POST-TRAUMATIC

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POST-TRAUMATIC RESPIRATORY INSUFFIENCY
Dr.R.Selvakumar Assistant Professor, Dept. of
Anaesthesiology, Madurai Medical College, Madurai
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RESPIRATORY FAILURE DUE TO TRAUMA
DIRECT
INDIRECT
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DIRECT CAUSES OF RESPIRATORY FAILURE

• Direct airway trauma, airway obstruction
• Chest injury
• flail chest
• pneumo/haemothorax
• pulmonary contusion
• cardiac tamponade
• Circulatory failure
• Head injury

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INDIRECT CAUSES
LONG BONE FRACTURES
IMPACT IN THE LUNGS
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PATHOLOGY OF LUNG INJURY AFTER TRAUMA
Trauma Local release of inflammatory mediators(
cytokines) from the Neutrophils - spread
activation of neuroendocrine, complement,
coagulative and fibrinolytic pathways
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PATHOLOGYcontd
Microvascular occlusion from fibrin and platelet
aggregates - Interstitial leakage of protein and
neutrophil rich fluid
LEADING TO
DIFFUSE ALVEOLAR DAMAGE
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(No Transcript)
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PATHOLOGY contd

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

END RESULT IS HYPOXEMIA
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TRAUMA
LONG BONE HIP FRACTURE
FAT EMBOLISATION SYNDROME
FAT EMBOLISATION
ACUTE LUNG INJURY
ARDS
MULTI ORGAN DYSFUNCTION SYNDROME
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DO ALL THE TRAUMA PATIENTS DEVELOP FAT EMBOLISM
AND ARDS?
YES AND NO
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• 90 of trauma patients show fat globules in the
  lung capillaries

• 1-5 of these patients develop ARDS

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

• Patients with a primed inflammatory response
• Secondary injury ( HITS )
• circulatory imbalance
• residual hypovolemia
• blood transfusion
• Fat embolism

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HOW TO DIAGNOSE ARDS..?

• Clinical signs
• Low O2 saturation in spite
• of oxygen supplement

Chest X-ray ABG PCWP
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OXIMETRY FORMS THE MAINSTAY OF DIAGNOSIS

• The biggest limitation is the relationship
  between
• paO2 and SpO2

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100
90
SpO2
80mm of Hg
60
paO2
OXYHAEMOGLOBIN DISSOCIATION CURVE
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IN NUTSHELL,
JUST BECAUSE O2 SATURATION IS NORMAL, U CANT
RULE OUT ARDS.
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IF FAT EMBOLISM IS ONE OF THE REASON FOR ARDS.
What is the impact of the timing and type of
surgery for fractures..?
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EARLY FIXATION OF FRACTURES HELP TO REDUCE THE
INCIDENCE OF ARDS

• In isolated fractures
• With injury to multiple systems

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THE BENEFITS OF EARLY FIXATION
IN ISOLATED FRACTURES

• Reduction of mortality
• No increase in the incidence of FE
• Decreased duration of mechanical ventilation
• Decreased incidence of nosocomial infection and
• Thromboembolic disease
• Decreased cost of treatment

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IN SEVERELY INJURED PATIENTS WITH MULTIPLE
INJURIES

• Life threatening complications take priority
• Temporary external stabilisation
• Pro-inflammatory condition
• Clinically occult tissue hypoxia and
  hypoperfusion-
• ? Role of reamed nailing
• Think of unreamed nailing,compression
  plates,venting
• during nailing, lavage of the medullary canal
  etc..

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PROBLEMS OF EARLY FIXATION IN MULTIPLE INJURIES

• inadequate time for total evaluation
• Missed abdominal and head injury
• The problems of massive blood transfusion
• Exhaustion of the team
• Inadequacies of the studies claiming good results
• after early fixation

AND FINALLY ....
THINK ABOUT THE POOR ANESTHETIST
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If definitive fixation is delayed
in Pro-inflammatory patients with multiple
fractures
When can we go for definitive surgery?
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ARGUMENT CONTINUES..
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TREATMENT OF ARDS

• Oxygen therapy venti mask preferred
• Non-invasive ventilation- mask CPAP
• Mechanical ventilation with or without PEEP
• Supportive nutritional,antibiotics etc..
• No role for steroids,heparin, anti inflammatory
  drugs

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SUMMARISING

• Post-traumatic respiratory failure occurs because
• of development of an inflammatory response
• Fat embolisation may lead to development ARDS
• Reaming of nailing doesnt seem to increase
• the incidence of ARDS
• Monitoring with pulseoximetry and ABG is
  essential in
• the diagnosis of ARDS
• The proof for the beneficial effect from
  modification of the
• timing and technique of fracture stabilisation
  is lacking

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CONCLUSION
initial and deligent resuscitation and early
fixation of fractures to certain extent prevent
the incidence of ARDS
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