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

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% on 40% face mask  Arterial Blood Gas 7.12/32/100/ -14  CXR  GCS 14  FAST exam  Obvious femur fracture 1

6/1/2013 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? 2

6/1/2013 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? 3

6/1/2013 Hospital Day 4  Low tidal volume ventilation Transfer to the ICU  Started with a PIP of 30 Plt 18  First 24 hours:  Now with PIP 52 and Plt 34  Desaturations when turning  Exam-Abdomen is more distended  What are the next steps in diagnosis  CXR shows ARDS and management?  The anticoagulation question  When will you fix the bone? Day 7 Bladder Pressure is 52  Creatinine 1.9  Options for Intra-abdominal compartment syndrome  Tea colored urine  CK 40,000  K 5.6 with peaked T waves 4

6/1/2013 Case #2  18 year old GSW to the epigastrium Follow Up Studies  Vitals: 70/P, 130 HR, RR 30  ABG: 6.9/38/90 -18  Long term care  Functional recovery  Initial Trauma Evaluation and Management Initial Management Initial CXR  What size chest tube?  Chest tube output=400cc in 15 minutes then slows down  Abdomen tender and distended 5

6/1/2013 OR Management Goals of ICU Care  Resuscitation plan  AVOID hypothermia, coagulopathy  Use of TEG and acidosis  Surgical plan  Open Abdomen  Findings: renal injury at hilum, small  Sedation meds/prevention of delirium spleen injury, stomach injury, pancreatic injury, small bowel injury  Anticoagulation  14 units PRBS, 10 units FFP, plts  Nutrition strategy  Goals for glycemic control Strategy of Abdominal Wound POD 7 Closure  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 6