Trauma Part II

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Trauma Part II
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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.

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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.

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• 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?

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• 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?

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• 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.
• What could be causing this?
• Consider
• Patient/ventilator dysynchony
• ETT obstruction
• ARDS and other causes of pulmonary edema
• Recurrent pneumothorax
• Increased intraabdominal pressure

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• 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

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• 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.

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• 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?

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• 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?

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• 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

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• 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

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What is the one issue we have not discussed in
this patients injury list?

• C7 fracture

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• 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.

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• 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?

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• 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?
• Prevention of secondary injury, similar concept
  to closed head injuries.

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

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• 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?

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• 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?

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• 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?
• Over 30
• Why are pressure ulcers important?
• Significant contributor to morbidity and
  mortality.
• How soon after admission do pressure ulcers
  begin?
• 3-4 hours of laying on the spinal board

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Questions??