1. Trauma Part II

2. 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 trying to cross a highway when he is struck on the passenger side. He is a single occupant trying to cross a highway when he is struck on the passenger side. His injuries include: His injuries include: Severe liver laceration Severe liver laceration Bilateral pneumothoraces Bilateral pneumothoraces C7 fracture C7 fracture We had talked about pelvic fractures but this patient does not have one. 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. He has had damage control surgery and is back in the ICU hypothermic, coagulopathic and acidotic.

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

4. Since admission, this patient has been given 14 units of blood, 10 units of FFP, 2 pooled platelets, and 1 unit of cryoprecipitate. 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 is the definition of a massive transfusion? What are the consequences of a massive transfusion? What are the consequences of a massive transfusion?

5. How do you approach a patient with a massive transfusion? How do you approach a patient with a massive transfusion? What is the role for Factor VIIa in trauma? What is the role for Factor VIIa in trauma? How does Factor VIIa work? How does Factor VIIa work? What are the side effects of Factor VIIa? What are the side effects of Factor VIIa?

6. 12 hours later, the patients bleeding and coagulopathy have resolved. 12 hours later, the patients bleeding and coagulopathy have resolved. The RT calls to tell you that the airway pressures have progressively increased and now the alarm is triggering. The RT calls to tell you that the airway pressures have progressively increased and now the alarm is triggering. What could be causing this? What could be causing this? Consider: Consider: Patient/ventilator dysynchony Patient/ventilator dysynchony ETT obstruction ETT obstruction ARDS and other causes of pulmonary edema ARDS and other causes of pulmonary edema Recurrent pneumothorax Recurrent pneumothorax Increased intraabdominal pressure Increased intraabdominal pressure

7. 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. 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? What is abdominal compartment syndrome? How is it diagnosed? How is it diagnosed? The bladder pressure is 35 The bladder pressure is 35

8. What are the consequences of abdominal compartment syndrome? What are the consequences of abdominal compartment syndrome? How would you treat IAH/ACS? How would you treat IAH/ACS? Coincidently, the surgeon stops by to take the patient to the OR for packing removal and closure. 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. Upon return, the wound is left open but the packings have been removed and all bleeding is resolved. The bladder pressure is now 12. The bladder pressure is now 12.

9. 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. 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? What is the most likely problem? In addition to the obvious trauma, what are some other causes for rhabdomyolysis? (not just in this case) In addition to the obvious trauma, what are some other causes for rhabdomyolysis? (not 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?

10. It has certainly been a busy 24 hours with this trauma patient but we are not done yet. 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. The family arrives and want an update. What information should you obtain from the family? What information should you obtain from the family? Past medical history: None, healthy Past medical history: None, healthy Medications: Occasional tylenol for headaches. 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. 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? How does this information change your management?

11. 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. 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? What are some of the most important missed injuries to look for? Closed head injury Closed head injury Aortic rupture Aortic rupture Hollow organ injuries Hollow organ injuries Pulmonary contusions Pulmonary contusions Crush injuries and rhabdomyolysis Crush injuries and rhabdomyolysis Compartment syndromes Compartment syndromes Small bone hand and feet fractures Small bone hand and feet fractures

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

13. What is the one issue we have not discussed in this patients injury list? C7 fracture

15. Three days after admission the patient stabilizes and begins to wake up. 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. 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. On detailed examination, he cannot extend his arms or wrist, move his legs and has no sensation below the nipple line.

16. What is the neurological level? What is the neurological level? Is it a complete or incomplete injury? What is the difference? 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. 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? This recovery is called spinal shock. What is it and how it is different from the often confused term neurogenic shock?

17. Let us suppose that this patients only injury was the C-spine and there were no complicating issues. Let us suppose that this patients only injury was the C-spine and there were no complicating issues. Why is aggressive resuscitation with defense against hypoxia and hypotension important? Why is aggressive resuscitation with defense against hypoxia and hypotension important? Prevention of secondary injury, similar concept to closed head injuries. Prevention of secondary injury, similar concept to closed head injuries.

18. What is the role for the use of steroids in spinal cord injuries? What is the role for the use of steroids in spinal cord injuries? What about cooling? What about cooling? How about early decompression and stabilization? How about early decompression and stabilization?

19. 10 days after the injury, the patient is still on the ventilator and has been difficult to wean. 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? What factors influence his inability to wean? Respiratory muscle weakness Respiratory muscle weakness Poor cough and secretion control Poor cough and secretion control Pneumonia Pneumonia 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 how long? What DVT prophylaxis should he get and for how long?

20. Three weeks later, the patient is slowly weaning off the ventilator, has recovered from all of his other injuries and is awake. 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. The bedside nurse calls you one evening because the patient is hypertensive, flushed, anxious, and sweating. What is going on? What is going on? Autonomic dysreflexia Autonomic dysreflexia What causes autonomic dysreflexia? What causes autonomic dysreflexia? How do you emergently treat this problem? How do you emergently treat this problem?

21. After a complete physical exam, you discover that the sacral ulcer is developing an erythematous edge with pus. 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? How frequently do pressure ulcers complicate spinal cord injuries? Over 30% Over 30% Why are pressure ulcers important? Why are pressure ulcers important? Significant contributor to morbidity and mortality. Significant contributor to morbidity and mortality. How soon after admission do pressure ulcers begin? How soon after admission do pressure ulcers begin? 3-4 hours of laying on the spinal board 3-4 hours of laying on the spinal board

22. Questions??