POST-TRAUMATIC POST-TRAUMATIC RESPIRATORY INSUFFIENCYRESPIRATORY INSUFFIENCY

Dr.R.SelvakumarDr.R.SelvakumarAssistant Professor,Assistant Professor,Dept. of Anaesthesiology,Dept. of Anaesthesiology,Madurai Medical College,Madurai Medical College,MaduraiMadurai

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RESPIRATORY FAILURE DUE TO TRAUMA:RESPIRATORY FAILURE DUE TO TRAUMA:

DIRECTDIRECT INDIRECTINDIRECT

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DIRECT CAUSES OF RESPIRATORY FAILURE:DIRECT CAUSES OF RESPIRATORY FAILURE:

•Direct airway trauma, airway obstructionDirect airway trauma, airway obstruction•Chest injuryChest injury

flail chestflail chestpneumo/haemothoraxpneumo/haemothoraxpulmonary contusionpulmonary contusioncardiac tamponadecardiac tamponade

•Circulatory failureCirculatory failure•Head injuryHead injury

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INDIRECT CAUSESINDIRECT CAUSES

LONG BONE FRACTURESLONG BONE FRACTURES

IMPACT IN THE LUNGSIMPACT IN THE LUNGS

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PATHOLOGY OF LUNG INJURY AFTER TRAUMA:PATHOLOGY OF LUNG INJURY AFTER TRAUMA:

Trauma – Local release of inflammatory mediators( cytokines) Trauma – Local release of inflammatory mediators( cytokines) from the Neutrophils - spread – activation of neuroendocrine,from the Neutrophils - spread – activation of neuroendocrine,complement, coagulative and fibrinolytic pathwayscomplement, coagulative and fibrinolytic pathways

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PATHOLOGY:…contd…

Microvascular occlusion from fibrin and platelet aggregatesMicrovascular occlusion from fibrin and platelet aggregates- Interstitial leakage of protein and neutrophil rich fluid- Interstitial leakage of protein and neutrophil rich fluid

LEADING TOLEADING TO

DIFFUSE ALVEOLAR DAMAGEDIFFUSE ALVEOLAR DAMAGE

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PATHOLOGY: contd…PATHOLOGY: contd…

•Decrease in pulmonary compliance•Pulmonary flooding•Decrease in FRC•Increased vascular shunting•V-Q mismatch

END RESULT IS HYPOXEMIAEND RESULT IS HYPOXEMIA

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TRAUMATRAUMA

LONG BONE & HIP FRACTURELONG BONE & HIP FRACTURE

FAT EMBOLISATIONFAT EMBOLISATION FAT EMBOLISATION FAT EMBOLISATION SYNDROMESYNDROME

ACUTE LUNG INJURYACUTE LUNG INJURY ARDSARDS

MULTI ORGAN DYSFUNCTION SYNDROMEMULTI ORGAN DYSFUNCTION SYNDROME

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DO ALL THE TRAUMA PATIENTS DEVELOP DO ALL THE TRAUMA PATIENTS DEVELOP FAT EMBOLISM AND ARDS…?FAT EMBOLISM AND ARDS…?

YES AND NOYES AND NO

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90% of trauma patients show fat globules in the lung capillaries90% of trauma patients show fat globules in the lung capillaries

1-5 % of these patients develop ARDS1-5 % of these patients develop ARDS

WHICH UNLUCKY PATIENTS WHICH UNLUCKY PATIENTS DEVELOP A.R.D.S…?DEVELOP A.R.D.S…?

Patients with a primed inflammatory responsePatients with a primed inflammatory responseSecondary injury ( HITS )Secondary injury ( HITS )

circulatory imbalancecirculatory imbalanceresidual hypovolemiaresidual hypovolemiablood transfusionblood transfusionFat embolism Fat embolism

HOW TO DIAGNOSE ARDS..?HOW TO DIAGNOSE ARDS..?

Clinical signsClinical signs

Low OLow O22 saturation in spite saturation in spite of oxygen supplementof oxygen supplement

Chest X-rayChest X-rayABGABGPCWPPCWP

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OXIMETRY FORMS THE MAINSTAY OF DIAGNOSISOXIMETRY FORMS THE MAINSTAY OF DIAGNOSIS

The biggest limitation is the relationship between paO2 and SpO2

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paO2paO2

SpO2SpO2

OXYHAEMOGLOBIN DISSOCIATION CURVEOXYHAEMOGLOBIN DISSOCIATION CURVETNOA-08

100%100%

80mm of Hg80mm of Hg60

90%90%

JUST BECAUSE OJUST BECAUSE O2 2 SATURATION IS SATURATION IS NORMAL, U CAN’T RULE OUT ARDS….NORMAL, U CAN’T RULE OUT ARDS….

IN NUTSHELL…,IN NUTSHELL…,

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IF FAT EMBOLISM IS ONE OF THE IF FAT EMBOLISM IS ONE OF THE REASON FOR ARDS….REASON FOR ARDS….

What is the impact of the timing and type What is the impact of the timing and type of surgery for fractures..?of surgery for fractures..?

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EARLY FIXATION OF FRACTURES HELP TO REDUCEEARLY FIXATION OF FRACTURES HELP TO REDUCETHE INCIDENCE OF ARDSTHE INCIDENCE OF ARDS

In isolated fracturesIn isolated fracturesWith injury to multiple systemsWith injury to multiple systems

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THE BENEFITS OF EARLY FIXATION…THE BENEFITS OF EARLY FIXATION…

Reduction of mortalityReduction of mortalityNo increase in the incidence of FENo increase in the incidence of FEDecreased duration of mechanical ventilationDecreased duration of mechanical ventilationDecreased incidence of nosocomial infection andDecreased incidence of nosocomial infection and Thromboembolic diseaseThromboembolic diseaseDecreased cost of treatmentDecreased cost of treatment

IN ISOLATED FRACTURES…IN ISOLATED FRACTURES…

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IN SEVERELY INJURED PATIENTS WITHIN SEVERELY INJURED PATIENTS WITHMULTIPLE INJURIES…MULTIPLE INJURIES…

oLife threatening complications take priorityLife threatening complications take priorityoTemporary external stabilisationTemporary external stabilisationoPro-inflammatory conditionPro-inflammatory conditionoClinically occult tissue hypoxia and hypoperfusion-Clinically occult tissue hypoxia and hypoperfusion-o? Role of reamed nailing? Role of reamed nailingoThink of unreamed nailing,compression plates,ventingThink of unreamed nailing,compression plates,venting during nailing, lavage of the medullary canal etc..during nailing, lavage of the medullary canal etc..

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PROBLEMS OF EARLY FIXATION PROBLEMS OF EARLY FIXATION IN MULTIPLE INJURIESIN MULTIPLE INJURIES

inadequate time for total evaluationinadequate time for total evaluationMissed abdominal and head injuryMissed abdominal and head injuryThe problems of massive blood transfusionThe problems of massive blood transfusionExhaustion of the teamExhaustion of the teamInadequacies of the studies claiming good resultsInadequacies of the studies claiming good results after early fixationafter early fixation

AND FINALLY ....

THINK ABOUT THE POOR ANESTHETISTTHINK ABOUT THE POOR ANESTHETIST

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If definitive fixation is delayed inIf definitive fixation is delayed inPro-inflammatory patients with multiple fractures …Pro-inflammatory patients with multiple fractures …

When can we go for definitive surgery…?When can we go for definitive surgery…?

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ARGUMENT CONTINUES…..ARGUMENT CONTINUES…..

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TREATMENT OF ARDS:TREATMENT OF ARDS:

Oxygen therapy – venti mask preferredOxygen therapy – venti mask preferredNon-invasive ventilation- mask CPAPNon-invasive ventilation- mask CPAPMechanical ventilation with or without PEEPMechanical ventilation with or without PEEPSupportive – nutritional,antibiotics etc..Supportive – nutritional,antibiotics etc..No role for steroids,heparin, anti inflammatory drugsNo role for steroids,heparin, anti inflammatory drugs

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SUMMARISING…SUMMARISING…

Post-traumatic respiratory failure occurs becausePost-traumatic respiratory failure occurs because of development of an inflammatory responseof development of an inflammatory responseFat embolisation may lead to development ARDSFat embolisation may lead to development ARDSReaming of nailing doesn’t seem to increase Reaming of nailing doesn’t seem to increase the incidence of ARDSthe incidence of ARDSMonitoring with pulseoximetry and ABG is essential in Monitoring with pulseoximetry and ABG is essential in the diagnosis of ARDSthe diagnosis of ARDSThe proof for the beneficial effect from modification of the The proof for the beneficial effect from modification of the timing and technique of fracture stabilisation is lackingtiming and technique of fracture stabilisation is lacking

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CONCLUSION:CONCLUSION:

‘‘initial and deligent resuscitation andinitial and deligent resuscitation andearly fixation of fractures to certain early fixation of fractures to certain extent prevent the incidence of ARDS…’extent prevent the incidence of ARDS…’

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