Notes:
Notes:
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Notes:
It’s Wednesday night and you are on call for the ICU.
Around 2:00 AM, you are called to the unit to admit
a new trauma patient who just arrived from the OR.
You have vaguely heard about this case earlier in
the evening from the charge nurse: “An intubated
patient was urgently transferred from the E.R. to
the O.R. in pretty bad shape".
You haven't talked to the Trauma Team Leader or to
any surgical team involved yet, but the nurse is
currently more concerned with the systolic BP at 70
than with providing you with a detailed history.
Notes:
You order a liter of fluid and take a look at the
Trauma Team Leader’s note, but the information
available is limited.
This patient was the unfortunate passenger of a
car that was hit on the highway by a beam
dropped from a truck. The beam caused a huge
dent in the passenger door. Not surprisingly, the
driver of the car then lost control of the vehicle,
which eventually ended up in a ditch.
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Notes:
Based on the chart, the 58-year-old patient was
found unconscious on scene and was intubated
in the Emergency Room for airway protection.
His initial BP was in the low 60’s and he received
two liters of NS by EMS. On arrival in the E.R.,
the patient received another 2L of crystalloids
for ongoing low BP and eventually 2 units of
PRBC.
Notes:
A first chest tube was inserted on the right side
for decreased air entry and immediately drained
1.2L of blood. The drain was clamped, but the
patient transiently arrested. The surgeon
proceeded with an urgent right thoracotomy,
clamped some vessels, and rushed the patient to
the OR.
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The right main pulmonary artery was injured and
at the end, the surgeon had to proceed with a
right pneumonectomy. The patient's hemodynamic status during the surgery appears to
have presented certain challenges for the
anesthetist!
Mr. Viscount received overall 3 liters of
crystalloids and 5 units of PRBC. A pool of
platelets was also administered. At the end of
the case, an infusion of norepinephrine was
started and is still running at 12mcg/min on
arrival to the ICU. A bolus of 1U of vasopressin
was also given in the latest part of the surgery.
Notes:
Notes:
In terms of injuries, the patient also had an open
right tibial fracture that couldn't be fixed during
the OR because of ongoing instability. A FAST
completed in the E.R. and repeated in the OR
didn't reveal significant amount of free fluid in
the abdomen. And that's about what you can
find quickly in the chart.
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Notes:
The BP has only responded subtly to your bolus of
fluid. You ask the RN to bring the Level 1 and order
another liter of RL. You make sure that blood is
available if needed. You complete a physical
examination.
The patient’s brainstem reflexes are normal and he
is flexing to central and peripheral pain. In fact, the
RN saw him move spontaneously his left arm and
gave him 25ug of fentanyl. He is in a hard collar. His
chest sounds a bit crackly on the left and quite
horrible on the right. There are 2 chest tubes on the
right side, both draining some sero-sanguineous
fluid in reasonable amount. The abdomen is soft.
The dressing on the right leg looks fairly dry. The
urine output has been about 20cc in the last hour.
The patient’s most recent vitals are:
You check in the computer for the most recent blood work, but
the results from the blood drawn in the ICU are not back yet.
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Notes:
The surgeon walks in the ICU to check on his
patient. When he learns about the 2 liters of
fluids given, he looks extremely upset.
Notes:
“Are you trying to kill my patient??
I’m worried that the left lung will get
flooded with fluids and that the patient
will develop a full-blown ARDS.”
Personally, I am
more worried about
the overall perfusion
of the patient...
Notes:
The atmosphere is getting a bit tense...
The RN announces that the blood work is back (a
welcome distraction!)…
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Notes:
Blood Gas Type
pH
pCO2
pO2
Bicarbonate
Saturation
FiO2
ARTERIAL
7.27
49
220
20
0.98
1.0
7.35 - 7.45
35 - 45 mm Hg
80 - 100 mm Hg
21 - 28 mmol/L
0.90 - 1.00
CBC
Hemoglobin
WBC Count
Neutrophils
Lymphocytes
Monocytes
Eosinophils
Basophils
Platelet Count
Hematocrit
88
16.8
15.3
3
0.6
0
0.1
167
0.395
115 - 165 g/L
4.0 - 11.0 x 10E9/L
2.0 - 7.5 x 10E9/L
1.0 - 4.0 x 10E9/L
0 - 1.0 x 10E9/L
0 - 0.7 x 10E9/L
0 x 0.3 x 10E9/L
150 - 400 x 10E9/L
0.340 - 0.490 L/L
1.7
0.71
0.92
31
2.20 - 2.60 mmol/L
0.70 - 1.05 mmol/L
0.87 - 1.52 mmol/L
35 - 50 g/L
Electrolytes
Sodium
Potassium
Chloride
CO2 Total
149
3.1
117
19
135 - 147 mmol/L
3.5 - 5.0 mmol/L
95 - 107 mmol/L
22 - 30 mmol/L
Glucose- Random
8.9
4.0 - 8.0 mmol/L
INR
PTT
1.59
33.0
0.9 - 1.10 INR
24.0 - 34.0 SECS
Renal Profile
Urea
Creatinine
9.5
119
3.0 - 7.0 mmol/L
44 - 106 umol/L
985
4
<0.01
0.28
< 195 IU/L
2- 6 ng/mL
< 0.05
< 0.10 ug/L
6.4
0.5 - 2.0 mmol/L
Calcium
Magnesium
Phosphate
Albumin
CK + CK-MB
CK
mB Mass
mB Mass Fraction
Troponin T
Lactate - Serum
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Notes:
Notes:
You check the chest x-ray and notice mild left
diffuse patchy infiltrates and a small right
pleural effusion. The ECG shows diffuse T waves
inversion. The surgeon is watching your next
move…
Notes:
Objectives
-To understand the
physiological changes
associated with a
traumatic
pneumonectomy.
-To adequately
investigate and
manage a shock
associated with a
polytrauma.
Questions:
- Why do you think the
surgeon is upset?
- How would you justify
the management so
far?
PROPERTIES
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- What is the etiology
of the low BP?
- Would you request
any further
investigations at this
point?
Anytime
Show upon completion
Next Slide
- What are the
expected
complications posttraumatic
pneumonectomy?
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- How is that different
than for an elective
pneumonectomy?
Notes:
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Notes:
You decide to start an infusion of vasopressin to
address temporarily the hypotension. You then
order a repeated echocardiogram to rule out any
cardiac contusions/dysfunction and to assess the
right ventricle. You will need some arguments to
convince the surgeon that this patient needs
more fluids. You're not even so sure anymore
that it's the case...
Notes:
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Notes:
You are pretty happy about the oxygenation for
now and you're not sure that the CO2 is a big
deal... The echo technician gives you a report:
the left ventricular function is normal, the right
ventricle is moderately depressed without
dilatation, there is only a trace of pericardial
effusion, and there is a moderate tricuspid
regurgitation.
Notes:
You review the final report of the CT scans done,
looking for other significant injuries. The BP is
now 92/55. You are breathing a bit better, but
the nurse is not. She had to increase the levo at
15mcg/min and to start the vasopressin at 2U/h
to get that BP. She asks you if you want to give
more fluids: "The patient is in atrial fibrillation
now and the HR is up to 140." You notice that the
CVP is 14. The surgeon had to go to the E.R. to
assess another patient...
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Notes:
Objectives
-To discuss the
challenges of
mechanical ventilation
after a
pneumonectomy.
-To assess the fluid
status of
hemodynamically
unstable trauma
patients.
-To discuss the
physiological
consequences and
management of
hypercapnia.
PROPERTIES
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Questions:
- Are you reassured by
the echo results?
- Do they affect your
management at this
point?
Anytime
Show upon completion
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- How do you apply
lung protective
ventilation during
single-lung ventilation?
- Any concern about
the use of PEEP for
this patient?
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Notes:
Notes:
Two weeks later, you are on call for the ICU. You
learn that Mr. Viscount is still there. He did
surprisingly well during the first few days after
his initial surgery.
However, his multiple rib fractures and flail chest
have complicated the weaning process. He failed
an extubation yesterday and is now scheduled
for a tracheostomy. According to the daytime
team, the reasons for his failure appeared to be
a mix of bad lung mechanics, poor secretion
management, and delirium.
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Notes:
Around 3:00am, you are called at the bedside of
Mr. Viscount. The nurse has noticed some
subcutaneous emphysema when she repositioned the patient. She asked for a chest x-ray
that is now available. You compare the image to
the one completed after the initial surgery:
Notes:
Questions:
- Which findings would
you expect on a CXR
immediately after a
pneumonectomy?
- How do you interpret
the second CXR?
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Notes:
The patient condition is overall stable. His
ventilatory settings (PS 14, PEEP 8, FiO2 50%)
haven't changed since his re-intubation. The
amount of secretions is moderate. A sample was
sent yesterday for culture. You have a new
consultation to review in the Emergency Room
so you ask the nurse to let you know if anything
changes. Hopefully, nothing will until the end of
your call...
Notes:
Objectives
-To discuss the
management of
bronchopleural fistula,
including adjustments
of mechanical
ventilation.
-To recognize the
indications for
diagnostic and
therapeutic drainage of
pleural effusions.
-To understand the
role of thoracic surgery
in the management of
empyema.
PROPERTIES
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Questions:
- What do you think is
happening?
- Why would the
patient deteriorate
further?
Anytime
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Which investigations
should be done?
- Which factors will
impact on the
immediate and
definitive
management?
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Notes:
References
Keel, M., Meier, C. Chest injuries – what is new? Curr Opin Crit Care. 13, 674-679 (2007).
Ricardo, A., Itamar, A., Kounavsky, G.,Kessel, B. Total pulmonectomy in trauma: a still
unresolved problem--our experience and review of the literature. Am Surgeon. 73 (4),
381-384 (2007).
Jackson, T.A., Mehran, R.J., Thakar, D., Riedel, B., Nunnally, M.E., Slinger, P. Postoperative
Complications After Pneumonectomy. J Cardiothor Vasc An. 21 (5), 743-751 (2007).
RCPSC Objectives
6.1.
RespiratoryDysfunction
6.1.1. The ability to
determine the
presence of respiratory
failure, provide for its
emergency support,
and have a plan of
action to subsequently
investigate and
manage problems.
6.1.2. Demonstrate
knowledge of:
6.1.2.1. normal
anatomy of the
respiratory system
6.1.2.2. physiology of
the gas exchange unit,
lung and chest wall
mechanics, airway
dynamics
6.1.2.3. chest imaging
of the ICU patient
6.1.2.4. the control of
respiration
6.1.2.5.
pathophysiology of
disease states leading
to respiratory failure
6.1.2.6. principles and
theory of mechanical
ventilation and other
methods of respiratory
support
6.1.2.7. respiratory
problems and their
management following
surgical interventions
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