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 Eyes spontaneous, command, pain, none
Verbal oriented, confused, inappropriate, inconprehensible, none
Motor obeys, 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:
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 Bibliography
Medical 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 – vii
Matox, Feliciano, Moore. Trauma Fouth Edition. McGraw-Hill Pages
Beers and Berkow. The Merck Manual of Diagnosis and Therapy Seventeenth Edition. Merck and Co Pages
Fauci et al. Harrison’s Principles of Internal Medicine Fourteenth Edition. McGraw-Hill Pages
Medical pictures from Up To Date.

42. Thanks for a fun morning!