Szoke, Ann Marie - Powerpoint_Ann_Marie_-_Handout.pdf · Right Knee Xray Tender: + Chest, and rib cage ... ***Different reading: Hyperdense focus Left ... ABC’s intact

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Ann Marie Szoke, DNP, CRNPSupervisor Advanced Practitioners

St. Luke’s University Hospital

To review multiple traumatic events through case presentations

Discuss the concept of the Hybrid Operating Room

Discuss the role of the Advanced Practitioner in caring for the Trauma patient with multiple injuries as a member of the trauma team.

An experience that causes physical, emotional, or psychological distress or harm.

It is an event that is perceived as a threat to one’s safety or to the stability of one’s world.

U.S. National Library of Medicine

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As we men in medicine grow in learning we more justly appreciate our dependence on each other. The sum total of medical knowledge is now so great and wide spreading that it would be futile for any one man… to assume that he has even a working knowledge of any part of the whole…

THE BEST INTEREST OF THE PATIENT IS THE ONLY INTEREST TO BE CONSIDERED, AND IN ORDER THAT THE SICK MAY HAVE THE BENEFIT OF ADVANCING KNOWLEDGE, UNION OF FORCES IS NECESSARY…… it has become necessary to develop medicine as a cooperative science; the clinician, the specialist, and the laboratory workers uniting for the good of the patient, each assisting in the elucidation of the problem at hand, and each dependent upon the other for support.

Dr. Wm. Mayo, Rush Medical College 1910

None

I have received permission form all four patients to discuss their events and utilize their radiographic findings for educational purposes.

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Trauma Alert : 2/4/14 8:00 a.m.

22 y/o female

MVC

Level B arrival 7 minutes

Restrained Driver Head on collision, involving another car One of multiple trauma’s in the bay at the

same time Prolonged Extrication Flown in by Pennstar Vitals stable during flight

A: patent B: CTA C: 2+ carotid, 2+ femoral D: GCS 15- 4/5/6 , positive C spine, T spine

and L spine tenderness E: + seatbelt signs, Discoloration of right

foot.

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FAST: negative CXR – multiple rib

fractures b/l.

Right Knee Xray

Tender: + Chest, and rib cage+ Abdomen in all 4 quadrants+ Entire T/L spine+ Left Hip+ Right Knee

Abrasions: Seat Belt sign

Laceration: Right Lateral Knee

Discoloration: Right Foot, + PT

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Allergies: NKDA Medications: MVI PMHx: None PSHx: s/p tonsillectomy Last meal: 2/13/14 at 10:30 pm pasta Events: Head on collision, LOC? 5 cars

involved. Restrained driver. SHx: No smoking/drinking/drugs

Vital signs: HR 99 BP 143/80 RR 20 SpO2 98% on 2L

Awake and talking with us as going to cat scan.

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Team assembly Trauma Laparotomy

- Packing/Explore- Findings: Small Bowel Perforation –

Resection: Grade 2 Splenic Laceration –

Splenectomy: Transverse colon serosal tear –

Primary repair****Zone 1 Retroperitoneal hematoma - Vascular

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Extubated Pain Control Hemoglobin/Hematocrit 11/34 Cr 0.5 ASA/Plavix Diet Advanced

Pain Control ASA/Plavix – Held Platelets: 1 unit TLSO Brace - Cast Shoe

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Psych Consult – Acute Stress Disorder Pain optimization Diet TLSO Cast shoe Ortho-Outpatient Right Calcaneal Fracture

repair 2/17/14 Discharge 2/15/14

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Post-op day 16 since Trauma Alert Dispositon Planning Plavix/ASA TLSO Brace WBAT on LLE, NWB RLE F/U with

Trauma/Neuro/Vascular/Ortho/Psych

Preop Diagnosis: MVC Level B Alert Hospital Diagnosis:

1. Abdominal Aortic transection – s/p EVAR2. Grade 2 Splenic Laceration – s/p

Splenectomy3. Small Bowel Perforation – s/p resection4. Transverse colon serosal tear – s/p

primary repair5. T12 Vertebral body fracture: s/p Min Perc

T11-L1 instrumentation

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6. B/L ribs – R 3-7, L 4-6 fractures: Nonpain, pain control

7. Right calcaneal fracture – s/p ORIF8. Sternal fracture – non-op9. B/l occult PTX – Resolved10. 10 Phalanx fractures – Left 1st/4th non-op11. Acute Stress Disorder – stress relief

techniques12. Abdominal wall hematoma / abrasions:

resolving

NONE SO FAR ******

MVC’s and SBS in 2yr period 671 patients 11.3% SBS in MVC’s Restraints 20%

Sharma et al. AM surg 2009

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SBS/Restraints vs Control

ISS 7.6 13 Mortality 1.1% 5.7% Rib fx 26% 11% HVI/SOI 8/17% 1/3% Splenic Trauma 9.7% 0.4%

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It is a surgical theatre equipped with advanced medical imaging, ie: CT scanners, C-arm, MRI capabilities

Allows different areas of problems and concerns to be addressed at the same time.

Combination of IR suite and OR

State of the art operating room providing a modern OR, interventional radiology lab, vascular, orthopedic and complex cardiac procedures.

Interventions done

Splenectomy Small Bowel Resection TVAR of Abdominal Aorta ORIF of T-spine ORIF of Right Calcaneous

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Discharge Instructions: Patient sent home with patients with home

services Fractures all healing well Follow up visits with Orthopedics,

Neurosurgery, Trauma and Vascular Surgery Long term issue of Pain Management….

22 y/o male S/P MVC

Unrestrained passenger, Fatality at scene

Trauma admission 8/23/14

Prolonged extrication

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One of multiple Trauma’s , 3 total in the bay

One other was fiancé of brother (fatality)

Third patient was driver of opposite car

B/P – 136/86 HR – 134 RR – 22 O2 sat 94% GCS - E=4 V=5 M=6

Alert and oriented Scalp Laceration Dentition intact Tachycardia C-collar on C-spine non-tender Abdomen soft

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FAST – neg CXR – neg HCT – neg CT C-spine – neg Right Femur xray – positive fracture Pelvis xray – Left acetabular fracture

CT Chest/Abdomen/Pelvis: Right Pneumothorax, Left Hemothorax, Adrenal Hematoma, Splenic laceration, Liver Laceration, Left Kidney Laceration, Thoracic Aortic Injury

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Echo – 55% to 65% Ct Chest – thoracic aortic dissection

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Transfer from ICU to Trauma Floor Pain Management Physical Therapy / Occupational Therapy Temperature Spikes overnight only Numerous sets of blood cultures and urine

cultures, repeat chest xrays over a 2 weeks period

Almost ready for transfer to Acute Rehab

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Duplex done Repeat CT scans, especially of the abdomen

and pelvis ALL results come back Negative. Decision to transfer to Acute Rehab

Fevers have resumed, chills present Doesn’t feel well Orthopedics consulted to see patient Wounds re-evaluated Ct scan of abdomen and pelvis re-ordered

(last scan 3 days prior) ***Different reading: Hyperdense focus Left

Iliopsoas muscle 14 x 19 mm adjacent to acetabular fixation hardware.

Radiology asked to re-read CT scan done 3 days prior to discharge, On review, same conclusion obtained.

Ortho takes T.L. to Or for a washout and closure. Therapy resumed, and discharged home 4 days later

Seen in outpatient office in 1 week, doing well.

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J.T. 18 y/o Female, student 7/27/14 Level A trama c/o “I can’t breathe”

Was sitting on an inner tube while being pulled by a boat on a river

Came around a turn, she flew off the tube and into a tree

Initial GCS had been a 15 and then declined to 13,12

Felt nauseous and confused Very anxious, unable to follow simple

commands PMH, PSH, allergies, medications, social hx,

family fx all unable to attain.

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ABC’s intact

GCS 13 E4 V4 M5

122/65 121 20 97 temp 100% O2 sat

Alert C-collar is on Tachycardia, crepitus right chest wall Guarding of upper abdomen Tenderness in suprapubic region Pelvis stable Accurate N/V exam difficult due to mental

status Distal pulses palpable

HCT – neg for hemorrhage, air in right lateral neck and retropharyngeal tissue

FAST - ? Free fluid CXR – PTX, Pneumomediastinum, right

posterior rib fractures, right midlungcontusion

CT C-spine – neg CT Chest – right 5-8 rib fractures, right

pneumothorax, right kidney contusion, Grade IV liver laceration

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Utilized the IR portion of the room with the ability to do emergency surgery should something have progressed during the procedure

Able to be discharged 7 days later Solid organ injury restrictions Unable to return to school

24 y/o male

Motorcycle vs auto

Level B trauma

Vital signs stable in the field and trauma bay

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GCS 15, E4 V5 M6

Airway intact, however some difficulty with deep breaths on left side, slightly decreased breath sounds on left

Deformity left arm and severe deformity of Left leg. Neurovascular status intact.

CXR – left pneumothorax, midlung contusion CT Left arm – comminuted fracture of the

humerus L tib/fib xray – non-displaced left fibular

diaphysis fracture HCT – neg CT C-spine – neg CT abd/pelvis – splenic laceration, b/l

acetabular fractures

CTA – splenic laceration with active extravasation and multiple intussescptionsand no bowel obstruction.

CTA of Lower extremity – diffuse spasm of left superficial femoral artery with 3 vesselcontinuous run off.

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Use of C-arm left hand had a closed reduction of 4th & 5th metacarpal fractures

Fixation of L femur

Splenectomy

Plan of care since still hospitalized is Physical therapy, Occupational therapy

Place in SNF rehab – NWB left upper extremity and b/l lower extremities

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You have the marrying of two areas with distinct and different problems and concerns.

This room gives you the integration of interventional and surgical techniques such as angiography and imaging capabilities.

The Hybrid Room combines a conventional surgical part including a skin incision with an interventional part using some sort of catheter based procedure guided with fluoroscopic of MRI imaging with interruption.