Insuficiencia Respiratoria en el Politraumatismo. C

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Insuficiencia Respiratoria en el Politraumatismo.
Cátedra de Medicina Intensiva28 de agosto de
2008Dr. A. Giordano.
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Bibliografía
Insuficiencia Respiratoria en el Traumatizado.
Cátedra de Medicina Intensiva .
Michaels AJ. Management of post traumatic
respiratory failure. Crit Care Clin 20- 2004
85-99 Ferdinand R. Rico, MD, Julius D. Cheng,
MD, MPH, Mark L. Gestring, MD, Edward S.
Piotrowski, MD. Mechanical Ventilation Strategies
in Massive Chest Trauma. Crit Care Clin 23 (2007)
299315 Colin R. Cooke, MD, et all .Predictors
of hospital mortality in a population-based
cohort of patients with acute lung injuryCrit
Care Med 2008 Vol. 36, No. 5 Hugo Bonatti, MD,
James Forrest Calland, MD. Trauma. Emerg Med
Clin N Am. 26 (2008) 625648
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Insuficiencia Respiratoria en el Politraumatismo
Insuficiencia Respiratoria en el Traumatizado.
Cátedra de Medicina Intensiva .

• En todo paciente traumatizado es esperable que se
  desarrolle algún grado de hipoxemia.
• Causalidad compleja
• Severidad multifactorial
• Evolución dinámica

• Edad
• Enfermedad pulmonar previa
• Severidad de la injuria-ISS

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Enfoque clínico
Insuficiencia Respiratoria en el Traumatizado.
Cátedra de Medicina Intensiva .
Inhalación
Trauma de abdomen
Transfusión
Contusión miocárdica
Embolia Grasa
Contusión
ARDS
Isquemia reperfusión
Trauma Maxilofacial
DOM
Trauma de tórax
Aspiración
S. compartimental
Infección
Trauma grave de miembros
Trauma de Cráneo
VILI
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Martin M, Salim A, Murray J, et al The
decreasing incidence and mortality of acute
respiratory distress syndrome after injury A
5-year observational study. J Trauma 2005
5911071113
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Crit Care Med 2008 Vol. 36, No. 5 Colin R.
Cooke, MD, et all .Predictors of hospital
mortality in a population-based cohort of
patients with acute lung injury
Figure 1. Kaplan-Meier estimates of hospital
survival among 65 patients with severe trauma and
89 patients with oliguric renal failure (defined
as urine output 500 mL in a 24-hr period and
serum creatinine 2.0 mg/dL) at onset of acute
lung injury (ALI) compared with 1,113 patients in
the entire cohort.
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Clasificación
Insuficiencia Respiratoria en el Traumatizado.
Cátedra de Medicina Intensiva .
Respecto a la Causa de la IR Con compromiso
pulmonar
Primario
Secundario Sin compromiso
pulmonar
Respecto de la evolución
Precoz
Mediato
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Hipoxemia No primariamente respiratoria
Insuficiencia Respiratoria en el Traumatizado.
Cátedra de Medicina Intensiva .

• TEC CR y edema neurogénico
• Compromiso CV edema y bajo gasto
• TRM

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Hipoxemia primariamente respiratoria
Insuficiencia Respiratoria en el Traumatizado.
Cátedra de Medicina Intensiva .

• Aspiración de vía aérea
• Contusión
• Ocupación pleural
• Lesiones de la pared torácica
• Atelectasias
• Embolias

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ALI - ARDS
Insuficiencia Respiratoria en el Traumatizado.
Cátedra de Medicina Intensiva .
Lesión pulmonar directa
Contusión

Aspiración Lesión pulmonar secundaria
Trauma
Necrosis tisular

Fracturas
Transfusión
S. Compartimental
Sepsis
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Causas
Insuficiencia Respiratoria en el Traumatizado.
Cátedra de Medicina Intensiva .
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Causas
Insuficiencia Respiratoria en el Traumatizado.
Cátedra de Medicina Intensiva .
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Causas
Insuficiencia Respiratoria en el Traumatizado.
Cátedra de Medicina Intensiva .
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Causas 9
Insuficiencia Respiratoria en el Traumatizado.
Cátedra de Medicina Intensiva .
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Causas
Insuficiencia Respiratoria en el Traumatizado.
Cátedra de Medicina Intensiva .
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Causas
Insuficiencia Respiratoria en el Traumatizado.
Cátedra de Medicina Intensiva .
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Evolución clínica
Insuficiencia Respiratoria en el Traumatizado.
Cátedra de Medicina Intensiva .
Injuria aguda ex físico y RX sp. Aumento de FC y
FR Período latente 6-48 hs. Alcalosis
respiratoria. Aumento del trabajo y de la DAaO2.
Mínimas RX Insuficiencia respiratoria aguda FR
y FC. Cae la compliance, Alteraciones en RX.
Auscultación. Distres severo
Gomez RJA, Apezteguía BC, Castillo SFJ
Pulmonary mechanics and gas exchange in ARDS.
Rev Clin Esp 16931, 1983
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Andrew J. Michaels, MD, MPH, FACS. Management of
post traumatic respiratory failure. Crit Care
Clin 20 (2004) 83 99
Fig. 1. Clinical onset of ARDS after initiating
events. Reprinted from Hudson LD, Milberg
JA,Anardi D, Maunder RJ. Clinical risks for
development of the acute respiratory distress
syndrome. Am J Respir Crit Care Med 1995151293
301
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ARDS
Insuficiencia Respiratoria en el Traumatizado.
Cátedra de Medicina Intensiva .
Michaels AJ. Management of post traumatic
respiratory failure. Crit Care Clin 20- 2004
85-99 50 de los sobrevivientes en VM a las 3
semanas. 50 hospitalizados a las 6 semanas.
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Quantitation and pattern of parenchymal lung
injury in blunt chest trauma. Diagnostic and
therapeutic implications.Wagner RB, Crawford WO
Jr, Schimpf PP, Jamieson PM, Rao KC.Department
of Surgery, Prince Georges Hospital Center,
Cheverly, Maryland.Sixty-nine patients with
nonpenetrating pulmonary trauma were studied by
chest computed tomography (CT) within 24 hours of
admission. The percentage of air-space filling
was quantitated and compared with the requirement
for ventilatory support. Pulmonary intraalveolar
hemorrhage always is gravity dependent
originating at the site of injury. Utilizing CT,
the patients' pulmonary status was classified
into three separate clinicoradiologic groups
Grade I injury (less than 18 air-space filling,
no ventilator support required), Grade II injury
(18-28 air-space filling, ventilator support
sometimes required), and Grade III injury
(greater than 28 air-space filling, ventilator
support always required). The CT quantitation
correlated with clinical functional studies and
was useful in the therapeutic management of
nonpenetrating lung injury.
Grado I- lt18 no VM GradoII
18-28 VM ??
GradoIII gt28 VM
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J Radiol. 1992 Dec73(12)657-62.  X-ray
computed tomography of thoracic injuries. Apropos
of 40 cases  Rahmouni A, Margenet-Baudry A,
Guerrini P, Anglade MC, Golli M, Vasile
N.  Service de Radiologie et Imagerie Medicale,
CHU Henri-Mondor, Creteil.  On chest radiographs,
the precise assessment of thoracic injuries
consecutive to blunt trauma is often compromised
by the nonspecific appearance of many
lesions. Furthermore, significant injuries are
frequently overlooked. However, the management of
the patients with chest trauma is still often
based primarily upon clinical and radiographic
findings and Computed Tomography (CT) is
often performed secondarily on the basis of
unexplained clinical signs or suspected radiograph
ic abnormality. Some authors have reported that
CT was a highly sensitive method for detecting
thoracic lesions frequently not seen
or underestimated on conventional supine chest
radiographs. However, the value that these new CT
findings could have in the therapeutic management
of these patients, have not been systematically
investigated to our knowledge, except in a
limited series suggesting that the course of
critically ill patients could be substantially
altered after thoracic CT. In order to estimate
the role of early CT in the management of patient
care, we report the therapeutic consequences
of CT findings in forty patients who we report
the therapeutic consequences of CT findings in
forty patients who had a thoracic CT within few
hours following a chest injury.
We showed that early thoracic CT scan in patients
with blunttrauma detected significantly more
lesions than did chest X-Ray and appreciably
modified the treatment modalities in 70 of our
patients. We then recommend that all the patients
admitted in ICU after chest trauma undergo a
thoracic CT scan as soon as possible in order to
optimize their treatment modalities.
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Guerrero-Lopez F, Vazquez-Mata G, Alcazar-Romero
PP, Fernandez-Mondejar E,Aguayo-Hoyos E,
Linde-Valverde CM. Evaluation of the utility of
computed tomography in the initial assessment of
the critical care patient with chest trauma.
Crit Care Med. 2000 May28(5)1370-5.
Trupka A, Waydhas C, Hallfeldt KK, Nast-Kolb D,
Pfeifer KJ, Schweiberer L. Value of thoracic
computed tomography in the first assessment of
severely injured patients with blunt chest
trauma results of a prospective study.J Trauma.
1997 Sep43(3)405-11 discussion 411-2.
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Historia clínica
Insuficiencia Respiratoria en el Traumatizado.
Cátedra de Medicina Intensiva .
Paciente de 20 a sin AP a destacar. PTG el 22 de
mayo cuando viaja en automóvil sin cinturón de
seguridad Ingresa a emergencia trasladada por
UEMPH Lúcida, TEC sin PC. Trauma de tórax
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Ingreso
Insuficiencia Respiratoria en el Traumatizado.
Cátedra de Medicina Intensiva .
TRM. Paraplegia. Nivel de anestesia en T5.
Polipnea de 28 pm Hemodinamia estable
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Ingreso en emergencia
Insuficiencia Respiratoria en el Traumatizado.
Cátedra de Medicina Intensiva .
TAC de cráneo normal TAC de tórax Luxofractura
T3 a T5. Sección medular. Neumotórax
laminar. Laceración esplénica. Fractura de fémur
cerrada 
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Primeras 24 hs.
Insuficiencia Respiratoria en el Traumatizado.
Cátedra de Medicina Intensiva .
Paciente en decúbito dorsal. Disnea. Gasometría
arterial con MFL PaO2 100 PaCO2 40 PH 7,32
HCO3 20 Se resuelve drenar neumotórax y
nebulizaciones
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Primeras 48 hs.
Insuficiencia Respiratoria en el Traumatizado.
Cátedra de Medicina Intensiva .
Polipnea superficial de 45 pm. Respiración
paradojal Hipoventila en ambas bases Gasometría
arterial con MFL PaO2 55 PaCO2 49 PH 7,28
HCO3 22
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Ingreso a CTI50 hs del trauma
Insuficiencia Respiratoria en el Traumatizado.
Cátedra de Medicina Intensiva .
IOT se aspiran muy abundantes secreciones. Ver RX
Cuál es la causa de la IR? Planteos
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Causas de la IR
Insuficiencia Respiratoria en el Traumatizado.
Cátedra de Medicina Intensiva .
Hipodinamia Contusión Atelectasia Neumonia Hipope
rfusión ARDS
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Causas de la IR
Insuficiencia Respiratoria en el Traumatizado.
Cátedra de Medicina Intensiva .
713 x .5 40/0,8 310 DAa 300- 55
245 713 x .5 49/0,8 300 DAa 310-100
210
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Evolución en CTI 1
Insuficiencia Respiratoria en el Traumatizado.
Cátedra de Medicina Intensiva .
FBC abundantes secreciones traqueales No se
observan tapones ni obstrucción bronquial lobar
o segmentaria a izq.   LBA del 24/5 estéril AT
24/05 Haemófilus Influenza. PAFI 220
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Evolución a 9 días del trauma
Insuficiencia Respiratoria en el Traumatizado.
Cátedra de Medicina Intensiva .
  Deterioro gasométrico VCV, PEEP 15, PaO2 89,
PaCO2 72 FiO21 Fiebre, GB en ascenso Cefuroxime
desde hace 5 días Ver TAC Sin otros focos
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Causas de la IR
Insuficiencia Respiratoria en el Traumatizado.
Cátedra de Medicina Intensiva .
Hipodinamia Contusión Atelectasia Neumonia Hipope
rfusión ARDS
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Cuál es la causa ?
Insuficiencia Respiratoria en el Traumatizado.
Cátedra de Medicina Intensiva .
Inhalación
Transfusión
Isquemia reperfusión
Contusión
ARDS
Aspiración
Embolia Grasa
Infección
S. compartimental
VILI
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. Virgos Senor B, Nebra Puertas AC, Sanchez Polo
C, MA. Predictors of outcome in blunt chest
traumaArch Bronconeumol. 2004 Nov40(11)489-94 Se
rvicio de Medicina Intensiva, Hospital
Universitario Miguel Servet, Zaragoza INTRODUCTION
Thoracic trauma is often associated with
polytrauma. Becausemortality is high, the search
for prognostic tools is useful. PATIENTS
ANDMETHODS A total of 108 patients with blunt
thoracic trauma, 73 of whom had multiple
injuries, were studied in an intensive care unit
(ICU). The variables named as potential
predictors of outcome were the need for
mechanical ventilation, duration of ventilation,
and high positive end-expiratory pressure (PEEP)
the presence of rib fractures, pulmonary
contusion, pleural involvement (hemo- and/or
pneumothorax), or lung infection the need for
emergency surgery mean duration of ICU stay, and
age. We also studied whether or not the mortality
rate was higher in polytrauma patients. Student t
and chi2 tests (95 confidence level) and
multiple regression analysis (Hosmer-Lemeshow
goodness of fit) were used to analyze the
results. RESULTS The need for mechanical
ventilation, radiographic evidence of pulmonary
contusion, emergency surgery, and hemodynamic
instability were risk factors for increased
mortality. Higher risk of mortality was not
demonstrated for patients with multiple injuries.
For patients in need of mechanical ventilation,
high PEEP was a predictor of poor prognosis.
CONCLUSIONS The presence of the aforementioned
predictors (mechanical ventilation, high PEEP,
pulmonary contusion, emergency surgery, and
hemodynamic instability) indicate serious injury
to the lung parenchyma, which is the main
determinant of outcome for patients with thoracic
trauma.
CONCLUSIONS The presence of the aforementioned
predictors (mechanical ventilation, high PEEP,
pulmonary contusion, emergency surgery, and
hemodynamic instability) indicate serious injury
to the lung parenchyma, which is the main
determinant of outcome for patients with thoracic
trauma.
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Figure 9. An incremental approach to the
management of catastrophic acute respiratory
distress syndrome. A high-level recruitment
maneuver is used only in patients that are
without neurologic disease and bacterial
pneumonia and that have adequate blood pressure,
filling pressures, and cardiac output. PEEP,
positive end-expiratory pressure PAOP, pulmonary
artery occlusion pressure. Crit Care Med 2006
Vol. 34, No. 9 (Suppl.) S287 Severe respiratory
failure Advanced treatment options Mark R.
Hemmila, MD, FACS Lena M. Napolitano, MD, FACS,
FCCP, FCCM
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Situación especial
Insuficiencia Respiratoria en el Traumatizado.
Cátedra de Medicina Intensiva .
Intubación doble luz Separación anatómica
Hemoptisis Separación funcional Fístula
broncopleural Contusión Injuria bronquial
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