FRCA Notes

Intensive Care Management of Major Trauma

The curriculum mostly asks about this in the context of perioperative care, with ICM-specific trauma questions historically relating to TBI.

Resources

  • Patients with major trauma are admitted to ICU because they need organ support, or because their injury burden puts them at high risk of deterioration and death
  • The first 72 hours are characterised by ongoing resuscitation, correction of trauma-induced coagulopathy, management of the multisystem effects of injury and frequent returns to theatre or IR
  • The central challenge is competing injury priorities: guidelines for individual injuries often need adapting, which requires MDT decision-making
  • Since the introduction of major trauma centres (MTCs) in 2012, the odds of survival in England have risen by nearly 20%

  • Patients may arrive from theatre after damage control surgery, from IR or directly from the ED
  • The need for admission may be obvious (e.g. ongoing ventilation), but the high-risk patient without organ failure must not be missed

  • Five physiological variables predict death in patients with an ISS >15 and should prompt early discussion with the intensivist:
    1. Age >70 years
    2. Acidosis: base deficit >6 mmol/L
    3. Prehospital unconsciousness: GCS 3-8
    4. Hypotension: SBP ≤90 mmHg
    5. Coagulopathy: INR >1.4 or PTT >40 s

  • Mortality is around 3% with none of these, rising almost linearly to 86% with all five
  • Groups needing particular consideration include the elderly, children, anticoagulated patients and parturients

Handover and history

  • A clear summary of injury pattern, interventions performed, blood products and fluids given, and planned investigations or procedures
  • Confirm identity; obtain a collateral history from prehospital teams and family (mechanism, scene findings, past medical and drug history)
  • Consider medical causes of the event (e.g. arrhythmia, hypoglycaemia, seizure, intoxication)
  • Review operative records: findings, procedures, problems, blood loss and postoperative instructions

Examination and imaging

  • A full examination including a log roll (with spinal precautions) to inspect the back, look for wounds and assess burns
  • All critically injured patients should have had whole-body CT before ICU; patients who went straight to theatre may not have, and should be imaged at the earliest opportunity
  • Review all imaging to confirm the position of lines, tubes and drains; obtain final rather than provisional radiology reports

Secondary and tertiary surveys

  • The trauma team must complete any outstanding secondary survey as soon as possible
  • The tertiary survey is a repeat head-to-toe examination and review of all imaging after resuscitation and initial surgery, usually within 24 hours in ICU
  • It matters most in patients who cannot report pain, such as those with reduced consciousness or sedation
  • Missed injuries are common: one UK ICU found them in 22% of major trauma admissions, three-quarters of which were orthopaedic
  • Introducing a formal tertiary survey reduced missed injuries from 5.7% to 3.4% in one US centre
  • Neurological clinical clearance is only confirmed once the patient is awake and the tertiary survey (including neurological examination) is complete

Trauma-specific checks Ventilated patient and general care
Tertiary survey completed? Lung protective ventilation; head-of-bed elevation; oral care
All imaging completed and formally reported? Head injury BP, ICP and PaCO2 targets
Surgical plans for each injury? Sedation, analgesia and regional anaesthesia
Cervical spine cleared? VTE and stress ulcer prophylaxis; glycaemic control
Lines inserted in emergency changed? Nutrition; pressure area care


  • Most major trauma ICU admissions are high risk on the Canadian C-spine rule and arrive with full spinal precautions
  • Clinical clearance is impossible in the sedated or obtunded patient, so radiological clearance is considered

  • There is no international consensus on whether MRI is needed after a negative CT:
    • A 2017 meta-analysis found unstable injuries on MRI in only 0.17% of obtunded patients with normal CT
    • The risk of secondary brain injury from prolonged collar use and MRI transfer is probably greater than the risk of instability after a negative CT
  • British Orthopaedic Association standard: collars can be removed after negative high-quality CT, reported by a consultant MSK radiologist, provided there is no confounding comorbidity
  • If CT shows injury or there is a confounding condition: maintain precautions, refer to spinal surgery and consider early MRI (sensitivity for ligamentous injury falls after the first week)
  • With raised ICP concerns, the collar can be replaced by bolsters either side of the head, reapplying it for log rolls

Complications of prolonged collar use

  • Pressure ulcers
  • Raised ICP from impaired venous drainage
  • Difficult airway management and loss of internal jugular access
  • Poor oral care and ventilator-associated pneumonia
  • Aspiration risk
  • Delayed mobilisation and physiotherapy with increased VTE risk
  • Staffing burden (log rolls need around four staff)


Phase Main goals
Prehospital Life-saving interventions; damage control resuscitation with blood products if available
ED Primary survey; identify and treat life-threatening injuries and shock; cross-sectional imaging
Initial (theatre, IR) Achieve haemostasis; decisions about injury priorities; avoid lowering BP targets if head or spinal injury
ICU (early to late) Haemostasis then aggressive resuscitation; organ support for the sequelae of injury; possible return to theatre or re-imaging

  • Remain vigilant for the 'diamond of death': hypothermia, acidosis, coagulopathy and hypocalcaemia, driven by new or persistent bleeding from known or missed injuries
  • Patients are at high risk of further urgent surgery in the first 72 hours
  • See the major haemorrhage page for transfusion strategy

Respiratory

  • Pulmonary contusions cause worsening V/Q mismatch, consolidation and atelectasis over the first 24-48 hours, starting to resolve after about 3 days, with risk of pneumonia and ARDS
  • In blunt polytrauma without brain or cord injury use lung protective ventilation:
    • Tidal volume 6 ml/kg ideal body weight
    • PEEP titrated to FiO2 (e.g. ARDSnet table)
    • Permissive hypercapnia with pH >7.2

  • With coexisting TBI or spinal cord injury: target PaCO2 4.5-5.0 kPa to optimise cerebral or spinal perfusion
  • Increasing PEEP does not appear to raise ICP in non-obese patients with TBI & in obesity the effect is modest
  • Prone ventilation for refractory hypoxaemia is complicated by unstable spinal injuries, chest drains and an open abdomen, but is possible with MDT planning

Pleural injuries

  • Intercostal drains are often inserted under time pressure and dislodge during transfers: secure and re-image on ICU admission
  • Practice is moving away from reflexively draining any traumatic pneumothorax before PPV
    • Evidence suggests <10% of conservatively management pneumothoraces later required chest drains
    • Small, clinically-irrelevant pneumothoraces may not need empirical drainage
    • Low threshold for drain if patient deteriorates

Cardiovascular

  • 'Fill first, then squeeze': early hypotension is ongoing haemorrhage until proven otherwise
  • Once haemostasis and euvolaemia are achieved, persistent hypotension should prompt a search for other causes:
    • Tamponade or blunt cardiac injury
    • Neurogenic shock from high spinal cord injury
    • Vasodilatation from the systemic inflammatory response
  • Most patients need low-dose noradrenaline to offset sedation, inflammation and the effects of massive transfusion; this should be anticipated
  • Any significant increase in vasopressor dose must prompt immediate re-evaluation
  • Low-dose vasopressin reduced blood product use in haemorrhagic shock, but safety concerns (including splanchnic perfusion) limit routine use
  • Monitor trends in Hb and lactate or base deficit; remember Hb is a concentration and may be normal in acute bleeding

Blunt cardiac injury

  • Ranges from undetectable contusion to septal or valvular injury and (usually fatal) rupture; there are no agreed diagnostic criteria
  • Features: chest pain, ECG changes (e.g. RBBB, arrhythmias), valvular dysfunction, cardiac failure
  • If suspected: continuous ECG monitoring and transthoracic echo
  • A negative troponin is useful to rule out significant injury; cardiac MRI is more accurate but involves transfer risk

Vascular and limb injury

  • Extremity arterial injury needs revascularisation within a maximum of 4 hours
  • Monitor closely for compartment syndrome, especially without prophylactic fasciotomies; loss of pulses is a late sign
  • A rising creatine kinase should prompt review for compartment syndrome or the need for further debridement

Neurological

  • Brain injury deaths are now the leading cause of trauma death in European ICUs
  • Prevent secondary brain injury: avoid hypoxia, hypo- and hypercapnia, hypotension, hyperthermia and seizures
  • Patients sedated to a level where they cannot be assessed clinically should be discussed with neurosurgery regarding ICP monitoring
  • Spinal cord and brain injuries impose perfusion pressure targets that may conflict with conservative management of visceral injuries

Renal

  • Acute kidney injury from hypoperfusion, contrast and rhabdomyolysis (particularly crush injury and compartment syndrome)
  • Hyperkalaemia after massive transfusion and reperfusion

Gastrointestinal

  • Damage control laparotomy may leave an open abdomen with negative pressure dressing: monitor effluent and watch for abdominal compartment syndrome
  • Bowel may be left in discontinuity pending anastomosis or stoma, influencing feeding decisions
  • Severe pancreatic injury may cause loss of endocrine function, requiring insulin

Nutritional and metabolic

  • Early nutrition (within 72 hours) reduces sepsis threefold compared with delayed feeding (ESPEN)
  • Enteral is preferred to parenteral: better use of nutrients, prevents mucosal atrophy, preserves gut flora, reduces the stress response and maintains immunocompetence
  • Continuous feeding is often interrupted by repeated surgery, gastrointestinal injury and ileus; minimise fasting for scheduled procedures
  • Hyperglycaemia is common and associated with mortality: target glucose ≤10 mmol/L and avoid hypoglycaemia (NICE-SUGAR, 2009)
  • Correct hypothermia and electrolyte disturbance (hypocalcaemia, hyperkalaemia) aggressively

Haematological

  • Fixed-ratio transfusion evidence relates to the initial phase; by the time patients reach ICU, coagulopathy needs a more tailored approach
  • Viscoelastic testing offers faster turnaround than conventional tests, helps communication with haematology and helps judge when to stop products (ITACTIC, 2021)
  • European guideline targets in ongoing bleeding: Hb 70-90 g/L, platelets >50 × 109/L (>100 in TBI), fibrinogen >1.5 g/L, ionised calcium 1.1-1.3 mmol/L
  • Reverse anticoagulants as part of haemorrhage control
  • VTE: patients quickly become hypercoagulable
    • Use mechanical prophylaxis unless contraindicated
    • Withhold chemical prophylaxis until haemorrhage and coagulopathy are controlled
    • Start at the earliest safe opportunity with timing agreed by the trauma team

MSK

  • Timing of definitive fixation is guided by daily reassessment of physiology (see trauma pathophysiology)
  • Daily physiotherapy (respiratory and range of movement) and early rehabilitation referral
  • Remove scoops and boards early; meticulous pressure area care

Non-operative management

  • Non-operative management (NOM) of blunt and penetrating trauma has increased, reliant on rapid, expert CT interpretation and interventional radiology; it is less applicable in resource-limited settings
  • NOM is the treatment of choice for haemodynamically stable minor, moderate and severe liver injuries without other injuries needing surgery
  • NOM requires frequent reassessment and a low threshold for intervention

After damage control surgery

  • DCS aims to return a living patient to ICU for physiological resuscitation, with temporary cavity closure (ideally <90 minutes operating, with regular sitreps)
  • Key questions for the ICU team:

Question Implication
Is haemostasis definitive, or are temporising measures in place (packs, vascular shunts)? Risk of further bleeding; planned relook surgery
Which organs have been damaged or removed? Replace lost function: e.g. insulin after pancreatic injury; vaccination against encapsulated organisms 2 weeks after splenectomy and lifelong antibiotic prophylaxis
Is the bowel in continuity or stapled off? Influences feeding route and timing
What is the degree of contamination? Spectrum and duration of antimicrobial cover

  • ICU goals: rewarm, correct acidosis, coagulopathy and calcium, restore volume (guided by lactate), lung protective ventilation, sedation (and paralysis if needed) to protect the open abdomen, CK monitoring and antibiotics
  • Return to theatre for definitive surgery once rewarmed, with coagulopathy corrected and physiology normalised as far as possible; anticipate further bleeding and have products available

Complications of damage control surgery

  • Ongoing or new bleeding
  • Persistent hypothermia, acidosis and coagulopathy
  • Abdominal compartment syndrome
  • Enterocutaneous fistula with an open abdomen
  • Missed injuries, as the initial work-up was abbreviated

  • Trauma disrupts skin and soft tissue, often in heavily contaminated environments; prophylaxis must be balanced against antimicrobial stewardship

Injury Recommendation
Head Indicated after penetrating brain injury
Insufficient evidence for basal skull fracture even if CSF leak
Chest Reduce empyema after chest drain insertion in penetrating trauma
Not indicated for blunt chest trauma
Abdomen Suggested for 24 hours after laparotomy if a hollow viscus is injured
Open fractures Gram-positive cover a± Gram-negative cover if significant injury

  • Also consider tetanus status, local microbiology guidance and the need for source control or debridement
  • Later in the ICU course, sepsis and progression to multiple organ failure are the greatest risks

  • Patients over 60 years now make up more than half of patients with an ISS >15 in the TARN database
  • Admission decisions balance potentially life-saving organ support against burdensome treatment in a group at high risk of ICU complications (delirium, pressure damage, loss of function) and death
  • Decisions should be patient-centred, made by an ICU consultant within the trauma MDT, using objective information:
    • Injury burden and its associated risk of death
    • Comorbidities and objectively scored frailty (e.g. Clinical Frailty Scale)
    • Outcomes the patient would find acceptable
  • Where benefit is uncertain, a time-limited trial of treatment allows more information to be gathered
  • The London Major Trauma System suggests a palliative approach may be considered with:
    • Catastrophic injury (e.g. TBI with herniation)
    • Disabling injury with anticipated poor quality of life (e.g. high spinal cord injury)
    • Significant pre-morbid frailty or comorbidity with likely death within 12 months
    • Other terminal illness (e.g. metastatic malignancy, end-stage organ failure)
  • Early, compassionate conversations with families should explore acceptable goals of care before urgent decisions about life-changing interventions
  • See major trauma in the elderly