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The last few decades have seen great advances in the care of the injured patient from prehospital triage and transport to care in the intensive care unit (ICU). Care in the ICU is designed to reestablish homeostasis and minimize secondary and iatrogenic injury. Excluding early deaths in the operating room, most traumatic hospital deaths will occur in the ICU. More than ever, the outcome of critically injured patients is dependent on a solid understanding of the pathophysiology and evolution of traumatic injuries. Attention to detail is critical and an awareness of the pitfalls is essential if one is to be successful in avoiding preventable morbidity and mortality.
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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. A modern surgical ICU in the 21st century provides evidence-based care using algorithms, clinical practice guidelines (CPGs), and checklists; uses cutting-edge technology for physiologic monitoring; and has a robust quality improvement process to continuously 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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ORGANIZATION OF 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.
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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. 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 and trauma ICUs have a “semiopen” or collaborative plan of practice whereby the ICU is staffed with intensivists who coordinate care with primary surgeons. While primary surgeons may write orders on their patients, critical care team involvement with each patient is typically either mandatory or expected. There are often specific areas of designated Critical Care autonomy, such as the management of mechanical ventilators, invasive hemodynamic monitoring, pain management, and sedation. In these units, the ultimate responsibility for the patient remains with the primary team, but patient care is a collaborative effort. This semiopen model combines the advantages of critical care expertise for trauma and surgery patients while maintaining primary surgical service responsibility ...