외상환자 관련

0) 초진환자

응급실 내원환자

    전신 손상의심(자전거, 오토바이, 추락 등) -> 반드시 흉부, 복부 검사 시행

    CT (Chest, Abdomen-pevis) X-ray (Chest, Abdomen, Pelvis)

    의식저하나 중증환자의 경우 가급적 T_bay로 이동

    의식이 명료한 경우 (특히 chronic SDH) NPO time확인

T-bay 내원환자

    외상보다 의식소실이 먼저인게 확인된 경우 -> CT angio

    GCS < 9, 개방성 뇌손상, 두개골 기저부의 심한손상시 (또는 심한 안면 손상) CT angio

 

1) 초기 외상 소생술

Airway – Intubation 이 필요하다고 판단되면, 즉시 시행. A-line이나 C-line이 먼저가 아님.

Vital sign 유지 – 혈압이 높다고 급하게 낮추지 말 것. 불가피하게 Perdipine은 특히 1번 주게 되면 (혹은 응급의학과에서 줬다면) 1시간 이내에 재투여 절대 금지.

ICP monitoring insertion – 응급실에서 시행하지 말고 반드시 중환자실로 빨리 입원 후에 시행. 삽입시에 sedation이 필요하다면, 윗년차 혹은 외상외과에 도움요청

 

2) 초기 상태 평가

생체 징후 안정화 후에 확인, 혹은 첫 대면 의료진에게 확인

GCS – 단, alcohol 복용이 확인된다면 윗년차나 교수에게 반드시 전달할 것.

Combined injury 의 중증도 정확히 평가. – open fracture여부, Deep laceration or defect 등 여부.

 

3) 입원결정

외상 환자의 경우 특별한 경우 외에는 전원이 불가하므로 응급실 내원 환자이며 다른 주요 외상이 없다면 빠른 시간내에 외상 중환자실로 입원시킬 것.

(전원 가능한 특별한 경우 – 환자 보호자의 전원 요청. 적극적 치료 거부(고령, 내과적질환환자등))

 

4) Hyperacute bleeding 감별

CT에서 slightly high or iso intensity to brain 인 경우 출혈이 진행되고 있음을 의심해야 함.(혹은 DIC와 같은 응고장애 발생가능성도 있음) 이러한 경우 Mannitol은 금기이며, 수술 준비 및 급성 악화 가능성 설명, Short term CT f/u (1~2시간)고려해야함.

*참고 Mannitol contraindication

  - Active intracranial bleeding except during craniotomy
  - Anuria due to Severe renal disease
  - Severe Pulmonary Congestion / Edema
  - Progressive renal disease / heart failure / Pulmonary congestion

5) Angio CT 결정

환자 GCS 8점 이하, 개방성 손상, 안면부의 심한 손상 (기저부골절의심)이 있다면 뇌혈관 CT촬영을 해도 무방함.

 

6) ICP insertion indication

- GCS 8점 이하 환자

- GCS 9~12점이나 sedation이 필요한 환자 (intubation or combined injury)

- 당장은 herniation이나 swelling이 심하지 않으나(shifting <5mm미만) 진행가능성이 높은 경우 (급성기)

 

<< 환자 중증도에 따른 정리 >>

Initial GCS < 9

-  Intubation / ICP monitoring insertion / Central line insertion / Jugular venous catheter insertion

Initial GCS 9~12

-  Intubation 은 전신상태, 호흡 확인후 시행

-  Sedation 이 필요하다면 ICP monitoring insertion / Jugular venous catheter

Initial GCS > 12

-  Close observation, q 1 hr pupil check-in ICU

-  Short term CT f/u scan within 3~24 hrs (초기 출혈 양상에 따라)

-  Irritability -> 경구 가능하면 Seroquel 25~50mg, 경구 투여 협조 안되면 Dextomine

 

7) Sedation protocol (진정치료단계)

1단계 - To Irritability control : Dextomine or Midazolam(low dose IV shooting)

2단계 - To ICP control : Midazolam + Vecaron (혈압 저하 여부에 따라 투약 용량 조절)

3단계 - To ICP control 2 : Entobar therapy – Caution to Dyskalemia, arrhythmia

 

8) Seizure prophylaxis

No evidence for prevention of long term seizure attack

AED for 1 week (Valproic acid -> side 발생시 Keppra)

 

9) Target

ICP / CPP target (단위에 유의: 20 mmHg = 27.2 cmH2O)
Best
- ICP < 20mmHg, CPP > 60mmHg
Better
- ICP 20~22mmHg
Caution
- ICP > 22mmHg, CPP < 60mmHg

Target BP – Systol 120~140mmHg (CPP유지가 중요, 60이상)

Hyperosmolar therapy
Mannitol – Serum osmol 320 이하
Hypertonic Saline – Serum Na 150~155내외

Hyperosmolar therapy는 BBB가 손상되지 않은, 즉 다치지 않은 뇌조직의 부피를 줄이는 효과. 손상된 부분에는 작용하지 않음.

급성 출혈 진행시기이 투여시 출혈이나 뇌탈출 악화.

 

Summary of adult trauma management guidelines
Topic	Guidelines
Blood pressure and oxygenation	Level II—Monitor blood pressure, avoid hypotension (SBP < 90 mm Hg) Level III—Monitor oxygenation, avoid hypoxia (PaO 2< 60 mm Hg or O 2saturation < 90%)
Hyperosmolar therapy	Level II—Mannitol may effectively control elevated ICP; dosing at 0.25 to 1 g/kg. Avoid SBP < 90 mm Hg Level III—Minimize use of mannitol in patients without ICP monitoring; use in unmonitored patients with clinical signs of neurologic deterioration or herniation
Prophylactic hypothermia	Level III—Based on BTF meta-analysis. Decrease in mortality when temperature maintained for > 48 h. Associated with improved GCS outcome
Infection prophylaxis	Level II—Antibiotics during intubation reduce pneumonia risk, without altering length of stay or mortality. Early tracheostomy is recommended, but does not affect mortality Level III—Early extubation in patients who meet clinical criteria does not affect pneumonia risk. Antibiotics during ventriculostomy placement are not recommended
DVT prophylaxis	Level III—Mechanical prophylaxis with compression stockings or pneumatic compression devices recommended until patients are ambulatory. Chemical prophylaxis is recommended, but carries a risk of expanding intracranial hemorrhage
Indications for intracranial pressure monitoring	Level II—ICP monitoring for TBI patients with a GCS score of 3–8 and presence of an intracranial contu- sion, hematoma, edema, or effacement of basal cisterns on head CT Level III—ICP monitoring in TBI patients with GC 3–8 and normal head CT if two or more of these criteria are met: > 40 years, unilateral or bilateral posturing, SBP > 90 mm Hg
Intracranial pressure monitoring technology	The ventricular catheter is considered to be the most cost-efficient and accurate means for monitoring ICP
Intracranial pressure threshold	Level II—Begin treatment when ICP > 20 mm Hg Level III—Management of ICPs requires evaluation of clinical examination, ICP measurement, and imaging findings
Cerebral perfusion thresholds	Level II—Avoid aggressively maintaining CPP > 70 mm Hg to minimize risk of ARDS Level III—Maintain CPP 50–70 mm Hg
Brain oxygen monitoring thresholds	Level III—Treat for jugular venous saturation < 50% or brain tissue oxygen < 15 mm Hg
Anesthetics, analgesics, sedatives	Level II—Prophylactic burst suppression with barbiturates not recommended. Avoid high-dose barbitu- rate management of ICPs Propofol is recommended for ICP management, but high doses should be avoided
Nutrition	Level II—Goal of full caloric provision by day 7
Antiseizure prophylaxis	Level II—Phenytoin and valproate not recommended for prevention of late posttraumatic seizures
Hyperventilation	Level II—Prophylactic hyperventilation (PaCO 2< 25 mm Hg) is not recommended Level III—Hyperventilation may serve as a temporizing measure; it is not recommended within the first 24 h of injury. Monitoring jugular venous oxygen saturation or brain oxygen tension is recommended
Steroids	Level I—Not recommended for managing outcome or ICP
Abbreviations: BTF, Brain Trauma Foundation

Table 19.2 Treatment guidelines for traumatic brain injury
Surgical lesion	Guidelines
Acute epidural hematoma		Serial head CT and clinical examination: • EDH < 30 cm3, clot thickness < 15 mm, midline shift < 5 mm, GCS score > 8, and without focal neurologic deficit Emergent surgical evacuation: • All EDH > 30 cm3, GCS score < 9 with anisocoria
Acute subdural hematoma		ICP monitoring: • GCS score < 9 Emergent surgical evacuation: • SDH of > 10 mm thickness, or with > 5 mm MLS • GCS score < 9, and a SDH of < 10 mm thickness and < 5 mm MLS, if GCS score decreased by > 2, if ICP > 20 mm Hg, or if anisocoric
Traumatic parenchymal lesions		Close observation: • Neurologically stable without midline shift, mass effect, elevated ICP Emergent surgical intervention: • Neurologic deficit/decline, mass effect, or intractable ICP • GCS score 6–8 with frontal or temporal IPH > 20 cm3 and either > 5 mm MLS or cistern compression on head CT • IPH > 50 cm3
Posterior fossa mass lesion		Observation: • Patients without mass effect or neurologic deficit Emergent operative intervention: • Patients with mass effect or neurologic deficit
Depressed skull fractures		Observation: • < 1 cm depression, no dural tear, large hematoma, frontal sinus involvement, pneumocephalus, or wound infection/contamination Operative intervention: • Open fractures displaced greater than the thickness of the skull should undergo surgery
Abbreviations: CT, computed tomography; GCS, Glasgow Coma Scale; ICP, intracranial pressure; IPH, intraparenchymal hemorrhage; MLS, midline shift; SDH, acute subdural hematoma.