4 H&PCC: s/p MVAHPI: pt 30y/o male in comes to the ED after an MVA with multiple injuriesPMHx/PSHx: insignificantMeds: noneAllergies: none
5 Physcical Exam BP 110/85, HR 115, RR 32 Neuro: in C-collar, GCS 10 (E3V3M4)CVS: tachycardic,Resp/chest: dyspnea, tachypneic, tenderness on right chest, CTA bilat, decreased inspiratory excursionABD: nondistended, soft, tender in right upper quadrantEXT: 18g IV in left AC and 16g IV right AC, moves all 4 ext, deformity of left thigh, tender to palpation, pulses intact
7 Physcical Exam BP 110/85, HR 115, RR 32 Neuro: in C-collar, GCS 10 (E3V3M4)CVS: tachycardic,Resp/chest: dyspnea, tachypneic, tenderness on right chest, CTA bilat, decreased inspiratory excursionABD: nondistended, soft, tender in right upper quadrantEXT: 18g IV in left AC and 16g IV right AC, moves all 4 ext, deformity of left thigh, tender to palpation, pulses intact
8 Injury Survey Small subdural hematoma over right frontal lobe Right sided rib fractures 5-8Lung contusionLiver contusionLeft femur fracture
9 Operating Room Ventilator 10 cc/kg, 10 Resp/min Isoflurane Arterial line and introducerFour units packed red blood cellsConservative mx for liverOff to SICU for continued mx
36 Ventilator Strategies High PEEP early – 16 cm H2OWatch plateau pressure <35 cm H2OLow tidal volume – 6-8 cc/kgBe careful with manual ventilationHypercapniaPressure controlled ventilation
37 For Longer Term Care Treat underlying infections Proning ECMO Trach ‘em earlyNO!Steroids?
38 BibliographyAmato MBP, Barbas CSV, Medeiros DM, et al: Effect of a protective ventilation strategy on mortality in the acute respiratory distress syndrome. NEJM 1998; 338:The Acute Respiratory Distress Syndrome Network: Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. NEJM 2000; 342.M McCunn, MD, MIPP, A Sutcliffe, MBChB, W Mauritz, MD, PhD and the ITACCS Critical Care Committee: Guidelines for Management of Mechanical Ventilation for Critically Injured Patients.
39 Bibliography continued PEEP in ARDS – How much is enough? Levy M. M. N Engl J Med 2004; 351: , Jul 22, 2004 Medical Progress: The Acute Respiratory Distress Syndrome. Kollef M. H., Schuster D. P. N Engl J Med 1995; 332:27-37, Jan 5, 1995. Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome. The National Heart, Lung, and Blood Institute ARDS clinical Trials Network. N Engl J Med 2004; 351: , Jul 22, 200
40 More BibliographyMedical Progress: The Acute Respiratory Distress Syndrome. Ware L. B., Matthay M. A. N Engl J Med 2000; 342: , May 4, 2000. Effect of age on the development of ARDS in trauma patients. Johnston CJ - Chest - 01-AUG-2003; 124(2): 653-9 Glucocorticoids and acute lung injury. Thompson BT - Crit Care Med - 01-APR-2003; 31(4 Suppl): S253-7 Effect of acute lung injury and acute respiratory distress syndrome on outcome in critically ill trauma patients. Treggiari MM - Crit Care Med - 01-FEB-2004; 32(2):
41 Bibliography Continued Management of post traumatic respiratory failure. Michaels AJ - Crit Care Clin - 01-JAN-2004; 20(1): 83-99, vi – viiMatox, Feliciano, Moore. Trauma Fouth Edition. McGraw-Hill PagesBeers and Berkow. The Merck Manual of Diagnosis and Therapy Seventeenth Edition. Merck and Co PagesFauci et al. Harrison’s Principles of Internal Medicine Fourteenth Edition. McGraw-Hill PagesMedical pictures from Up To Date.