Trauma Part II To recap… 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: 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… 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. 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? 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? 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? Consider: Patient/ventilator dysynchony ETT obstruction ARDS and other causes of pulmonary edema Recurrent pneumothorax Increased intraabdominal pressure 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 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. 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? 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? 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? 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? Closed head injury Aortic rupture Hollow organ injuries Pulmonary contusions Crush injuries and rhabdomyolysis Compartment syndromes Small bone hand and feet fractures 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 What is the one issue we have not discussed in this patient’s injury list? C7 fracture 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. 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”? 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? Prevention of secondary injury, similar concept to closed head injuries. What is the role for the use of steroids in spinal cord injuries? What about cooling? How about early decompression and stabilization? 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? 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? 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? Autonomic dysreflexia What causes autonomic dysreflexia? How do you emergently treat this problem? 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? Why are pressure ulcers important? Over 30% Significant contributor to morbidity and mortality. How soon after admission do pressure ulcers begin? 3-4 hours of laying on the spinal board Questions??