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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3080_Библиотеки_им_академика_М_И_Перельмана
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The Patient with Abdominal Pain and Vomiting
69
What are the management strategies for patients
presenting with acute pancreatitis?
Fluid resuscitation–regardless of the severity of pancreatitis, it is well
recognised that initial management should include adequate uid resusci-
tation (usually at a rate of 5–10
mL/kg/h unless contraindicated), especially
for severe acute pancreatitis. The rapid restoration and replacement of
intravascular volume has the potential to reduce the incidence of acute
renal failure in severe acute pancreatitis. In addition, adequate volume
repletion can help to restore pancreatic microcirculation and prevent
further cellular death. Higher rates of pancreatic necrosis are associated
with inadequate intravascular volume replacement. However, care should
be taken when administering excessive volumes of uid as this may be
associated with an increased need for mechanical ventilation and a greater
risk for intra-
abdominal compartment syndrome, sepsis and mortality.
Managing respiratory failure–respiratory dysfunction is a common
manifestation in acute pancreatitis and can be due to both mechanical
and biochemical factors. Severe acute pancreatitis can often cause
marked abdominal distension, which reduces the functional residual
capacity (FRC), impairing both spontaneous and mechanical ventilation.
The release of pancreatic phospholipase A2into the circulation is also
thought to degrade lung surfactant and therefore aect lung compliance.
These, along with other factors, give rise to acute respiratory distress
syndrome (ARDS) that may require mechanical ventilation.
Analgesia–the pain associated with acute pancreatitis can be severe,
often necessitating the use of opioids. In addition, adequate pain relief
may improve respiratory dysfunction.
Nutritional support–patients with mild pancreatitis can usually be
started on oral supplements within a few days of presentation, so long
as nausea, vomiting or ileus is not present. For severe acute pancreatitis,
enteral nutrition when compared to parenteral nutrition has been shown
to reduce the risk of death, multiple organ failure, infection, surgery and
mean length of hospital stay. Moreover, total parenteral nutrition (TPN)
should be avoided in patients with acute pancreatitis as higher rates of
infection and line-
related complications have been observed.
Which complication of acute pancreatitis
could this be?
With evidence of systemic infection in the presence of an episode of acute
pancreatitis, Brian may have developed intra- abdominal sepsis, a pseudocyst
or necrotising pancreatitis.
What is necrotising pancreatitis?
Necrotising pancreatitis is a serious local complication that can either be sterile
or infected. It is dened by the presence of focal or diuse areas of non- viable
pancreatic parenchyma.
Brian continues to improve for the next 10days on your unit, but on day
11 he begins to experience pyrexia, abdominal pain and haemodynamic
compromise requiring vasopressor support.
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Clinical Cases in Critical Care
70
How would you diagnose necrotising pancreatitis?
This can be difficult to establish since clinical manifestations of systemic
inammation and nosocomial infections are common in patients with acute
pancreatitis. An increase in procalcitonin levels or air in the necrotic tissue as
demonstrated by CT may suggest infection. However, the gold standard involves
CT-
guided ne needle aspiration that should only be performed when infection
is suspected on clinical grounds.
What is the role of surgery in pancreatic necrosis?
It is now generally accepted and expected that a conservative approach is taken
in managing patients with suspected pancreatic or peripancreatic infection. Dis-
covering infection on a CT-
guided ne needle aspiration is no longer a rm indi-
cation for surgery. In fact, administration of antibiotics directed by the results
of culture and sensitivity and percutaneous drainage alone may be curative.
Surgical debridement or endoscopic drainage with necrosectomy is gen-
erally reserved for deteriorating patients on antibiotics who fail to respond.
What are the long- term outcomes
for these patients?
Severe acute pancreatitis and necrotising pancreatitis can be dicult and chal-
lenging to manage. In patients with end- organ failure for greater than 48 hours,
and/or infectious complications of pancreatic necrosis, mortality is in the range
of 15–20%.
Survivors can have prolonged ICU and hospital stay and may still require
other interventions once the episode has resolved (e.g. cholecystectomy or drain-
age of pancreatic pseudocysts). In addition, up to a third of survivors of severe
necrotising pancreatitis may develop diabetes mellitus. Other long-
term sequelae
include pancreatic stulae and chronic pancreatitis with chronic abdominal
pain that can be debilitating and dicult to manage. Nevertheless, most survi-
vors can return to a quality of life that is equal to age- matched controls.
Further reading
Mehta, A., Emmett, J., and Emmett, M. (2008). GOLD MARK: an anion gap
mnemonic for the 21st century. Lancet 372: 892. Original article detailing the use
of the acronym GOLDMARK and the rationale for its use.
Dutta, A., Goel, A., Kirubakaran, R. etal. (2020). Nasogastric versus nasojejunal
tube feeding for severe acute pancreatitis. Cochrane Database of Systematic Reviews
3: CD010582. Highly informative Cochrane systematic review.
Joint British Diabetes Societies Inpatient Care Group (2021) The Management of
Diabetic Ketoacidosis in Adults. London: Diabetes UK. Authoritative guideline that
gives excellent clinical strategies for managing DKA.
Brian responds appropriately to his course of antibiotic therapy, and is suc-
cessfully discharged to the ward under the joint care of the surgical and
medical teams.
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Clinical Cases in Critical Care, First Edition. Alice Myers and Theophilus Samuels.
© 2023 John Wiley & Sons Ltd. Published 2023 by John Wiley & Sons Ltd.
5
A
25- year- old female patient named Danielle has been involved in a head-
on road trac collision travelling at approximately 50 mph. She was the
driver, wearing a seatbelt, and has remained GCS 15 throughout. Extraction
time was under 30
minutes. She is brought to the Major Trauma Centre (MTC)
resuscitation area. You are nominated as team leader, taking an end- of- the- bed
approach and delegating specic tasks.
What are the goals of the primary survey?
The primary survey is designed to detect and correct all immediate threats
to life. After ensuring that there is no danger from the environment or
situation (e.g. petrochemical spill, risks of electrocution), an ABCDE
assessment (Airway, Breathing, Circulation, Disability and Exposure/Envi-
ronmental) with cervical spine immobilisation as per Advanced Trauma
and Life Support® (ATLS®) guidance should be performed. In an emergency
department setting, the risk of danger to sta may still be present depend-
ing on the scenario (e.g. the rare case of organophosphate poisoning). In a
team situation, roles and responsibilities would ideally be assigned prior to
the patient arriving. This enables eective communication throughout and
allows for concurrent interventions to be applied, such as oxygen therapy
and intravenous cannulation.
The Patient
Involved in a Road
Trac Collision
During the primary survey, Danielle begins saying she ‘can't breathe’ and
that her ‘chest hurts’. The examining doctor informs you that the left side of
her chest is not expanding fully and despite 15 L/min oxygen therapy, her
pulse oximetry is 92%. Her respiratory rate is over 30 breaths per minute.
Her GCS is 15. You are informed that her blood pressure is 90/60 mmHg,
and she is tachycardic at 130 bpm.
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Clinical Cases in Critical Care
72
What are the potentially life- threatening conditions
associated with these clinical ndings and how
should each one be managed?
Tension pneumothorax –as air progressively accumulates in the
pleural space, it begins to compress the lungs and heart, which leads to
respiratory and haemodynamic compromise. Tension pneumothorax
should be suspected in any case of chest trauma with otherwise unex-
plained haemodynamic instability. Classic clinical ndings (e.g. hyper-
resonance, tracheal deviation, absent breath sounds) may present late
and can be dicult to detect. Immediate needle decompression should
be performed by inserting an appropriately sized cannula into the fth
intercostal space along the midclavicular line in adults. Resolution of the
haemodynamic instability should occur very quickly, with the patient
stabilising soon thereafter. It is important at this stage, whether needle
decompression was successful or not, to insert an intercostal chest drain
and attach it to an underwater seal for ongoing management.
Open (sucking) pneumothorax–following penetrating chest trauma, if
air enters the pleural space through this defect but is not able to exit,
then pressure will increase and potentially cause mediastinal compres-
sion and cardiorespiratory compromise. This is managed by applying a
non- adherent dressing to the wound by sealing it along three edges only.
This allows air to escape but does not allow air to enter. It is imperative
that you insert an intercostal chest drain away from the defect site.
Massive haemothorax–this occurs when more than 1500 mL of blood or
over one- third of the patient’s blood volume rapidly accumulates within
the chest cavity. With the potential to cause marked hypovolaemia and
reduced venous return to the heart, this can lead to life-
threatening
cardiovascular collapse. Immediate drainage of >1500
mL of blood or
>200 mL for 2–4 hours may indicate a need for urgent thoracotomy.
Flail chest–consider a ail chest if two or more consecutive ribs are
fractured in two or more places and paradoxical movement occurs dur-
ing breathing. If conservative management fails (e.g. oxygen therapy or
non-
invasive ventilation) and respiratory failure begins to occur, then
mechanical ventilation and intubation should be considered. Usually, pro-
longed mechanical ventilation is not required, unless associated injuries
and co- morbidities are severe. Surgical stabilisation can be considered if
the ail chest is severe. However, this is not routinely carried out.
Pericardial tamponade–excess pericardial uid can lead to severe dis-
ruption of myocardial dynamics. The ability of the right ventricle to
ll during diastole is severely impaired. Increasing extrinsic pressure
applied by the accumulation of uid prevents the free wall from relax-
ing completely. With the right ventricle unable to eject blood eectively
into the pulmonary circulation, it simultaneously reduces the volume of
blood ejected into the systemic circulation by the left ventricle, leading to
severe haemodynamic compromise. A subcostal view of the heart using
ultrasound can quickly be obtained as part of a focused assessment by
an experienced operator. Assuming the image quality is adequate, it can
rule out signicant pericardial eusion.
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The Patient Involved in a Road Trac Collision
73
A useful and widely used pneumonic for ruling out life- threatening chest
injuries during the primary survey is ATOM-
FC:
Airway obstruction or disruption
Tension pneumothorax
Open pneumothorax
Massive haemothorax
Flail chest
Cardiac tamponade
While intravenous access is being established and blood withdrawn for the
appropriate tests, a focused ultrasonographic assessment of Danielle’s chest
is performed at the same time.
What are the advantages and disadvantages
of using focused assessment with sonography
in
trauma (FAST) versus radiographic imaging?
Advantages
Ultrasonography can be completed much faster than radiography.
Specic areas can be targeted for assessment.
Higher diagnostic accuracy for pneumothorax and haemothorax.
Avoids the use of ionising radiation (especially in women of child-
bearing age).
Can be performed at the same time as the primary survey with minimal
interruption.
Disadvantages
Requires an experienced operator.
It does not demonstrate rib fractures or other bony injuries.
Acquisition of images and their storage require robust clinical
governance.
How might bedside focused lung ultrasonography
help identify the cause of Danielle’s deterioration?
Pneumothorax.
Lung sliding–has a very high negative predictive value for diagnosing
a pneumothorax (should lung sliding be observed then pneumothorax
is not present at the point where the probe is applied to the chest wall).
However, the absence of sliding is not enough to make the diagnosis
as many other disorders are also consistent with absent lung sliding
(e.g. atelectasis, acute respiratory distress syndrome).
B- lines–the widening of the subpleural interlobular septa due
to fluid accumulation, for example, produces these characteristic
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Clinical Cases in Critical Care
74
Figure 5.1: Lung ultrasound taken at the left PLAPS point demonstrating
a large anechoic area (blue outline) consistent with a pleural effusion
(diaphragm – yellow arrows).
Source: Theophilus Samuels.
vertical ray- like artefacts. However, if a pneumothorax were present,
this interface between the visceral pleura and interlobular septa
would be lost and therefore the presence of a single B-
line effec-
tively rules out the diagnosis of a pneumothorax. Sadly, even the
absence of both lung sliding and B- lines still does not diagnose a
pneumothorax.
Lung point–with a partially collapsed lung that remains adherent
to the parietal pleura, this lung point can be visualised as a transient
appearance of a recognised ultrasonographic lung pattern (e.g.
lung sliding and/or B-
lines). This lung point is 100% specific for the
diagnosis of pneumothorax but cannot be visualised in totally col-
lapsed lungs.
Lung pulse–when lung sliding is synchronous with the heartbeat,
it creates a lung pulse on ultrasound. Therefore, even in the absence
of all the other described findings, if the slightest lung pulse is seen
it effectively rules out a pneumothorax.
Haemothorax–uid within the pleural space appears as an anechoic area
between the two pleural layers in the most dependent chest areas (e.g.
lateral-
basal lung areas in the supine patient). It is important to identify
the diaphragm and solid organs immediately below (e.g. liver or spleen)
as normal lung will transiently move into view with breathing, obscuring
these landmarks like a curtain (hence the ‘curtain sign’). However, the
absence of this curtain sign and presence of a large anechoic area are
highly suggestive of an eusion (Figure5.1), with the visualisation of
internal echoes (e.g. laments or mobile particles) being highly sugges-
tive of haemothorax.
Focused lung ultrasonography conrms the presence of a large left- sided
eusion. Danielle remains hypotensive and tachycardic and is becoming
mildly confused (unable to give her correct date of birth when asked).
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The Patient Involved in a Road Trac Collision
75
What might the effusion suggest and what are
the treatment goals?
Danielle is demonstrating signs of haemodynamic compromise from
apotentially massive haemothorax. Your goals at this point would be as follows:
Management of the haemothorax–your team need to insert an inter-
costal drain and attach it to an underwater seal. It would be appropriate
to activate the hospital-
wide ‘major haemorrhage/code red trauma’ alert
to facilitate provision of emergency blood products.
Managing hypotension–consider that the hypotension may in part be due
to hypovolaemia from blood loss. Administering O-
negative blood if type-
specic or cross- matched blood is not immediately available may be indi-
cated. Most institutions will have policies in place for emergency provision
of blood products. Fluid resuscitation should be ongoing until blood products
are available and being administered, but care should be taken to avoid exten-
sive haemodilution using crystalloid solutions (as these can aect both proco-
agulant and anticoagulant levels, leading to a complex coagulation disorder).
Source/site of bleeding–identifying an ongoing source of the bleeding,
if present, is imperative as uncontrolled bleeding will make continued
transfusions ultimately futile. Thoracotomy may need to be performed.
Tranexamic acid–the Clinical Randomisation of an Antibrinolytic in
Signicant Haemorrhage- 2 trial (CRASH- 2) demonstrated that if admin-
istered within the rst 3 hours of presentation, tranexamic acid can safely
reduce in- hospital mortality within 28 days of injury.
What are the most common blood groups?
Blood group A–these are patients with surface antigen A and plasma
antibodies to surface antigen B.
Blood group B–these are patients with surface antigen B and plasma
antibodies to surface antigen A.
Blood group AB–possess no plasma antibodies to either group A or B
and are known as a universal recipient.
Blood group O–no surface antigens are present to react to plasma anti-
bodies. Known as the universal donor.
Rhesus system–in addition to the ABO blood grouping system, patients
can be either Rhesus antigen positive or negative.
You suspect that Danielle will need blood transfusion, but her blood type is
unknown at this point.
What issues should you consider when transfusing
Danielle specically with regard to blood typing?
In a life- threatening exsanguination, group O blood can be given if
type- specic blood is not immediately available. However, type- specic
uncross- matched blood can then be used as it is considered relatively
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Clinical Cases in Critical Care
76
safe since the benet of transfusion outweighs the risk of a reaction. In
addition to administering blood, every attempt must be made to control
the source/site of bleeding.
Universal donor blood should preferably be group O and Rhesus nega-
tive, particularly if it is to be administered to women of child-
bearing age.
Identifying type- specic blood involves ensuring the donor blood is ABO
and Rhesus compatible with the recipient’s blood and can be provided
by most blood banks within 10
minutes.
Fully cross- matched blood is ultimately desirable and involves com-
paring the donor’s and recipient’s blood using not only the ABO and
Rhesus blood antigens, but also by directly testing for antibodies against
antigens present within the blood from the recipient. This process takes
longer and can be completed usually within 60
minutes.
Haemothorax is confirmed following insertion of the intercostal drain.
Type- specic blood is being given and her BP and HR begin to improve. No
further life- threatening injuries are found during the primary survey.
What would be your next steps in Danielle's
management?
Once the primary survey has been completed with all immediate life- threatening
injuries recognised and resuscitative eorts under way, consider performing diag-
nostic imaging as soon as possible. Usually, trauma patients would be expected
to have CT imaging performed within 1
hour (or 30 minutes if in an MTC).
Given that CT scanning is very rapid, it can be considered appropriate to take an
unstable patient ‘through the scanner’ accompanied by the trauma team and with
resuscitation ongoing. CT imaging of the head, neck, chest, abdomen and pelvis
with intravenous contrast (e.g. for aortic angiography) is commonly requested.
Prior to transferring Danielle to the CT scanner, she becomes unresponsive.
Her blood pressure is elevated at 150/80 mmHg, heart rate is 90 bpm and her
pulse oximetry reads 100% on 15 L/min of oxygen.
What do you think could be causing this change
in her neurological status?
You are concerned that Danielle has also suered a traumatic brain injury
(TBI). This may include the following.
Subdural haematoma (SDH)–found between the delicate arachnoid
mater (middle layer of dura) and the dura mater (outermost layer), this
‘potential’ space contains numerous bridging veins that connect the
cerebral hemispheres to the superior sagittal sinus (Figure5.2a). Shear
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The Patient Involved in a Road Trac Collision
77
forces applied to these bridging veins by rapid acceleration and decelera-
tion of the brain result in tearing and consequent haemorrhage; arteries
can also be aected. The overall mortality is higher than EDH, usually
reported as being between 40% and 60%. Prognosis is particularly poor
in patients aged 60 years and over, particularly when they present with
an acute SDH.
Epidural/extradural haematoma (EDH)–blood may accumulate between
the dura mater and the skull. Most associated with road trac collisions,
haemorrhage usually occurs from damage to the middle meningeal artery,
but may also involve the middle meningeal veins, diploic veins or venous
sinuses (Figure5.2b). Typically, patients will present with a transient
loss of consciousness followed by a period of lucidity where they often
appear neurologically intact. However, as blood begins to accumulate,
the brainstem becomes compressed, resulting in loss of consciousness.
Traumatic subarachnoid haemorrhage (SAH) – the CSF- filled
compartment between the subarachnoid mater and brain parenchyma
contains the major cerebral blood vessels. Cerebral vasospasm may occur
with traumatic SAH (though it is seen more commonly in aneurysmal
SAH) and result in further parenchymal damage (e.g. ischaemia, infarc-
tion). It is important to note that traumatic SAH can be a marker of
severe primary brain injury.
Contusions and haematomas–these entities may be considered as two
ends of a spectrum, where contusions are smaller heterogeneous areas
of haemorrhage or oedema and haematomas are homogeneous demar-
cated collections of blood within the brain parenchyma. Contusions can
potentially increase in size relatively soon after they are found, hence
the use of early CT scanning. Contusions can be categorised as follows:
Coup–usually due to inertial forces causing injuries to brain
parenchyma at the impact site (e.g. as possibly in this case, the
patient’s head striking the steering wheel of her car).
Contre- coup–these are located away from the site of impact and are
usually associated with deceleration injuries resulting in areas of low
pressure and increased tensile strain.
(a) (b)
Figure 5.2: Schematic diagram representing a computed tomography (CT) scan of head
demonstrating (a) subdural haematoma with midline shift (note the concave shape of
the lesion), (b) epidural/extradural haematoma (note the biconvex shape that is classic)
and fracture (arrow).
Source: Theophilus Samuels.
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Clinical Cases in Critical Care
78
Diuse axonal injury (DAI)–patients with this type of injury will be ren-
dered unconscious at the time of injury due to diuse tearing of axons
and small blood vessels. Deceptively, the initial CT scan may appear
normal, due to the damage being mainly microscopic. Sadly, patients
with severe DAI who survive may have profound neurological disability.
Those with mild DAI may recover completely. DAI should be suspected
in patients with impaired consciousness alongside normal CT ndings
and normal intracranial pressures.
Other–other pathology that may result in depressed consciousness
includes, but is not limited to, seizures, hypoglycaemia, toxins, drugs,
hypoxaemia and/or hypercarbia.
Danielle is promptly and safely intubated by the anaesthetic team and sta-
bilised. CT brain conrms the presence of a small left-
sided subdural hae-
matoma with no evidence of midline shift. It does not require immediate
neurosurgical intervention. CT chest demonstrated a fracture of the sternum
and several left- sided rib fractures with evidence of underlying pulmonary
contusions.
A total of approximately 1200
mL of blood is drained from the intercostal
drain, with minimal ongoing losses. Her blood pressure and tachycardia
improve, and she appears to be stable. She is admitted to your neurosurgical
intensive care unit for further management.
Dene the role of an antibrinolytic agent in
traumatic brain injury (TBI)
CRASH- 3was an international randomised placebo- controlled trial of
tranexamic acid (TXA) in adult patients with TBI. The key nding was that
TXA given within 3
hours of injury reduces deaths from mild to moderate trau-
matic brain injuries. It is thought that those patients with mild to moderate
symptoms are likely to have smaller, slower bleeds, which are more ame-
nable to TXA treatment. Early treatment was more effective, with a 10%
reduction in eectiveness for every 20 minutes from the time of injury. There
was no increased risk of death or complications, or prevalence of disability
in survivors.
What is the evidence for cooling in TBI?
Inducing hypothermia had been thought to be neuroprotective and conse-
quently improve long- term neurological outcomes. However, robust evidence
in the form of randomised control trials had been lacking. The POLAR- RCT
trial in 2018 by the POLAR Trial Investigators and the ANZICS Clinical Trials
Group demonstrated that hypothermia compared to normothermia had no
signicant eect on neurological recovery at 6 months. The Eurotherm group
in 2015 determined that therapeutic hypothermia with standard care did not
result in better outcomes compared to standard care alone.
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