ICU Management of Trauma Patients

Samuel A. Tisherman, MD, FCCM; Deborah M. Stein, MD, MPH, FCCM

Disclosures

Crit Care Med. 2018;46(12):1991-1997. 

In This Article

Airway and Ventilator Management

Airway management in trauma patients must take into account the patient's injuries and physiologic state, potential for anatomic distortion, risk for cervical spine injury, a potentially full stomach, and premorbid status. The indications for securing an airway include airway injury, impaired gas exchange, shock, and depressed mental status with a decreased ability to protect the airway. Rapid sequence induction is standard. Use of video laryngoscopy may not improve outcomes compared with direct laryngoscopy.[12–14] If orotracheal intubation is unsuccessful, a supraglottic airway (e.g., intubating laryngeal mask airway) may be a useful rescue device, although there are some circumstances, for example, severe facial trauma, in which the initial airway should be surgical, for example, cricothyrotomy or awake tracheostomy.

The potential harmful effects of mechanical ventilation, ventilator-induced lung injury, including barotrauma, volutrauma, and atelectrauma, need to be considered when applying mechanical ventilation to trauma patients. A lung-protective strategy, using tidal volumes of 6–8 mL/kg and maintaining plateau pressures under 30 torr, is beneficial for high risk patients and, likely, all patients. An "open lung" strategy using appropriate levels of positive end-expiratory pressure along with recruitment maneuvers remains controversial.[15] "Permissive hypercapnia" can be used with the caveat that it can worsen intracranial hypertension in patients with severe TBI.

Ventilator-associated pneumonia (VAP) is another risk of mechanical ventilation. Minimizing the length of time that an artificial airway is in place and that a patient requires mechanical ventilation is critical to the prevention of VAP. In addition, the Institute for Healthcare Improvement has promoted a ventilator bundle to decrease the rate of VAP. Components of the bundle include the following: 1) elevation of the head of the bed, 2) daily sedative interruption and daily assessment of readiness to extubate, 3) peptic ulcer disease prophylaxis, 4) deep venous thrombosis prophylaxis, and 5) daily oral care with chlorhexidine.[16]

Critically ill trauma patients are at high risk for developing severe hypoxemia due to pulmonary contusions, aspiration, pneumonia, or the acute respiratory distress syndrome. Airway pressure release ventilation (APRV) is a mode of ventilation that can be used to improve oxygenation by maximizing mean airway pressure and subsequent alveolar recruitment while limiting barotrauma. Early use of APRV compared with low tidal volume ventilation seems safe, but clear benefit has not been demonstrated.[17–19] For patients with refractory hypoxemia, rescue therapies may include prone positioning[20] and pulmonary vasodilators (epoprostenol or inhaled nitric oxide).[21] Extracorporeal membrane oxygenation (ECMO), originally thought to be contraindicated because of bleeding risk, can also be used safely in selected patients.[22–24] Clear benefits of these interventions are difficult to demonstrate.

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