group 3 case study (2)

PREPARED BY

OFORI-ADDO

MVC CASE STUDY

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.


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


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.


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

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


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


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


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


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


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


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

PATIENT X-RAY

X-RAY

Normal X-Ray

X-RAY –March 15, 2015

X-RAY: March 26, 2015

MEDICATIONS

Levalbuterol

Brand Name – XopenexDrug Class: Selective Beta 2 adrenergic agonistTreats or prevents bronchospasm in patients with

asthma or other reversible lung diseases.Given concomitantly to prevent bronchospasms

from…

Acetylcysteine

Brand Name – MucomystDrug Class – Mucolytic/Antidote for acetaminophenTreatment 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.

Ipratropium Bromide

Brand Name – AtroventDrug 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.

Labetalol

Brand Name – TrandateDrug 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

Promethazine

Brand Name – PhenerganDrug Class – Anti-emeticPrevents 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.

Propranolol

Brand Name – InderalDrug Class – Beta BlockersTreats high blood pressure, angina, irregular

heartbeat, migraine headaches, tremors, and lowers the risk of repeated heart attacks.

Given for daily control of elevated BP.

Meperedine

Brand Name – DemerolDrug Class – OpioidShort-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!

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!

Quetiapine

Brand Name – SeroquelDrug 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.”

Other Medications

Bacitracin – topical antibiotic on woundsOxymetazoline – bacterial nares infectionAcetaminophen – feverCepacol – Sore throatFentanyl – Concurrent with Hydromorphone

for pain (1-10)Ondansetron – nauseaEnoxaparin – prophylactic anticoagulant Docusate – stool softener

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.

DISCHARGE

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.

MENTAL/EMOTIONAL

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/

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. Schizophrenic2. Agitated3. 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.

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 anxiety3. Phobias and fears about vehicles

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.

Emotional Treatment

Treatment may include:1. Anxiety management 2. Breathing and relaxation exercises3. Medications to relieve anxiety and/or

help sleep.

QUESTIONS?

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.

group 3 case study (2)

Documents

acidotic ph

ventilator settings

pip map pplat etco2

mode mmv vt

mode vcsimv ps vt

medical history

diagnosis patient

nasal fracture