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You are called to perform an interfacility transport of a 38 year old male who was involved in an up an over motorcycle accident. He sustained bilateral femur fractures and a hepatic laceration. Haemostasis was accomplished following the injury and the femur fractures were stabilised about 24 hours later. The patient developed poor lung compliance following the second surgery and abdominal compartment syndrome was identified after a foley transducer was placed. The patient has just returned from a decompressive laparotomy. The facility is a level two trauma centre and the patient is being transferred to a level one about 25 minutes by ground.

Take it away...

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How bout some baseline vitals?

Alert & oriented? or is he still vented?

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P-122, B/P-80/62, SpO2-88%, RR- ventilator in AC with mandatory rate of 12 & total rate of 24, Temp-97.9 F, patient responds to tactile stimuli with eye opening.

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Hello,

With femur fractures this patient is at risk of developing a fat embolism. Which, from my understanding, typically present 24 hours post injury.

  • Dose he have a rash?

First, I would work on his BP. His abdomen is open I assume so I would give him 1000cc of NS.

  • What do his lungs sound like?
  • What dose his WOB look like?
  • What size tube?
  • Tube depth?
  • Any recent CXR or ABG?
  • What are his PIP and Plateau Pressure?
  • What is his Vt
  • What is his FiO2?
  • What is his PEEP?

Next I would turn up his FiO2 and increase the set rate to 24 match the patient. Then I would sedate (...with cation...) to deep sedation (RASS -3). He is in a shock state and the ventilator should take on the medibolic demand imposed by breathing.

Depending on how his lungs sound or how high we need to go on the FiO2 I would adjust his PEEP.

Depending on his airway presures I would adjust his Vt.

I would keep the ARDSnet in the back of my brain.

Third, I would get to know the patient better. Get a formal report, chart review and detailed head-to-toe.

Cheers

=)

Edited by DartmouthDave

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No rash. Crackles in all the lobes. You can calculate WOB but he's currently in a controlled mode and he appears to be triggering the ventilator with little effort. 8.0 ETT at 23 cm. Yes to both Cxr & ABG. PIP is 48, Pplat is 42. Vt is 700 ml. FiO2 is 0.8. PEEP is 8. Nothing else upon report that wasn't already mentioned. You want to give crystalloids or blood products?

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I love your scenarios Chris and I would love to participate but am going to silently observe this time. This guy is way to complicated for me.

Is he even stable enough for transport by ground?

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Hello,

ET 8.0

The tube is a good size so that isn't accounting for the high pressures.

Is the patient sedated enough to maintain patient-ventilator synchrony? Not fighting the vent? If he is well sedated that will not explaining the high pressures.

Maybe use some Ketamine as sedation to improve compliance some. He is young with no CV risk factors.

Vt=700

What is his ideal body weight? I would started with 8cc/kg by IBW.

CXR & ABG

Get somebody to look at the CXR (I am not very good at this) and see if it is patchy looking (ARDS) or wet. Check the ABG to see what his Hgb, lactate, PaCO2, PaO2 and calcualted the Pa02/FiO2 ratio. Maybe the A-a.......not that I actually remember how that works. =)

I think his problem is a diffusion defect. His sats suck for a FiO2 of .80. Maybe an ALI/ARDS or a fat embolism or a TRALI (depending on how much blood products he may have had).

I would start working through an ARDS net protocol. Start with a Vt of 8cc/kg and work down to 6cc/kg. Work up on the PEEP as per ARDSnet. Do some stepwise recruitment manuvers.

I still would give a 1000cc bolus and hold on blood (until I see some numbers) and see how the vent manuvers work.

I would also consider switching to PCV....I am not sure. This is getting outside of my area of expereince. Time to phone a friend.

As for transport. I think his airway pressures and sats need to be corrected first.

Cheers....

Time to run..

DD

Edited by DartmouthDave

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The patient weighs 108 kg and is 5 feet 9 inches tall.

ABG:

pH 7.04

PaCO2 53 mmHg

PaO2 58 mmHg

HCO3- 17 mEq/L

Haemoglobin 10 g/dl

Serum Lactate 10 mmol/L

SaO2 84%, SPO2 is currently reading 86%

Chest X-ray:

8f46bb2e.jpg

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PV loop on the ventilator looks like this:

74a4e262.jpg

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Hello,

Hmmmm...

I don't know PV loops. Is the patient auto-peeping? Is it dynamtic hyperinflation? Without a COPD history I wouldn't think so. But, I would like to rule this out before I would go with my next plan.

I have limited expereince running an ARDS net solo. I also have little expereince with CXR but this looks fluffy to me. Add to this a poor ABG and high airway pressures makes me lean towards ARDS. I would slowly increase the rate to 30 and drop the Vt 550. I would increase the PEEP to +14.

I would be willing to drop the Vt lower if need be to reduce the airway pressures. I would also ensure a deep level of sedation so the patient would ride the vent and not trigger any assisted breaths. I would keep him deeper than I would in an ICU because of the stress imposed by a transfer.

My goal would be a Sp02 88% or greater with a decrease in the CO2 (if possible).

If possible, take a peek at the IVC with an u/s or shoot a CVP (weak) or do a SvO2 to see how the heart is doing and get an idea of the patient's volume status.

Any recent VS?

I don't want to tunnel in too much on the vent/lungs.

Cheers

Edited by DartmouthDave

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