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Chapter 55

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The last two decades have seen great advances in the care of the injured patient, both in prehospital triage and transport and in the intensive care unit (ICU). More than ever, the outcome of these patients, in terms of both morbidity and mortality, is very dependent on a solid understanding of the pathophysiology and also of the evolution of certain injuries. Attention to detail is critical and an awareness of the pitfalls is essential, if one has to be successful in avoiding preventable morbidity and mortality.

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Excluding early deaths in the operating room, most complications and subsequent deaths following injury will occur in the ICU. Care in the ICU is designed to reestablish normal homeostasis and minimize complications of primary, secondary, and iatrogenic injury. Surgical critical care is inherently different from medical intensive care insofar as surgical patients, and particularly trauma patients, require intensive care as the result of an acute surgical intervention or injury and not as part of the (often inexorable) progression or exacerbation of chronic disease. This fundamental difference affects a multitude of patient management practices and decisions.

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In the last several years, increasing emphasis has been placed on quality of care indicators and physician staffing models for ICUs. Therefore, a modern surgical ICU in the 21st century has to provide evidence-based care using algorithms, clinical management guidelines (CMGs), and checklists, use cutting-edge technology for physiologic monitoring, and has to have a robust continuous quality improvement process to constantly evaluate its outcomes and to identify opportunities for improvement.

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This chapter focuses on elements of critical care essential to the management of the acutely injured patient, reviews some recent advancements in the monitoring of the critically ill patient, and lists some of the common complications and pitfalls observed in the ICU.

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Given the wide variety of clinical expertise and patient populations, several patterns of ICU physician organization have developed. The first is the “closed” unit that relies almost exclusively on a critical care team (or attending intensivist) for primary patient management. Under this scheme, comprehensive management is assumed by the ICU team along with responsibility for all orders and procedures, with other services providing care as consultants on an as-needed basis. Most medical ICUs are staffed in this manner along with some surgical ICUs where the ICU team is directed by another surgeon.

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In an alternative model, the “open” unit, there may or may not be a designated ICU director, a separate ICU team, or even an intensivist immediately available to the ICU. Under this system, individual physicians manage and direct intensive care for their respective patients, depending on their institutional privileges, with or without house staff. Consultative involvement of a board-certified intensivist is at the discretion of each primary attending physician, and is neither required nor necessarily expected.

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Many larger surgical ICUs have a “semi-open” or transitional unit plan of practice whereby the ICU is staffed, ...

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