1. RESPIRATORY INSUFFIENCY
POST-TRAUMATIC
RESPIRATORY INSUFFIENCY
Dr.R.Selvakumar
Assistant Professor,
Dept. of Anaesthesiology,
Madurai Medical College,
Madurai
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2. RESPIRATORY FAILURE DUE TO TRAUMA:
DIRECT
INDIRECT
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3. 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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4. INDIRECT CAUSES
LONG BONE FRACTURES
IMPACT IN THE LUNGS
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5. 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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6. PATHOLOGY:…contd…
Microvascular occlusion from fibrin and platelet aggregates
- Interstitial leakage of protein and neutrophil rich fluid
LEADING TO
DIFFUSE ALVEOLAR DAMAGE
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8. 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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9. TRAUMA
LONG BONE & HIP FRACTURE
FAT EMBOLISATION
SYNDROME
FAT EMBOLISATION
ACUTE LUNG INJURY
ARDS
MULTI ORGAN DYSFUNCTION SYNDROME
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10. DO ALL THE TRAUMA PATIENTS DEVELOP FAT EMBOLISM AND ARDS…?
YES AND NO
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11. 90% of trauma patients show fat globules in the lung capillaries
1-5 % of these patients develop ARDS

12. 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

13. HOW TO DIAGNOSE ARDS..? Clinical signs Low O2 saturation in spite
of oxygen supplement
Chest X-ray
ABG
PCWP
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14. OXIMETRY FORMS THE MAINSTAY OF DIAGNOSIS
The biggest limitation is the relationship between
paO2 and SpO2
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15. 100%
90%
SpO2
80mm of Hg 60
paO2
OXYHAEMOGLOBIN DISSOCIATION CURVE
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16. IN NUTSHELL…,
JUST BECAUSE O2 SATURATION IS
NORMAL, U CAN’T RULE OUT ARDS….
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17. 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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18. EARLY FIXATION OF FRACTURES HELP TO REDUCE
THE INCIDENCE OF ARDS
In isolated fractures
With injury to multiple systems
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19. 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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20. 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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21. 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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22. If definitive fixation is delayed in
Pro-inflammatory patients with multiple fractures …
When can we go for definitive surgery…?
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23. ARGUMENT CONTINUES…..
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24. 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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25. SUMMARISING…
Post-traumatic respiratory failure occurs because
of development of an inflammatory response
Fat embolisation may lead to development ARDS
Reaming of nailing doesn’t 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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26. ‘initial and deligent resuscitation and
CONCLUSION:
‘initial and deligent resuscitation and
early fixation of fractures to certain
extent prevent the incidence of ARDS…’
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