signs are easy to obtain non-invasively and they form the basic patient assessment. Now, heart rate variations can be one of the earliest signs of hypovolemia and malperfusion, but we also know that heart rate and blood pressure can be within normal ranges despite ongoing shock. So even though these typical parameters are easy to obtain and trend, they should not be used in isolation and should be supplemented by other elements. Similarly, mean arterial pressure is a common endpoint with a typical target of 65, though the ideal map is still unknown and still debated, especially with some data showing mortality benefits with hypotensive resuscitation strategies using even lower numbers. Central venous pressure or CVP is used to assess preload, hoping that this will improve cardiac output if you improve CVP, but CVP does not necessarily correlate well with actual intravascular volume or right ventricular volume and can be altered by mechanical ventilation or pulmonary hypertension. Also, aggressive pursuit of specific CVP goals can lead to over-resuscitation, which can cause worsened patient outcomes. CVP is better used when trended over time and should not be used in isolation either. Mixed venous oxygenation saturation provides information about total body oxygenation extraction and is used as a marker volume assessment, but requires an invasive pulmonary artery catheter, which has largely fallen out of favor. Now, a central venous oxygen saturation can be obtained from a regular central line. And though the reading is typically a little greater than the mixed value, it generally correlates. A central venous oxygen saturation greater than 70% is usually the target. And for trauma, it can help assess volume responsiveness and is an helpful adjunct and can be similarly used to lactate. Newer non-invasive monitors allow for pulse wave analysis that can calculate stroke volume variations, stroke volume index, cardiac index. The caveat is that in order for pulse pressure variations to be calculated by an arterial catheter, the patient should have regular respirations with a controlled vent mode and ideally be in sinus rhythm. Bedside ultrasound to assess fluid responsiveness, assess basic cardiac function has become a very useful adjunct. It allows you to assess the IVC collapsibility. It allows us to see the cardiac ventricular size, assess the function and overall contractility. And of course, it's also very helpful to evaluate patients who are maybe newly unstable to assess for free fluid that would warrant operative intervention. It's non-invasive. It can be done serially. The pitfalls are that dressings, open abdomen or chest, injuries or the body habitus can obscure the view. Occult shock and ongoing tissue malprofusion is still possible despite normal hemodynamics. Anaerobic metabolism results in lactic acidosis, which allows us to measure the extent of impaired tissue profusion by measuring lactate. Not only does the initial lactate correlate with mortality, but how quickly it normalizes also is predictive of mortality. Lactate clearance by two to 24 hours is associated with lower mortality, whereas mortality is greater than 80% if it does not clear or takes more than 48 hours to do so. So trending the lactate is important. Most literature recommends checking it every four to six hours or sooner, depending on the clinical scenario. Base deficit is another reliable marker of metabolic stress and is easily obtained and also predictive of mortality, but a little less reliable in immediate identification of shock and more reliable at 24 hours after injury, which makes it inferior to lactate. It can also be influenced by many factors such as renal failure, diabetic ketoacidosis, CO2 retention, but it is a helpful adjunct that can be obtained easily. PH is another measurement of metabolic stress with non-survivors typically having PH less than 7.21. The general endpoints for hemostasis is evidence that bleeding has stopped and I also include normothermia as an important endpoint to be included with hemostasis. These are the general recommended targets for the traditional coagulation testing and you can easily look up the normal parameters for viscoelastic testing if you're going to use that as well. Now, if bleeding is controlled and the patient is still requiring further support, then judicious use of crystalloid fluids is recommended. Which type and how much? Good question. This is still hotly debated and also depends on the type of injury and the type of patient you have. Again, you need to tailor your approach to your patient. Best case scenario and what we hope for is early capture of patients and to be able to correct that lethal triad and reach the end points of resuscitation within the first 24, 48 hours. Then you wanna prepare the patient to return to the operating room for definitive repairs and complete any necessary evaluations or imaging that you may not have been able to obtain earlier. We have gotten better with our resuscitation strategies, but there are pitfalls to look out for. for. The most common problem is severe electrolyte abnormalities, especially with massive transfusions and patients typically need to be supplemented with calcium. Hyperkalemia is also a problem to be mindful of. The common pitfalls for trauma patients in the ICU include failure to recognize surgical bleeding and sometimes it's really hard to tell if it's uncontrolled surgical bleeding or coagulopathy. The other problem is relying on the drains to indicate if there's massive bleeding. Do not rely on the drain output. Massive amounts of blood can accumulate underneath temporary abdominal dressings or clot off. This pertains to any drain including chest tubes. There's a high potential for missed injuries. This includes traumatic as well as iatrogenic injuries. It's easy to miss fractures, lacerations or even head bleeds because a patient's been too unstable to to fully evaluate or image. Sometimes we cause a iatrogenic injury and so it's not even your radar so it gets missed. That's why it's so important to reconfirm that primary and secondary survey and I always ask for a tertiary once the patient is stable. Require your staff and team to continue to review all images and examine the patient again. The other pitfall to watch out for is late updated radiology reads that they never call you about. Toxins or comorbidities can confuse a clinical picture and there are certainly complications that happen with over resuscitation. Compartment syndrome can happen with over resuscitation or from certain injury patterns that would require urgent fasciotomies and it is still possible to get abdominal compartment syndrome even with an open abdomen. The dressing we place and the temporary coverage may still cause significant significant constriction if the bowels continue to swell. Those patients with severe injuries have a high potential for a prolonged ICU stay. Nearly 40% of polytraumatized patients can develop multi-organ failure especially if they present in hemorrhagic shock. They are at increased risk for infections such as ventilator-associated pneumonias, ARDS, sepsis, acute kidney injury. I won't go into the full management details because it's similar to management of multi-organ failure for medical and surgical patients except that you always need to consider the existing injuries, risk for bleeding, and the various infectious complications related to the surgeries the patient has undergone or the injuries the patient has. Trauma patients become hypercoagulable and are at increased risk for DVTs so DVT prophylaxis should be initiated as soon as it seems safe. Now the critically injured patient has increased metabolic demands and so it's really important to initiate enteral feeding as soon as possible to preserve intestinal function. Studies show that it also helps to limit bacterial translocation and the infectious complications. However, if your patient has severe abdominal injuries that prevent you from doing enteral feeding then you need to start thinking about starting parenteral nutrition. The surgical complications you need to consider while managing the patient in the ICU include the following which would necessitate further intervention or surgeries. Now there are certain trauma patients that need a bit more nuanced approach. Adults 65 years and older are the fastest growing population and accounts for 23 percent of all trauma admissions and trauma is the fifth leading cause of death among the geriatric population. Managing traumatic injuries in this population is challenging because they have a blunted physiologic response to stress and injury and in the trauma bay I am very mindful of occult hypotension and that systolics of a hundredth is not normal within the geriatric population. They have less reserve and tend to have multiple comorbidities. This problem is exacerbated by medications they may be taking like beta blockers and antihypertensives. The aging heart has a greater dependence on preload and so even minor hypovolemia can result in severe cardiac dysfunction but aggressive resuscitation can also lead to pulmonary edema due to poor left ventricular compliance. Many elderly patients are on anticoagulants and so the risk of bleeding is much higher and their resuscitation endpoints are difficult to assess due to their baseline physiologic changes, reduced renal flow, underlying cardiac issues and pulmonary changes and so this is when adjuncts like the bedside ultrasonography can be particularly helpful. The elderly are also prone for delirium and infections. The American College of Surgeons also has a geriatric trauma management guideline regarding best practices and this is about to be updated soon actually so there will be a new version coming out hopefully within the next year. Now the recommendations focus on quick assessment not only the traumatic injuries but basic injuries but baseline frailty, delirium and medications because this will give you an understanding of the patient's overall prognosis and potential for major complications and their expected course. This is really necessary to guide goals of care discussion. Early palliative care consultation and documentation of advanced directives have been shown to decrease resource utilization without impacting mortality. The main thing I want to get across for trauma patients who are pregnant is that the focus needs to be on the mother. The primary survey is still ensuring the stability of the mother. You need to know the common physiologic changes that occur to understand the common pitfalls of management. You need to be prepared for difficult airway and difficult intubation due to the airway edema that occurs and in pregnancy, the tidal volume gets larger while the respiratory rate stays the same. There is a chronic compensated respiratory alkalosis. So a normal ABG may actually be an indication of impending respiratory failure. There is less respiratory reserve and the fetus is very sensitive to hypoxia. So all pregnant trauma patients should be given supplemental oxygen. The plasma volume increases by nearly 50% and the pregnant female can have nearly 30% blood loss before the blood pressure drops. So there's this delayed recognition of hemorrhage. Furthermore, the cardiac output can be impacted due to IVC compression by the uterus starting at 20 weeks. So remember to displace the uterus or place the patient on her left side. Chest tubes need to be inserted much higher due to the elevation of the diaphragm. And so in the ICU, being prepared for the potential difficulties is key along with having a multidisciplinary approach between the ICU, trauma and OB team. I wanna emphasize that not only are we at risk of delaying resuscitation because we fail to recognize hemorrhage, there's also a delay in identifying the source. There's a significant concern for imaging in the pregnant patient, but the American College of Obstetrics and Gynecologists as well as trauma organizations both recommend not to delay imaging, including CAT scan if the patient has sustained major trauma. Resuscitation in pregnant trauma patients still requires a balanced transfusion, but shoot for higher fibrinogen levels due to that physiologic change that causes increased levels. Some things to look forward to in the near future are not new, but have gained renewed interest. The use of whole blood is back in the forefront and studies showing improved 24 hour and 28 day mortality early studies are also showing safety of low titer group O whole blood in women of childbearing age. Advantages are that it's logistically easier to transfuse, less volume, reduce patient exposure to donors, but the donor pool is limited and most centers are limited in the quantity of whole blood that's available to avoid wastage because it has a shorter shelf life. But certainly expect more research to be put out in the near future. Direct peritoneal resuscitation involves infusion of hyperosmolar solution within the peritoneal cavity. The hypertonicity is thought to cause visceral vasodilation, which helps to maintain flow. And it's been shown to be associated with reduced local inflammatory cytokines, preserve endothelial function and mitigate organ edema, allowing for earlier closure of the abdomen. Large multi-center randomized trials would be beneficial to validate the initial findings. Thank you for your time. If you have any questions or have comments, please feel free to reach out.

ICU management

trauma patients

critical care

resuscitation strategies

damage control resuscitation

massive transfusion protocols

coagulopathy management

multidisciplinary approach