High speed motor vehicle accidents (MVAs) on rural highways, often involving automobiles and truck collisions, frequently result in massive blunt trauma. Rapid resuscitation and transfer to a Level I trauma center are advocated, as two thirds of all MVA mortalities occur in rural areas. Priorities include minimizing neurological impairment and controlling hemorrhage.
Up to 40% of patients with major blunt abdominal trauma have central nervous system (CNS) injuries. If there is associated spinal cord injury, use methylprednisolone neuroprotection protocols. Methylprednisolone initiated 3 to 8 hours after acute spinal cord injury must be maintained for 48 instead of 24 hours. The 21-aminosteroid tirilizad, a potent inhibitor of iron-dependent lipid peroxidation, also exerted significant beneficial effects on spinal cord function and may be cleared later for treatment of blunt CNS injuries.(1) Avoid CNS hypoperfusion or hypoxemia. A cerebral perfusion pressure (CPP) of 70 mm Hg (acutely use mean arterial pressure (MAP) of 70 mm Hg) may improve neurologic outcome in traumatic brain injury. An intracranial pressure (ICP) of 15 mm Hg is associated with a much lower mortality rate than pressures of >20 mm Hg. CPP = MAP - ICP.
Consider hypertonic resuscitation techniques.(2) Intra-abdominal pressures > 12 mm Hg are associated with decreases in CPP < 70 mm Hg and increases in ICP.(3) A patient with a Glasgow Coma Scale score of 8 or less should be intubated; prehospital intubation by the paramedics is encouraged to improve neurological outcome.(4) Clear the cervico-thoracic spine, if possible, in the emergency room (ER); treat as fractured until proven otherwise. Watch for the SCIWORA (spinal cord injury without radiographic abnormality) syndrome and document all lateralizing neurologic signs.
Check for hemopneumothorax and obtain a portable chest X-ray. Avoid drops in the venous return to the heart by over- aggressive positive pressure ventilation, because this leads to pulseless electrical activity (PEA). Online electrocardiogram, SaO2, ScvO2, capnography, and right atrial filling pressures may be used to direct therapy and reduce the risk of death.(5) Diastolic pressures must be maintained to ensure adequate coronary perfusion pressures. Coronary perfusion pressure is proportional to the diastolic pressure minus the left ventricular end diastolic, or wedge, pressure. Alpha-1 agonists may improve cerebral and coronary perfusion.(6)
If cardiac injury appears clinically, rule out tamponade with FAST (Focused Abdominal Sonogram in Trauma) with visualization of the pericardial sack and possible effusion.(7) A pericardial window may be performed to avoid tamponade and ensure maintenance of the central venous pressure (CVP)-intrapericardial pressure (IPP) gradient, i.e., cardiac output is proportional to the CVP:IPP gradient.(8) Place chest tubes as necessary, especially in patients with fractured ribs and subcutaneous emphysema requiring positive pressure ventilation to prevent tension pneumothorax and arrest during transport. Allow spontaneous breathing to occur, if possible, to facilitate venous return to the heart.
Placement of central venous lines may be facilitated with ultrasound, especially in cases of low systolic pressure or near arrest states.(9) Femoral venous access is valuable in large volume resuscitations. Packed red cells may be sent with the patient and transfused en route.
Anesthesia services should be called to assist in the resuscitation and preparation for transfer to a Level I trauma center or
damage control surgery before transfer. Use the operating room (OR) if possible. Ultrasound studies are preferably done at the bedside in the ER or OR and may assist in venous access. In children, large hemoperitoneums may be watched if the patient stabilizes. Transfer of patients with an expanding hematoma and developing acute abdominal compartment syndrome requires special precautions. Consult with the Level I trauma surgeon and utilize Level I Pediatric Trauma Centers when indicated. The phone is your friend. Call the receiving trauma surgeon and give the condition and state of resuscitation of the patient. Discuss the transfer with the patient and family if possible. Complete the COBRA forms.
Avoid sudden hypotension with abdominal decompression and release of tamponade by adequate venous filling pressures. Try to have blood available in the OR. Recognize that the abdominal compartment syndrome may be present by utilizing Foley catheter pressure measurements: Grade 2=15-25, 3=25-35, 4>35 cm H2O. 1 cm H2O = 0.74 mm Hg. The mesenteric perfusion pressure is equal to the MAP minus the intra-abdominal pressure. Abdominal decompression may improve cardiac output, increase MAP, cerebral perfusion pressure and correct oliguria. Adequate venous return requires high filling pressures to avoid drops in MAP below 70 mm Hg with open laparotomy, positive pressure ventilation, and further blood loss. An internal jugular, subclavian vein, or femoral vein access with 14 ga to 8 Fr allows monitoring of venous pressure (5 to 10 mm Hg is desirable) and central venous gas analysis (PcvO2>28 mm Hg, ScvO2>54% are desirable). Triple lumen central venous catheters are used in conjunction with 8 Fr introducer sets and short large-bore peripheral IVs. Use a Level I fluid warming infusion system to avoid hypothermia and consider autotransfusion devices when appropriate.
On opening the abdomen, use direct pressure to control liver, spleen, aortoportacaval, and mesenteric bleeding. Avoid the suction syndrome. Squeezing and posterior compression may control catastrophic liver hemorrhage. Do not lift the liver up to expose retro-hepatocaval venous injuries until volume resuscitation is adequate and isolation obtained. The Pringle maneuver may not help in cases of grade 5 or 6 hepatovena caval injuries: pack, obtain tactical hemostasis, resuscitate, and transfer. The T bar may be used to maintain central aorta pressure but may increase venous bleeding if the vena cava is occluded.
Use the abdominal aortic zone exposure technique to access central arterial or venous hemorrhage. Use the Cattell Maneuver for the vena cava and suprarenal aortic zone 1 on the right; use the Mattox Maneuver for the abdominal aorta (zone 2) on the left; use the Visceral Sweep Maneuver to the right upper quadrant with a division of the ligament of Treitz for infrarenal aorta and iliac arteries or veins (zones 3 and 4).(10) Avoid exploring pelvic hematomas, pack them and transfer the patient.
Helpful instruments include sponge sticks, T bar, bull dog clamps, Rummel tourniquets, vascular instruments and Prolene vascular suture, mesh, Teflon pledgets, aortic and venous shunts and grafts, rib spreader, sternal knife, and GIA/TA stapling instrument (U.S. Surgical Corp., Norwalk, Conn.) Foley and embolectomy catheters may control aortic and vena caval and iliac hemorrhage as well as chest wall, extremity, and neck hematomas.(11)
Stop surgery if hypothermia and coagulopathy develop. Operating times should be short and directed toward obtaining hemostasis and packaging for transfer. Necrotic bowel may be resected to prevent enteric contamination without reanastomosis. The patient may be transferred intubated and anesthetized with a rapid, loose abdominal fascial closure, mesh or skin closure. Transfer is directly from the OR with continued anesthesia and surgical care to the transport vehicle. Further bleeding may require ongoing volume-pressor resuscitation to avoid hypotension during transfer. Avoid over-resuscitation with pseudo-ARDS (adult respiratory distress syndrome) and increase ICP syndromes with large crystalloid infusions. Monitor the FiO2:SaO2 gradient. Avoid supranormal pressures, which may restart tamponaded hemorrhage. Other surgical procedures should be delayed until full resuscitation and stabilization of cerebral-coronary perfusion, e.g., delay internal fixation of extremity fractures. Further surgery may decompensate the patient and result in secondary brain injury if hypotension occurs with induction of anesthesia or during the procedure.(12) Watch for extremity ischemia, compartment syndromes, and control extremity hemorrhage. Proper splinting and traction reduce pain, blood loss and improve extremity perfusion by preventing further neurovascular injury.
A transport ventilator may be useful if the patient is stable; manual ventilation may be necessary in unstable agitated patients. Avoid the auto-PEEP effect by allowing adequate exhalation time preventing overinflation and PEA. If possible, allow the patient to have spontaneous respiration to facilitate venous return. This may be difficult in transporting patients with developing abdominal compartment syndrome, head injury, and respiratory distress and agitation. Complete neuromuscular blockade can lead to hypotension in evolving abdominal compartment syndrome and hypovolemia.
Weather conditions may delay transfer and alter transfer routes. Blunt trauma patients may come in groups and triage must be effective. On-site transfer may go directly to Level I centers. Medical control is performed by the receiving Level I trauma center if radio communication is possible. The Level I center should report the condition of the patient to the referring center.
References
| 1. | Bracken MB, Shepard MJ, Holford TR, et al. Administration of methylprednisolone for 24 or 48 hours or tirilazad mesylate for 48 hours in the treatment of acute spinal cord injury, Results of the Third National Acute Spinal Cord Injury Randomized Controlled Trial. JAMA 277:1597, 1997. |
| 2. | Chesnut RM. Avoidance of hypotension: Conditio sine qua non of successful severe head-injury management. J Trauma 42:S4, 1997. |
| 3. | Bloomfield GL, Ridings PC, Blocher CR, et al. Effects of increased intra-abdominal pressure upon intracranial and cerebral perfusion pressure before and after volume expansion. J Trauma 40:936, 1996. |
| 4. | Winchell RJ, Hoyt DB. Endotracheal intubation in the field improves survival in patients with severe head injury. Arch Surg 132:592, 1997. |
| 5. | Scalea TM, Simon HM, Duncan AO, et al. Geriatric blunt multiple trauma:Improved survival with early invasive monitoring. J Trauma 30:129, 1990. |
| 6. | Paradis NA, Martin GB, Rivers EP, et al. Coronary perfusion pressure and the return of spontaneous circulation in human cardiopulmonary resuscitation. JAMA 263:1106, 1990. |
| 7. | McKenney MG, Gross RI, Lentz KA, et al. Symposium: Ultrasound in trauma. Contemporary Surgery 50:188, 1997. |
| 8. | Knott-Craig CJ, Dalton RP, Rossouw GJ, et al. Penetrating cardiac trauma: Management strategy based on 129 surgical emergencies over 2 years. Ann Thorac Surg 53:1006, 1992. |
| 9. | Hilty WM, Hudson PA, Levitt MA, Hall JB. Real-time ultrasound-guided femoral vein catheterization during cardiopulmonary resuscitation. Ann Emerg Med 29:331, 1997. |
| 10. | Fry WR, Fry RE, Fry WJ. Operative exposure of the abdominal arteries for trauma. Arch Surg 126:289, 1991. |
| 11. | Mullins RJ, Huckfeldt R, Trunkey DD. Abdominal vascular injuries. Surg Clin N Am 76:813, 1996. |
| 12. | Jaicks RR, Cohn SM, Moller BA. Early fracture fixation may be deleterious after head injury. J Trauma 42:1, 1997. |
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