Central Venous Catheterization

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Central Venous Catheterization

• The most common indications for central venous
  catheterization are to secure access for fluid
  therapy, drug infusions or parenteral nutrition,
  and for central venous pressure (CVP) monitoring.
  Central venous catheters have also been used to
  aspirate air in case of embolism during
  neurosurgical procedures in the sitting position,
  for placement of cardiac pacemakers or inferior
  vena cava filters, and for hemodialysis access.

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Central Venous Catheterization

• While central venous lines are placed primarily
  for venous access, useful information
  occasionally can be obtained by measuring the
  CVP. The CVP may be useful in a hypotensive
  trauma patient to differentiate pericardial
  tamponade from hypovolemia. Pericardial tamponade
  causes elevation and equalization of the right
  atrial, pulmonary artery diastolic and wedge
  pressures.

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Central Venous Catheterization

• Analysis of the CVP tracing may also be helpful
  in the diagnosis of pericardial tamponade (y
  descent is damped or absent due to restricted
  early ventricular filling), tricuspid
  insufficiency (v wave becomes prominent, the x
  descent is obliterated and the y descent is
  steep), and in the differential diagnosis of
  certain cardiac arrhythmias (i.e., a wave is
  absent in patients with atrial fibrillation, and
  flutter a waves at a regular rate of 250 to 300
  per minute frequently are observed in patients
  with atrial flutter).

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Central Venous Catheterization

• A properly placed catheter can be used to measure
  right atrial pressure which, in the absence of
  tricuspid valve disease, will reflect the right
  ventricular end-diastolic pressure.
• A central venous pressure (CVP) catheter can not
  be used to assess left ventricular function in
  critically ill patients, since ventricular
  disparity and independence of right and left
  atrial pressures have been confirmed repeatedly
  in these patients.

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Massive Hemothorax

• Incidence of haemothorax and haemopneumothorax
• 50-60 in penetrating trauma
• 60-70 in blunt trauma.
• Majority are not massive
• Massive haemothorax defined as gt1500 ml of blood
  in chest cavity

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Massive Hemothorax

• Clinical Signs
• Unilateral dullness to percussion
• Shock
• Unilateral absence of breath sounds
• Deviation of trachea
• Neck veins may be flat due to severe hypovolaemia
  or distended because of the mechanical effects of
  intrathoracic blood
• Blood loss complicated by hypoxia

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Massive Hemothorax

• Management
• manage initially by simultaneous restoration of
  volume deficits and decompression of chest
  cavity. If auto-transfusion device is available
  it should be used
• emergency thoracotomy for massive haemothorax or
  haemothorax with ongoing loss of gt200 ml of blood
  per hour for 3-4 h

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Emergency Thoracotomy

• Indicationspatients who have sustained truncal
  trauma and remains unstable or moribund despite
  adequate resuscitation by way of infusion, chest
  drainage and ventilation
• Lack of pupillary response is not a
  contraindication to operation, though it is an
  indication for thoracotomy in casaulty rather
  than transfer to theatre
• Patients who have shown no respiratory effort and
  no cardiac output since pick-up will not survive

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Emergency Thoracotomy

• Criteria for discontinuation of resuscitation
• Irretrievable anatomic injury (eg ruptured heart)
  
• Failure of volume resuscitation within 15 mins of
  starting
• Failure to sustain spontaneous cardiac rhythm and
  maintain mean systemic blood pressure gt 50 mmHg,
  with or without inotropic support, within 30 mins

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Emergency Thoracotomy

• In general those who survive with reasonable
  cerebral function are young, previously fit and
  have only a short period of circulatory arrest
• Patients with blunt trauma have a poor outcome
  and it may be deemed unwise even to consider
  further measures if standard resuscitation fails
• Overall only 5 of those undergoing emergency
  thoracotomy survive and many of these have
  prolonged convalescence and cerebral damage

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Urgent surgery

• Purpose is to repair structures that will not
  heal optimally without surgery and to prevent
  late complications

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Urgent surgery- Absolute indications

• Cardiac arrest due to tamponade or exsanguination
  
• Significant and continued haemorrhage immediate
  blood loss gt 1500 ml Loss gt 500 ml in first hr.
  or 200 ml/hr thereafter
• Decision to operate should be made early before
  occurrence of a dilutional coagulopathy
• Dangerous predicted track/mediastinal traversing
• Massive air leak
• Certain specific injuries

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Urgent surgery- Relative indications

• Thoracoabdominal injury
• Bullet embolism
• High-velocity gunshot wound
• Missile retrieval.
• In general missiles should only be removed if
  they pose a risk of embolization from heart or
  pulmonary artery, erosion of adjacent structures
  due to repetitive cardiorespiratory movements or
  infection due to non-metallic pieces
• Certain specific injuries

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Urgent surgery- Relative contraindications

• Cardiac contusion
• Pulmonary parenchymal contusion
• Pneumomediastinum (without other injury).
• Exclude tracheobronchial tear, pneumothorax,
  oesophageal perforation or gas forming organisms
  within pericardium

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Priorities with multiple injuries

1. Thoracic hemorrhage or tamponade
2. Abdominal hemorrhage
3. Pelvic hemorrhage
4. Extremity hemorrhage
5. Intracranial injury
6. Acute spinal cord injury

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Second-priority Injuries for Surgical Treatment
after Resuscitation
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Clinical analysis of craniocerebral trauma
complicated with thoracoabdominal injuries in
2165 cases.

• Chinese journal of traumatology 2004
  Jun7(3)184-7. Chen WQ, Wang G, Zhao W, He LZ.
• July 1993 - June 2003
• 382 severe craniocerebral trauma (167 with
  shock), 733 thoracic injuries, 645 abdominal
  injuries and 787 thoraco-abdominal injuries.
• 294 developed shock on admittance

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Craniocerebral Trauma Complicated with
Thoracoabdominal Injuries

• Traditional viewsHypotension in traumatic shock
  should be treated with fluid resuscitation with
  vaso-active substances to raise blood pressure.
• New conceptsDelayed resuscitation

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Craniocerebral Trauma Complicated with
Thoracoabdominal Injuries

• Delayed resuscitation
• Suggested for shock caused by pure active
  hemorrhage without complicated CCT or ?ICP
• Small volume of balanced saline to satisfy the
  bodys basic needs instead of rapid large volumes
  of fluid resuscitation for patients present with
  active hemorrhage.
• In patients with severe CCT, early resuscitation
  with a large volume of fluid would aggravate
  cerebral edema.

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Craniocerebral Trauma Complicated with
Thoracoabdominal Injuries

• For intracranial hematoma with serious thoracic /
  abdominal hemorrhage and need hemostasis, fluid
  transfusion should be appropriately controlled
  (SBP, 90 mm Hg)
• Prevent ischemia and hypoxia in important organs,
  and aggravation of hemorrhage
• Prompt hypertonic and hyperosmotic solution and
  whole blood to ensure fast restoration of BP and
  improvement in microcirculation and to reduce the
  volume of solution to be infused

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Craniocerebral Trauma Complicated with
Thoracoabdominal Injuries

• Hypertensive drugs
• Should not be administrated for mild shock
• Small quantity is suggested for moderate shock
• For severe shock, should be given at early stage
  to improve the diseased condition for fluid
  infusion against shock.
• Those who need continuous support from
  hypertensive drugs probably have poor prognosis.
• Tend to develop multiple organ dysfunction
  syndrome (MODS) at advanced stage.

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Craniocerebral Trauma Complicated with
Thoracoabdominal Injuries

• Since complicated thoracic trauma is more complex
  than pure craniocerebral trauma, in the present
  study, firstly dealt with low blood pressure
  caused by thoracic trauma
• Unblocking the respiratory tract
• Relieving compressed lungs
• Restricting abnormal thoracic activities

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Craniocerebral Trauma Complicated with
Thoracoabdominal Injuries

• Life-saving operation
• Cerebral hernia(-) hemorrhagic shock(-)
• Craniotomy first when cranial hematoma was large,
  and laparotomy and/or thoracotomy first when
  rapid hemorrhage was present
• Hernia of brain() hemorrhagic shock(-)
• Craniotomy first and then thoracotomy
• Hemorrhagic shock () cranial hernia(-)
• Thoracotomy or laparotomy first and then
  craniotomy
• Both intracranial hematocele and severe
  hemorrhagic shock
• Craniotomy and thoracotomy or laparotomy at the
  same time.

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Craniocerebral Trauma Complicated with
Thoracoabdominal Injuries

• Brain-stem failure vs Severe shock
• Shock, deep coma, bilateral pupil dilation,
  irregular breathing
• Severe shock
• Large volumes of uncoagulated blood could be
  drained
• Symptoms improved.after antishock treatment
• Patients who need large doses of hypertensive
  drugs or great amount of fluid transfusion
• Thoracotomy or laparotomy first to achieve
  hemostasis.
• Measures which do not aggravate disturbance in
  respiratory and circulatory systems are
  recommended as early as possible