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GROUP 3 CASE STUDY (2)
- 1. P R E P A R E D B Y O F O R I - A D D O MVC CASE STUDY
- 2. MEDICAL HISTORY AND DIAGNOSIS On March 15, 2015, A 36yo male was admitted to SAMMC after ejecting out of vehicle following a collision. Upon admission to SAMMC, Pt. was found to be Hypotensive Tachycardic, Acidotic (pH 6.9) Lactate of 8, Base deficit of 16, Pt. was tested positive to a FAST exam.
- 3. MEDICAL HISTORY AND DIAGNOSIS He was intubated in the Emergency Department and transported to the Operating Room where he underwent an exploratory laparotomy including splenectomy repair of a small left hemidiaphragm injury bilateral tube thoracostomies placement of intraabdominal drains for a moderate hemoperitoneum abdominal wound vac placement
- 4. MEDICAL HISTORY AND DIAGNOSIS Patient postoperatively was febrile with thick tracheal secretions Cultures demonstrated E. facaelis bacteremia, however the Patient on March 21, 2015, underwent bronchoscopy and was subsequently successfully extubated. Pt continued to have intermittent fevers through 26 March though cultures had been negative since the initial bacteremia was identified.
- 5. MEDICAL HISTORY AND DIAGNOSIS Patient noted to have the following complications MVC with ejection: Nasal Fracture Left distal clavicle fracture Left scapula fracture Left Pneumotorax and hemothorax Left 2-8 rib fractures with flail chest Left diaphragm injury Left Adrenal and Renal Laceration Grade II liver injury - Superficial left of falciform Small pancreatic tail leak Oblique fracture of the distal shaft of the radius Spinous and transverse process fractures of C6-T1, T6, T8, and T10
- 6. ABGs and Ventilator Settings
- 7. ABGs and Ventilator Settings 0842 pH 7.09 PCO2 54.2 PO2 73 HCO3 16.2 FiO2 60 tHct 32 tHb 10.8 0930 Mode VC/AC VT set 540 Vte 469 RR 18 tRR 18 PS 0 T Ve 8.4 PEEP 10 PIP 25 MAP 14 PPLAT ETCO2 21 1115 pH 7.26 PCO2 44 PO2 143 HCO3 19.3 FiO2 60 tHct 34 tHb 11.7 15Mar2015
- 8. ABGs and Ventilator Settings 1821 pH 7.27 PCO2 51.3 PO2 58 HCO3 22.9 FiO2 50 tHct 38 tHb 12.8 2025 Mode VC/AC VT set 540 Vte 472 RR 20 tRR 20 PS T Ve 9.3 PEEP 10 PIP 25 MAP 15 PPLAT 24 ETCO2 36 2106 pH 7.3 PCO2 41.6 PO2 174 HCO3 19.9 FiO2 100 tHct 36 tHb 12.4 15Mar2015 2345 pH 7.3 PCO2 42.6 PO2 139 HCO3 20.4 FiO2 60 tHct 34 tHb 11.7
- 9. ABGs and Ventilator Settings 0411 pH 7.3 PCO2 40.9 PO2 77 HCO3 19.8 FiO2 50 tHct 34 tHb 11.6 0440 Mode VC/AC VT set Vte RR tRR PS T Ve PEEP 8 PIP MAP PPLAT ETCO2 0944 pH 7.31 PCO2 43.8 PO2 69 HCO3 21.4 FiO2 50 tHct 33 tHb 11.1 17Mar2015 2052 pH 7.32 PCO2 42.9 PO2 89 HCO3 21.8 FiO2 60 tHct 38 tHb 12.9 1700 Mode VC/AC VT set 540 Vte 422 RR 22 tRR 22 PS T Ve 11.3 PEEP 10 PIP 22 MAP 13 PPLAT ETCO2 32
- 10. ABGs and Ventilator Settings 1158 pH 7.38 PCO2 38.8 PO2 140 HCO3 22.6 FiO2 50 tHct 29 tHb 9.8 1818 pH 7.39 PCO2 39.5 PO2 107 HCO3 23.5 FiO2 40 tHct 28 tHb 9.5 18Mar2015
- 11. ABGs and Ventilator Settings 0715 Mode VC-SIMV+PS VT set 540 Vte 665 RR 14 tRR 30 PS 15 T Ve 14.4 PEEP 10 PIP 24 MAP 18 PPLAT ETCO2 44 2121 pH 7.35 PCO2 42.2 PO2 113 HCO3 23 FiO2 40 tHct 32 tHb 10.9 19Mar2015 1215 Mode MMV VT set 540 Vte 539 RR 14 tRR 19 PS 15 T Ve 11.9 PEEP 10 PIP 26 MAP 14 PPLAT ETCO2 38
- 12. ABGs and Ventilator Settings 0249 pH 7.38 PCO2 41.8 PO2 84 HCO3 24 FiO2 35 tHct 33 tHb 11.2 0750 Mode MMV VT set 540 Vte 520 RR 14 tRR 34 PS 15 T Ve 17.2 PEEP 8 PIP 24 MAP 13 PPLAT ETCO2 31 2106 pH 7.41 PCO2 39.4 PO2 92 HCO3 24.4 FiO2 35 tHct 28 tHb 9.4 20Mar2015 1100 Mode MMV VT set 540 Vte 559 RR 14 tRR 21 PS 10 T Ve 11.9 PEEP 5 PIP 16 MAP 7.4 PPLAT ETCO2 31
- 13. ABGs and Ventilator Settings 1105 pH 7.35 PCO2 40.8 PO2 71 HCO3 21.8 FiO2 35 tHct 27 tHb 9.2 0800 Mode MMV VT set 540 Vte 576 RR 14 tRR 20 PS 5 T Ve 10.2 PEEP 5 PIP 15 MAP 8 PPLAT ETCO2 31 21Mar2015
- 14. PATIENT X-RAY
- 16. X-RAY –March 15, 2015
- 17. X-RAY: March 26, 2015
- 18. MEDICATIONS
- 19. Levalbuterol Brand Name – Xopenex Drug Class: Selective Beta 2 adrenergic agonist Treats or prevents bronchospasm in patients with asthma or other reversible lung diseases. Given concomitantly to prevent bronchospasms from…
- 20. Acetylcysteine Brand Name – Mucomyst Drug Class – Mucolytic/Antidote for acetaminophen Treatment of abnormal, sticky, or thick mucus secretions in various lung problems (chronic emphysema, bronchitis, asthmatic bronchitis, pneumonia, during anesthesia, following surgery or various lung tests). Given because Pt had flail chest and a laparotomy which severely decreased his ability to clear secretions.
- 21. Ipratropium Bromide Brand Name – Atrovent Drug Class – Anti-cholinergic Ipratropium is used to control and prevent wheezing and shortness of breath caused by chronic lung disease. It works by relaxing the muscles around the airways so that they open up and you can breathe easier. Given to reduce the amount of secretions by blocking the muscarinic acetylcholine receptors & for its long lasting bronchodilating effects.
- 22. Labetalol Brand Name – Trandate Drug Class – Beta blocker Treats high blood pressure. Labetalol is an adrenergic receptor blocker. It works by blocking both alpha and beta receptors in the body, which lowers blood pressure. High point of 207/65 on 29March2359 given prn for bouts of high BP
- 23. Promethazine Brand Name – Phenergan Drug Class – Anti-emetic Prevents and controls motion sickness, nausea, vomiting, and dizziness. Also used to relieve or prevent allergic reactions, helps people go to sleep, and control their pain or anxiety before or after surgery or other procedures. Given to relieve the stress on the abdomen by preventing vomiting after surgery and as a sleep aid from delirium.
- 24. Propranolol Brand Name – Inderal Drug Class – Beta Blockers Treats high blood pressure, angina, irregular heartbeat, migraine headaches, tremors, and lowers the risk of repeated heart attacks. Given for daily control of elevated BP.
- 25. Meperedine Brand Name – Demerol Drug Class – Opioid Short-term treatment of moderate to severe pain. It may also be used before or during surgery to support anesthesia. Meperidine is a narcotic analgesic, it works in the brain and nervous system to decrease pain. Given to Pt to reduce post operative non-thermoregulatory shivering. Depresses the Respiratory system!
- 26. Hydromorphone Brand Name - Dilaudid Drug Class – Opioid Hydromorphone is used to treat moderate to severe pain (6-10 on the PACU scale). The extended-release form of this medicine is for around-the-clock treatment of moderate to severe pain. Depresses Respiratory drive!
- 27. Quetiapine Brand Name – Seroquel Drug Class – Atypical Anti-psychotic Treating schizophrenia or bipolar disorder. Exactly how it works is not known except that it interrupts communication among the nerves of the brain. Given because Pt showed signs of schizophrenia and delirium from extended ICU stay. States he is “At Sears in the mall and someone is playing with my feet.”
- 28. Other Medications Bacitracin – topical antibiotic on wounds Oxymetazoline – bacterial nares infection Acetaminophen – fever Cepacol – Sore throat Fentanyl – Concurrent with Hydromorphone for pain (1-10) Ondansetron – nausea Enoxaparin – prophylactic anticoagulant Docusate – stool softener
- 29. Pt. Fever/Infection Enterococcus Faecalis is a non-motile, gram-positive, spherical bacterium. It can be observed singly, in pairs, or in short chains, and is most often found in the large intestine of humans. It is a facultative anaerobe with a fermentative metabolism. It can often be confused with S. pneumonia, but E. Faecalis contains many identification features that can be verified with testing. E. Faecalis is listed as the first to the third leading cause of nosocomial infections. Most of these infections occur after surgery of the abdomen or a puncturing trauma E. Faecalis is among the most antibiotic resistant bacteria known. It is also considered to be a carrier of Vancomycin resistance for other genera of bacteria. With E. Faecalis occurring frequently in hospital secondary infections, these multiple drug resistant strains create a scary concept. Due to its extremely wide resistance to antibiotic treatments, new treatments are being developed that allow the bacteria to attack the “Host Treatment” that eventually leads to its destruction.
- 30. DISCHARGE
- 31. Patient Care Is Ongoing • Patient is current eating soft solid foods on his own. • Patient is not longer on ventilator support. • Patient was seen at the SAMMC Oral and Facial Surgery Clinic for a fractured left medial orbital wall and a non displaced distal nasal bone fracture.
- 32. MENTAL/EMOTIONAL
- 33. Glasgow Comma Scale (GCS) I. Motor Response 6 – Obeys commands fully 5 – Localizes to noxious stimuli 4 – Withdraws from noxious stimuli 3 – Abnormal flexion 2 – Extensor response 1 – No response II. Verbal Response 5 – Alert and Oriented 4 – Confused, yet coherent speech 3 – Inappropriate words and jumbled phrases consisting of jumbled words. 2 – Incomprehensible sounds 1 – No sounds III. Eye Opening 4 – Spontaneous eye opening 3 – Eyes open to speech 2 – Eyes open to pain 1 – No eye opening Mild (13-15) Moderate (9-12): ■ Loss of consciousness greater than 30 minutes ■ Physical or cognitive impairments which may or may not resolve Severe (3-8): ■ Coma: unconscious state. No meaningful response, no voluntary activity. Vegetative State (Less Than 3): ■ Sleep wake cycles ■ Arousal, but no interaction with environment ■ No localized response to pain Persistent Vegetative State: ■ Vegetative state lasting longer than one month Brain Death: ■ No brain function ■ Specific criteria needed for making this diagnosis http://www.traumaticbraininjury.com/symptoms-of-tbi/glasgow-coma-scale/
- 34. Pts Mental Progress Over Course of Treatment When Patient was brought to SAMC he was rated 3-6 on the Glasgow Comma Scale. He also had a blood alcohol level of .25. Through the 16-20 of March Patient’s GCS was between a 6-9 due to being sedated for the following behaviors. 1. Schizophrenic 2. Agitated 3. Combative Starting on the 21 March to the present Patient’s GCS has been between 14- 15. Patient has not suffered any serious injury affecting his brain. To better confirm any long term affects Patient should be further evaluated by CT or MIR Neruo scan.
- 35. Emotional Patient was involved in a motor vehicle accident. Individuals who suffer this type of trauma are at higher risk for: 1. Post Traumatic Stress Disorder 2. Long term anxiety 3. Phobias and fears about vehicles
- 36. Emotional The feelings of stress can compile and affect the Patient's life by interfering with their work and relationships which can eventually lead to depression, anxiety, and sleep problems If symptoms persist from more than 3 months after the accident it is highly recommend to seek help from a provider specializing in Post Traumatic Stress Disorder treatment.
- 37. Emotional Treatment Treatment may include: 1. Anxiety management 2. Breathing and relaxation exercises 3. Medications to relieve anxiety and/or help sleep.
- 38. QUESTIONS?
- 39. ETHICAL QUESTION Is it ethical for this patient to be sent as a priority to the facial plastic surgeon (Maxilofacialary surgery) ahead of the other SAMMC military patients for facial reconstruction when he was intoxicated and without insurance? Note that, Pt. had a .25 on his blood/alcohol level!!! And his family denied drug/alcohol abuse.