Trauma Part II. To recap… 45 year old man is involved in a two vehicle MVC. 45 year old man is involved in a two vehicle MVC. He is a single occupant.

Trauma Part IITrauma Part II

To recap…To recap… 45 year old man is involved in a two vehicle 45 year old man is involved in a two vehicle

MVC.MVC. He is a single occupant trying to cross a highway He is a single occupant trying to cross a highway

when he is struck on the passenger side.when he is struck on the passenger side. His injuries include:His injuries include:

Severe liver lacerationSevere liver laceration Bilateral pneumothoracesBilateral pneumothoraces C7 fractureC7 fracture

We had talked about pelvic fractures but this We had talked about pelvic fractures but this patient does not have one.patient does not have one.

He has had damage control surgery and is back He has had damage control surgery and is back in the ICU hypothermic, coagulopathic and in the ICU hypothermic, coagulopathic and acidotic. acidotic.

Back to the case…Back to the case… After the initial resuscitation post op, the After the initial resuscitation post op, the

patient stabilizes. However, 6 hours later, patient stabilizes. However, 6 hours later, the bedside nurse calls to inform you that the bedside nurse calls to inform you that the output from the JP has increased.the output from the JP has increased.

The hemoglobin is 61, down from 97 and The hemoglobin is 61, down from 97 and INR is 1.6.INR is 1.6.

The surgeon tells you that she has The surgeon tells you that she has definitely controlled all of the bleeding and definitely controlled all of the bleeding and this is diffuse oozing. She will not consider this is diffuse oozing. She will not consider taking the patient back to the OR until you taking the patient back to the OR until you fix the medical bleeding.fix the medical bleeding.

He is given 5 more units of red cells and 2 He is given 5 more units of red cells and 2 units of FFP.units of FFP.

Since admission, this patient has Since admission, this patient has been given 14 units of blood, 10 been given 14 units of blood, 10 units of FFP, 2 pooled platelets, and units of FFP, 2 pooled platelets, and 1 unit of cryoprecipitate.1 unit of cryoprecipitate.

What is the definition of a massive What is the definition of a massive transfusion?transfusion?

What are the consequences of a What are the consequences of a massive transfusion?massive transfusion?

How do you approach a patient with How do you approach a patient with a massive transfusion?a massive transfusion?

What is the role for Factor VIIa in What is the role for Factor VIIa in trauma?trauma?

How does Factor VIIa work?How does Factor VIIa work? What are the side effects of Factor What are the side effects of Factor

VIIa?VIIa?

12 hours later, the patient’s bleeding and 12 hours later, the patient’s bleeding and coagulopathy have resolved.coagulopathy have resolved.

The RT calls to tell you that the airway The RT calls to tell you that the airway pressures have progressively increased pressures have progressively increased and now the alarm is triggering.and now the alarm is triggering.

What could be causing this?What could be causing this? Consider:Consider:

Patient/ventilator dysynchonyPatient/ventilator dysynchony ETT obstructionETT obstruction ARDS and other causes of pulmonary edemaARDS and other causes of pulmonary edema Recurrent pneumothoraxRecurrent pneumothorax Increased intraabdominal pressureIncreased intraabdominal pressure

When you assess the patient, the nurse When you assess the patient, the nurse also tells you that the urine output has also tells you that the urine output has been essentially zero for the last 4 hours been essentially zero for the last 4 hours despite repeated fluid boluses. You despite repeated fluid boluses. You suspect that the two problems are suspect that the two problems are related.related.

What is abdominal compartment What is abdominal compartment syndrome?syndrome?

How is it diagnosed?How is it diagnosed? The bladder pressure is 35The bladder pressure is 35

What are the consequences of abdominal What are the consequences of abdominal compartment syndrome?compartment syndrome?

How would you treat IAH/ACS?How would you treat IAH/ACS? Coincidently, the surgeon stops by to take Coincidently, the surgeon stops by to take

the patient to the OR for packing removal the patient to the OR for packing removal and closure.and closure.

Upon return, the wound is left open but Upon return, the wound is left open but the packings have been removed and all the packings have been removed and all bleeding is resolved.bleeding is resolved.

The bladder pressure is now 12.The bladder pressure is now 12.

Throughout the course of the last 24 hours, you Throughout the course of the last 24 hours, you have noted that the CK has been climbing have noted that the CK has been climbing progressively. It is now 12000. The urine is progressively. It is now 12000. The urine is dark tea colored.dark tea colored.

What is the most likely problem?What is the most likely problem? In addition to the obvious trauma, what are In addition to the obvious trauma, what are

some other causes for rhabdomyolysis? (not some other causes for rhabdomyolysis? (not just in this case)just in this case)

Why is rhabdomyolysis dangerous?Why is rhabdomyolysis dangerous? What is the treatment for rhabdomyolysis?What is the treatment for rhabdomyolysis? Is there a role for dialysis? Is there a role for dialysis?

It has certainly been a busy 24 hours with this It has certainly been a busy 24 hours with this trauma patient but we are not done yet.trauma patient but we are not done yet.

The family arrives and want an update.The family arrives and want an update. What information should you obtain from the What information should you obtain from the

family?family? Past medical history: None, healthyPast medical history: None, healthy Medications: Occasional tylenol for headaches.Medications: Occasional tylenol for headaches. Social history: Likes to binge drink. Especially on Social history: Likes to binge drink. Especially on

weekends when hanging out with the band and the weekends when hanging out with the band and the groupies. Has had alcohol withdrawal seizures in groupies. Has had alcohol withdrawal seizures in the past.the past.

How does this information change your How does this information change your management?management?

When caring for trauma patients, it is important to When caring for trauma patients, it is important to reexamine them every day to look for undiagnosed reexamine them every day to look for undiagnosed injuries. The probability of missed injuries injuries. The probability of missed injuries increases if the patient was rushed to the OR.increases if the patient was rushed to the OR.

What are some of the most important missed What are some of the most important missed injuries to look for?injuries to look for? Closed head injuryClosed head injury Aortic ruptureAortic rupture Hollow organ injuriesHollow organ injuries Pulmonary contusionsPulmonary contusions Crush injuries and rhabdomyolysisCrush injuries and rhabdomyolysis Compartment syndromesCompartment syndromes Small bone hand and feet fracturesSmall bone hand and feet fractures

Iatrogenic complications of trauma are Iatrogenic complications of trauma are also an important problem. What are also an important problem. What are some issues to look out for when some issues to look out for when caring for a trauma patient?caring for a trauma patient? Transfusion related complicationsTransfusion related complications Contrast induced nephropathyContrast induced nephropathy DVT and PE (by the way, what is the DVT and PE (by the way, what is the

appropriate DVT prophylaxis for trauma?)appropriate DVT prophylaxis for trauma?) Gastric stress ulcers Gastric stress ulcers

What is the one What is the one issue we have not issue we have not discussed in this discussed in this patient’s injury patient’s injury

list?list?C7 fractureC7 fracture

Three days after admission the patient Three days after admission the patient stabilizes and begins to wake up.stabilizes and begins to wake up.

During daily assessment you note that During daily assessment you note that the patient is not moving his legs the patient is not moving his legs spontaneously.spontaneously.

On detailed examination, he cannot On detailed examination, he cannot extend his arms or wrist, move his extend his arms or wrist, move his legs and has no sensation below the legs and has no sensation below the nipple line.nipple line.

What is the neurological level?What is the neurological level? Is it a complete or incomplete injury? Is it a complete or incomplete injury?

What is the difference?What is the difference? One week after the injury, the patient One week after the injury, the patient

starts to notice some recovery of starts to notice some recovery of sensation at the lower sacral level but no sensation at the lower sacral level but no improvement in motor function.improvement in motor function.

This recovery is called spinal shock. What This recovery is called spinal shock. What is it and how it is different from the often is it and how it is different from the often confused term “neurogenic shock”?confused term “neurogenic shock”?

Let us suppose that this patient’s Let us suppose that this patient’s only injury was the C-spine and only injury was the C-spine and there were no complicating issues.there were no complicating issues.

Why is aggressive resuscitation with Why is aggressive resuscitation with defense against hypoxia and defense against hypoxia and hypotension important?hypotension important? Prevention of secondary injury, similar Prevention of secondary injury, similar

concept to closed head injuries.concept to closed head injuries.

What is the role for the use of What is the role for the use of steroids in spinal cord injuries?steroids in spinal cord injuries?

What about cooling?What about cooling? How about early decompression and How about early decompression and

stabilization?stabilization?

10 days after the injury, the patient is still on 10 days after the injury, the patient is still on the ventilator and has been difficult to wean.the ventilator and has been difficult to wean.

What factors influence his inability to wean?What factors influence his inability to wean? Respiratory muscle weaknessRespiratory muscle weakness Poor cough and secretion controlPoor cough and secretion control PneumoniaPneumonia

Will he ever be ventilator-free?Will he ever be ventilator-free? Tracheotomy or not?Tracheotomy or not? What DVT prophylaxis should he get and for What DVT prophylaxis should he get and for

how long?how long?

Three weeks later, the patient is slowly Three weeks later, the patient is slowly weaning off the ventilator, has recovered weaning off the ventilator, has recovered from all of his other injuries and is awake.from all of his other injuries and is awake.

The bedside nurse calls you one evening The bedside nurse calls you one evening because the patient is hypertensive, flushed, because the patient is hypertensive, flushed, anxious, and sweating.anxious, and sweating.

What is going on?What is going on? Autonomic dysreflexiaAutonomic dysreflexia

What causes autonomic dysreflexia?What causes autonomic dysreflexia? How do you emergently treat this problem?How do you emergently treat this problem?

After a complete physical exam, you discover After a complete physical exam, you discover that the sacral ulcer is developing an that the sacral ulcer is developing an erythematous edge with pus.erythematous edge with pus.

How frequently do pressure ulcers How frequently do pressure ulcers complicate spinal cord injuries?complicate spinal cord injuries? Over 30%Over 30%

Why are pressure ulcers important?Why are pressure ulcers important? Significant contributor to morbidity and Significant contributor to morbidity and

mortality.mortality. How soon after admission do pressure ulcers How soon after admission do pressure ulcers

begin?begin? 3-4 hours of laying on the spinal board3-4 hours of laying on the spinal board

Questions??Questions??