The Complex Trauma 48 year-old man belted in high- and Critical - - PDF document

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The Complex Trauma 48 year-old man belted in high- and Critical - - PDF document

Dec 02, 2022 275 likes •345 views

6/1/2013 The Scenario The Complex Trauma 48 year-old man belted in high- and Critical Care Patient speed MVC Field vitals: BP 90/P HR 110 RR 26 Moving all four extremities The Trauma Bay 80/P HR 115 RR 24 O2 saturation 96%

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SLIDE 1

6/1/2013 1

The Complex Trauma and Critical Care Patient

The Scenario

  • 48 year-old man belted in high-

speed MVC

  • Field vitals:
  • BP 90/P HR 110 RR 26
  • Moving all four extremities

The Trauma Bay

  • 80/P HR 115 RR 24 O2 saturation

96% on 40% face mask

  • Arterial Blood Gas 7.12/32/100/ -14
  • CXR
  • GCS 14
  • FAST exam
  • Obvious femur fracture
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SLIDE 2

6/1/2013 2

The Trauma Bay

  • What is your choice for initial

resuscitation?

  • Any other diagnostic modalities

you need right now?

  • 2 units PRBS given
  • BP 110/p HR 90 for 6 minutes
  • Do you want to intubate?

Transient Responder

Disposition Choices

  • CT scan
  • Operating room
  • Interventional radiology
  • Intensive Care Unit

WHERE DO WE GO FROM HERE?

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SLIDE 3

6/1/2013 3 CT Scan results IR Embolization

  • Anything you would tell the

Interventionalist?

  • How would you manage the

resuscitation in this setting?

  • To coil or to gel foam?
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SLIDE 4

6/1/2013 4 Transfer to the ICU

  • First 24 hours:
  • Desaturations when turning
  • CXR shows ARDS
  • The anticoagulation question

Hospital Day 4

  • Low tidal volume ventilation
  • Started with a PIP of 30 Plt 18
  • Now with PIP 52 and Plt 34
  • Exam-Abdomen is more distended
  • What are the next steps in diagnosis

and management?

  • When will you fix the bone?

Bladder Pressure is 52

  • Options for Intra-abdominal

compartment syndrome

Day 7

  • Creatinine 1.9
  • Tea colored urine
  • CK 40,000
  • K 5.6 with peaked T waves
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SLIDE 5

6/1/2013 5 Follow Up Studies

  • Long term care
  • Functional recovery

Case #2

  • 18 year old GSW to the epigastrium
  • Vitals: 70/P, 130 HR, RR 30
  • ABG: 6.9/38/90 -18
  • Initial Trauma Evaluation and

Management

Initial CXR Initial Management

  • What size chest tube?
  • Chest tube output=400cc in 15 minutes

then slows down

  • Abdomen tender and distended
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SLIDE 6

6/1/2013 6 OR Management

  • Resuscitation plan
  • Use of TEG
  • Surgical plan
  • Findings: renal injury at hilum, small

spleen injury, stomach injury, pancreatic injury, small bowel injury

  • 14 units PRBS, 10 units FFP, plts

Goals of ICU Care

  • AVOID hypothermia, coagulopathy

and acidosis

  • Open Abdomen
  • Sedation meds/prevention of delirium
  • Anticoagulation
  • Nutrition strategy
  • Goals for glycemic control

POD 7

  • Tmax 39.0
  • WBC 18, hypotensive, tachycardic
  • UA +WBCS, gram negative rods
  • New infiltrate and moderate PMNs,

gram negative rods, mod secretions, NO vent setting changes

Strategy of Abdominal Wound Closure