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ARDS in Trauma Karl Wagner MD 11/30/04. 30 y/o male (note eyes covered to protect identity)

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Presentation on theme: "ARDS in Trauma Karl Wagner MD 11/30/04. 30 y/o male (note eyes covered to protect identity)"— Presentation transcript:

1 ARDS in Trauma Karl Wagner MD 11/30/04

2 30 y/o male (note eyes covered to protect identity)

3 2 Dudes (Probably these two)

4 H&P CC: s/p MVA HPI: pt 30y/o male in comes to the ED after an MVA with multiple injuries PMHx/PSHx: insignificant Meds: none Allergies: 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 excursion ABD: nondistended, soft, tender in right upper quadrant EXT: 18g IV in left AC and 16g IV right AC, moves all 4 ext, deformity of left thigh, tender to palpation, pulses intact

6 Glasgow Coma Scale Eyesspontaneous, command, pain, none Verbaloriented, confused, inappropriate, inconprehensible, none Motorobeys, localizes, withdraws, flex, extension, none

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 excursion ABD: nondistended, soft, tender in right upper quadrant EXT: 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 5-8 Lung contusion Liver contusion Left femur fracture

9 Operating Room Ventilator 10 cc/kg, 10 Resp/min Isoflurane Arterial line and introducer Four units packed red blood cells Conservative mx for liver Off to SICU for continued mx

10 All in a days work

11 Lung Injury Range of entities Local not clinically significant Unable to exchange gases across mebranes and participate in respiration Somewhere in between

12 Inflammation Blunt injury Neutrophiles Cytokines Macrophages Complement Cascade Coagulation Cascade

13 Normal Lung Tissue

14 Exudative Phase Starts early. Interstitial and alveolar edema Hyaline membrane formation Endothelial cell damage Type I cell necrosis Infiltration with neutrophiles

15 Diffuse Alvolar Damage

16 Proliferation Phase Type II cells increase in number Type II cells can become Type I cells

17 Fibrotic Stage Fibroblasts Myofibroblasts Collagenation Arteriolar hypertrophy Obliteration of pulmonary vasculature

18 Late Diffuse Alveolar Damage

19 Neutrophiles Already there… Secrete toxins… Connected for activation… Protected from deactivation… Location, Location, Location…

20 Map to the Neighborhood

21 Macrophages Killing machines Keep going and going and going… Complement IL-1, -6, -8 TNF Impaired judgment?

22 Endothelium Express cytokines Secrete vasoactive substance Procoagulant Metabolically active

23 Phospholipids On all cells Great cellular messenger Makes more cellular messengers Arachadonic acid Thromboxane Prostacylin PAF

24 Pulmonary Edema Hydrostatic pressure Oncotic pressure Lymph system Increase distance from capillary lumen to alveolar lumen Pulmonary hypertension Hypoxemia Lung compliance decreases

25 Diffuse Alveolar Infultrates

26 Patchy Densities

27 Phase 1 Dyspnea Tachypnea Normal CXR Hypoxemia Hypocarbia Neutrophiles

28 Phase 2 Changes on CXR Changes on PE Pulmonary Hypertension Change in pulmonary mechanics Microscopic lung changes/damage

29 Phase 3 Worse CXR Worse PE Worse cardiopulmonary mechanics Decreased hemoglobin oxygen extraction Occlusion of vessels

30 Phase 4 Diffuse infiltrates with superimposed pneumonia Sepsis MOF More lung impairment Cellular changes in the lung

31 Diagnosis of ARDS Diffuse alveolar infiltrates on CXR Noncardiogenic pulmonary edema PaO2/FiO2 ratio <200 12-39% Trauma Population Mortality 25-30%

32 Risk Factors Shock Gastric aspiration Pulmonary contusion Near-drowning Fractures Smoke inhalation Multiple transfusions Fat embolism Pneumonia Sepsis Injury severity score > 16 Blunt injury Trauma score < 13 Surgery to head +/- admission lactate, pH, base deficit, serum bicarbonate Disseminated intravascular coagulation

33 Injury Severity Score Head and Neck Face Chest Abdomen Extremity External

34 Trauma Score Glasgow Coma Scale Systolic Blood Pressure Respiratory Rate

35 Strategy Spontaneous respiration Noninvasive positive pressure Beware oxygen toxicity Fluid balance Treat underlying causes

36 Ventilator Strategies High PEEP early – 16 cm H2O Watch plateau pressure <35 cm H2O Low tidal volume – 6-8 cc/kg Be careful with manual ventilation Hypercapnia Pressure controlled ventilation

37 For Longer Term Care Treat underlying infections Proning ECMO Trach ‘em early NO! Steroids?

38 Bibliography Amato MBP, Barbas CSV, Medeiros DM, et al: Effect of a protective ventilation strategy on mortality in the acute respiratory distress syndrome. NEJM 1998; 338: 347 354 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; 351:389-391, 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: 327-336, Jul 22, 200

40 More Bibliography Medical Progress: The Acute Respiratory Distress SyndromeMedical Progress: The Acute Respiratory Distress Syndrome. Ware L. B., Matthay M. A. N Engl J Med 2000; 342:1334-1349, May 4, 2000. Effect of age on the development of ARDS in trauma patients. Johnston CJ - Chest - 01-AUG-2003; 124(2): 653-9 Effect of age on the development of ARDS in trauma patients. Glucocorticoids and acute lung injury. Thompson BT - Crit Care Med - 01-APR-2003; 31(4 Suppl): S253-7 Glucocorticoids and acute lung injury. 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): 327-31 Effect of acute lung injury and acute respiratory distress syndrome on outcome in critically ill trauma patients.

41 Bibliography Continued Management of post traumatic respiratory failure. Management of post traumatic respiratory failure. Michaels AJ - Crit Care Clin - 01-JAN-2004; 20(1): 83- 99, vi – vii Matox, Feliciano, Moore. Trauma Fouth Edition. McGraw-Hill 2000. Pages 1309-1339. Beers and Berkow. The Merck Manual of Diagnosis and Therapy Seventeenth Edition. Merck and Co. 1999. Pages 551-555. Fauci et al. Harrison’s Principles of Internal Medicine Fourteenth Edition. McGraw-Hill 1998. Pages 1483- 1490. WWW.ARDSNET.ORG Medical pictures from Up To Date.

42 Thanks for a fun morning!


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