Transcript Trauma Part II - CriticalCareMedicine

Trauma Part II
To recap…
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45 year old man is involved in a two vehicle MVC.
He is a single occupant trying to cross a highway when he is
struck on the passenger side.
His injuries include:
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Severe liver laceration
Bilateral pneumothoraces
C7 fracture
We had talked about pelvic fractures but this patient does not
have one.
He has had damage control surgery and is back in the ICU
hypothermic, coagulopathic and acidotic.
Back to the case…
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After the initial resuscitation post op, the patient
stabilizes. However, 6 hours later, the bedside nurse
calls to inform you that the output from the JP has
increased.
The hemoglobin is 61, down from 97 and INR is 1.6.
The surgeon tells you that she has definitely controlled
all of the bleeding and this is diffuse oozing. She will
not consider taking the patient back to the OR until you
fix the medical bleeding.
He is given 5 more units of red cells and 2 units of
FFP.
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Since admission, this patient has been given 14
units of blood, 10 units of FFP, 2 pooled
platelets, and 1 unit of cryoprecipitate.
What is the definition of a massive transfusion?
What are the consequences of a massive
transfusion?
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How do you approach a patient with a massive
transfusion?
What is the role for Factor VIIa in trauma?
How does Factor VIIa work?
What are the side effects of Factor VIIa?
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12 hours later, the patient’s bleeding and coagulopathy
have resolved.
The RT calls to tell you that the airway pressures have
progressively increased and now the alarm is triggering.
What could be causing this?
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Consider:
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Patient/ventilator dysynchony
ETT obstruction
ARDS and other causes of pulmonary edema
Recurrent pneumothorax
Increased intraabdominal pressure
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When you assess the patient, the nurse also tells
you that the urine output has been essentially
zero for the last 4 hours despite repeated fluid
boluses. You suspect that the two problems are
related.
What is abdominal compartment syndrome?
How is it diagnosed?
The bladder pressure is 35
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What are the consequences of abdominal compartment
syndrome?
How would you treat IAH/ACS?
Coincidently, the surgeon stops by to take the patient to
the OR for packing removal and closure.
Upon return, the wound is left open but the packings
have been removed and all bleeding is resolved.
The bladder pressure is now 12.
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Throughout the course of the last 24 hours, you have
noted that the CK has been climbing progressively. It
is now 12000. The urine is dark tea colored.
What is the most likely problem?
In addition to the obvious trauma, what are some other
causes for rhabdomyolysis? (not just in this case)
Why is rhabdomyolysis dangerous?
What is the treatment for rhabdomyolysis?
Is there a role for dialysis?
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It has certainly been a busy 24 hours with this trauma
patient but we are not done yet.
The family arrives and want an update.
What information should you obtain from the family?
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Past medical history: None, healthy
Medications: Occasional tylenol for headaches.
Social history: Likes to binge drink. Especially on weekends
when hanging out with the band and the groupies. Has had
alcohol withdrawal seizures in the past.
How does this information change your management?
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When caring for trauma patients, it is important to reexamine
them every day to look for undiagnosed injuries. The probability
of missed injuries increases if the patient was rushed to the OR.
What are some of the most important missed injuries to look
for?
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Closed head injury
Aortic rupture
Hollow organ injuries
Pulmonary contusions
Crush injuries and rhabdomyolysis
Compartment syndromes
Small bone hand and feet fractures
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Iatrogenic complications of trauma are also an
important problem. What are some issues to
look out for when caring for a trauma patient?
Transfusion related complications
 Contrast induced nephropathy
 DVT and PE (by the way, what is the appropriate
DVT prophylaxis for trauma?)
 Gastric stress ulcers
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What is the one issue we
have not discussed in this
patient’s injury list?
C7 fracture
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Three days after admission the patient stabilizes
and begins to wake up.
During daily assessment you note that the
patient is not moving his legs spontaneously.
On detailed examination, he cannot extend his
arms or wrist, move his legs and has no
sensation below the nipple line.
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What is the neurological level?
Is it a complete or incomplete injury? What is the
difference?
One week after the injury, the patient starts to notice
some recovery of sensation at the lower sacral level but
no improvement in motor function.
This recovery is called spinal shock. What is it and how
it is different from the often confused term
“neurogenic shock”?
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Let us suppose that this patient’s only injury was
the C-spine and there were no complicating
issues.
Why is aggressive resuscitation with defense
against hypoxia and hypotension important?
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Prevention of secondary injury, similar concept to
closed head injuries.
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What is the role for the use of steroids in spinal
cord injuries?
What about cooling?
How about early decompression and
stabilization?
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10 days after the injury, the patient is still on the
ventilator and has been difficult to wean.
What factors influence his inability to wean?
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Respiratory muscle weakness
Poor cough and secretion control
Pneumonia
Will he ever be ventilator-free?
Tracheotomy or not?
What DVT prophylaxis should he get and for how
long?
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Three weeks later, the patient is slowly weaning off the
ventilator, has recovered from all of his other injuries
and is awake.
The bedside nurse calls you one evening because the
patient is hypertensive, flushed, anxious, and sweating.
What is going on?
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Autonomic dysreflexia
What causes autonomic dysreflexia?
How do you emergently treat this problem?
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After a complete physical exam, you discover that the
sacral ulcer is developing an erythematous edge with
pus.
How frequently do pressure ulcers complicate spinal
cord injuries?
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Why are pressure ulcers important?
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Over 30%
Significant contributor to morbidity and mortality.
How soon after admission do pressure ulcers begin?
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3-4 hours of laying on the spinal board
Questions??