17 yo trauma with pulmonary edema

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neuroride

neuroride

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17 yo female with no prev PHMx involved in MVA with ejection, large pelvic ring fracture, spleen is bleeding with bowel bleeding as well. She comes to the OR on face mask with blood running through the level 1.

Hb downstairs is 3.7 after 2 Units PRBC given. Good start to case with large bore IV's and art line placed. Belmont infuser is cranking with med student alternating FFP/PRBC while I and others manage hypotension with phenylephrine and norepi.

After about 1 hour, I noticed capnograph not reading and it reading occlusion. I looked up to see fluid refluxing back into the Dfend spirometry sensor. Next looked down at ETT to see fluid pouring up out the tube. Horrible pulmonary edema

We had to disconnect her from the circuit and just let it pour out of the tube like 15 times in the next 30 mins. Gave morphine once and lasix 20mg x 4. Manually ventilated her for the next 20 min.

She eventually got 22 Units PRBC, 14 FFP, 3 Units platelets, and 1 cellsaver bag. She was continually bleeding the entire time and they were not sure that all of her pelvic bleeding had stopped. Procedures ended up being a splenectomy, bowel resection, and pelvic ex-fix and also some repair on the perineum for open lacs. I am a CA-2 and have only seen this pulmonary edema once in an old CHF lady just after intubation in the ICU.

Any other experiences/suggestions for management? Too much product given? She was pretty dependent on the products infusing to maintain her BP. We evenutally got her packed up and ran to the ICU, she acutally had stabilized slightly when we got to the ICU
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Any injury to the pulmonary parenchyma itself? Blunt trauma? This is high on my differential as she was ejected. I've seen this type or pulm. edema before: Had to replace the anesthesia circuit 4-5 times during a case because it would fill up so dang quickly. She could have TRALI I suppose, but not usually associated with that kind of pulmonary edema. Traumatic/Neurogenic pulmonary edema is also high on my list, but again... in a 17 y/o with o/w healthy lungs, she should be able to handle those kind of fluid shifts w/o having massive pink frothy fluids accumulating in the circuit (unless there is a serious lung injury). Fat embolus? Not usually associated with this kind of pulm. edema.

BTW, these people are sometimes hard to manage as you think you are replacing fluids when in fact it's going in an IV and then right out the ETT. It really is a catch 22 as you don't want to over do it with fluids in the setting of pulmonary edema... but you also don't want her dry (careful with a lasix naive patient as I rather her have pulm. edema than acute renal failure). The patient I mentioned above had liters upon liters coming out the ETT both in the OR and ICU

PEEP helps a lot in this scenario. Perfect patient for low TV and generous PEEP. Massive pulm. edema usually gets better within a day or so.

I would re-scan her lungs looking for injury or misplaced line.
 
This is why you have a filter on the expiratory limb of your circuit.... depending on what kind of machine you have, it will help your machine from malfunctioning and being contaminated.
 
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Although you don't specifically mention head trauma, this patient seems like her situation may have resulted in some. My first thought when I read the scenario was neurogenic pulmonary edema. I have seen it once and it was so profound, we struggled to oxygenate the young person because of the voluminous edema fluid. The onset in my case was about 20 minutes after induction of anesthesia.
 
think about how much crystalloid she had to get to have that crit of roughly 10 after getting a field/ER resuscitation and then what you gave her. several blood volumes. TRALI is a concern here for sure. I dont think that NPE is a big factor, given the amount of catecholamines she had to get from you, its unlikely the native sympathetic system could compete.

this happens in these traumas occasionally. you are pumping tremendous amounts of product directly into the right heart, against a huge afterload, couple that with the possibility of LV stunning and/or acute heart failure due to the above, and pulmonary edema is certainly to be expected. I probably saw this 10 times during residency, and it was always a pretty poor prognostic sign. I actually equated it with the body giving up.

Cardiopulmonary trauma/contusion def need to be high on the differential. Ive seen PA rupture present late in a trauma, but that would typically be frank red blood and would not be salvageable.

Should also consider anaphylaxis to drugs or blood products. I have also seen ABO incompatibility present like this and while it is unlikely that is what happened here, it should be worked through.

Would be interested in seeing labs and coags. How much crystalloid did you give in the OR?

edit: no central line? i dont know about that...
 
neuroride said:
17 yo female with no prev PHMx involved in MVA with ejection, large pelvic ring fracture, spleen is bleeding with bowel bleeding as well. She comes to the OR on face mask with blood running through the level 1.

Hb downstairs is 3.7 after 2 Units PRBC given. Good start to case with large bore IV's and art line placed. Belmont infuser is cranking with med student alternating FFP/PRBC while I and others manage hypotension with phenylephrine and norepi.

After about 1 hour, I noticed capnograph not reading and it reading occlusion. I looked up to see fluid refluxing back into the Dfend spirometry sensor. Next looked down at ETT to see fluid pouring up out the tube. Horrible pulmonary edema

We had to disconnect her from the circuit and just let it pour out of the tube like 15 times in the next 30 mins. Gave morphine once and lasix 20mg x4:eek:. Manually ventilated her for the next 20 min.

She eventually got 22 Units PRBC, 14 FFP, 3 Units platelets, and 1 cellsaver bag. She was continually bleeding the entire time and they were not sure that all of her pelvic bleeding had stopped. Procedures ended up being a splenectomy, bowel resection, and pelvic ex-fix and also some repair on the perineum for open lacs. I am a CA-2 and have only seen this pulmonary edema once in an old CHF lady just after intubation in the ICU.

Any other experiences/suggestions for management? Too much product given? She was pretty dependent on the products infusing to maintain her BP. We evenutally got her packed up and ran to the ICU, she acutally had stabilized slightly when we got to the ICU
Click to expand...

we commonly see frothy pink stuff coming out the ett with our massive hemorrhage patients after sufficient resuscitation - it is inevitable. your situation sounds a bit - more... though.

fat embolus is somewhat likely, but how you sort that out vs massive transfusion related edema I'm not sure, and I don't think the treatments would differ markedly.

what you fail to mention is whether oxygenation and ventilation were a problem. sure, fluids pouring outta the ett, but what did her abg's look like?

how did you justify giving 80 MG of LASIX to an unstable MASSIVE HEMORRHAGE TRAUMA?!! I will give you the benefit of the doubt and assume that your oxygenation and ventilation were in dire straits ie paco2 >60 and pao2<60 on 100% with hi peep, and that you had suctioned the hell outta her, and bronched her, and bagged her, but you don't mention all of that in your post...

what was the discussion with the surgeons and your attending? her hemodynamics sure don't sound stable enough to me to give lasix...
 
I have no idea what you guys are talking about but this is the best clinical thread I have seen in months.

:highfive:

To make it out of the OR and to the ICU sounds like a win for this patient. From what I used to do in training, we'd see her in 4 weeks and get her a cozy rehab bed. You guys rock. Post updates if you follow her in ICU.

Subscribed.
 
I had a case in residency where a young female who had been taken to the or for a pelvic bleed (she had been on coumadin for a dvt or pe if I remember correctly and her INR was around 10). At any rate she received some ffp intraop. I extubated her uneventfully and her sats were 98-99 post extubation. on transport to the pacu the patient reported feeling somewhat short of breath and was coughing repeatedly. Got to the recovery room and listened to her. She sounded wet, so I gave some lasix and shot a CXR, which showed bilateral diffuse pulmonary infiltrates. She was reintubated shortly after as her pO2 ended up dropping to the low 50's. Transferred to the ICU, ended up on inhaled nitric oxide. Diagnosis ARDS from TRALI. One interesting note was that she had copious frothy sputum but it was very proteinaceous and light brown in color.
 
i agree with idiopathic...

sometimes a low dose infusion of nitroglycerin helps to increase your venous capacitance while pumping in loads of fluid in a highly vasoconstricted state....

what was the final fluid count? uop?
 
Once we got into the pulmonary edema, her sats did sag down into the low 80's but that was partly from us having to disconnect her and drain the fluid taking about 20 seconds each time, once reconnected I hand ventilated, holding a good deal of PEEP.

There was no specific mention of cardiopulmonary damage but this was likely given the ejection.

She ended up only getting 4 L crystalloid as we had blood products most the time to give and when we got low, we choked back on the crystalloid to avoid dilution of what we had already given.

I will get an update back soon.

Thanks for those who have responded so far, good discussion
 
TEE is a big help in diagnosing what is going on in these cases. Guide your fluid replacement/ extraction based on the function of the ventricles. Look for evidence of PE etc.


- pod
 
periopdoc said:
TEE is a big help in diagnosing what is going on in these cases. Guide your fluid replacement/ extraction based on the function of the ventricles. Look for evidence of PE etc.
- pod
Click to expand...

TTE might be easier if you don't want to drop a probe, and you can get access to the chest. Especially useful in this particular case where I think the clinical questions are right heart function and volume status.
 
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Ive had this before as well. You gotta see it to beleive it. What youre describing is almost certainly capilary leak (non-cardiogenic pulm oedema), likely from trali, although any ards type pathology possible. Her pulm oedema fluid prolly looked like beer? You dont have enough info to conclusively r/out cardiogenic (TEE would be helpful).

For management you need to differentiate cardiogenic vs noncardiogenic. Assuming the later, your managemnt is mostly supportive. What you dont want to do is suction out the fluid, instead call down for an icu vent and hit the lungs with high peep, high mean pressures. Young adults can tolerate long episodes of low po2 so long as cardiac output is supported, so dont give up...keep the volume coming. ECMO is a good especially for trali where the pt will improve in a couple days.
 
gtb said:
TTE might be easier if you don't want to drop a probe, and you can get access to the chest. Especially useful in this particular case where I think the clinical questions are right heart function and volume status.
Click to expand...

Possibly, except in these cases the patient is always prepped from the sternoclavicular junction to the pubis so it can be tough to get a probe on the chest unless you want to scrub in and drape the probe.

If the patient is crashing, you could choose to break the sterile field.

Of course, I doubt that there are even fewer anesthesiologists that are comfortable with obtaining trans-thoracic images and interpreting that image than doing the same with a trans-esophageal probe.

- pod
 
sevoflurane said:
Any injury to the pulmonary parenchyma itself? Blunt trauma? This is high on my differential as she was ejected.
Click to expand...

Good thought, but I don't know if I'd expect a pulmonary contusion to cause abrupt pulmonary edema an hour into the case.



Whether you want to blame neurogenic pulmonary edema or all the exogenous catecholamines, the mechanism is basically the same there - high preload high afterload, maybe with some contused myocardium making things worse. Massive transfusion, fat embolism round out my top 3.



I'm also surprised you gave Lasix. If you can expand on that thought process when you post back I'd be interested. It doesn't seem to make sense to me.
 
I'm thinking more of a tear in the lung tissue itself from blunt trauma/ribs... not really a contusion although possible if severe enough. Reminds me of a case where a young 16 y/o was in a skiing accident where she ran into a tree. The outside looked a lot better than the inside. Opened her up to find her liver shattered into a billion little pieces.
 
We had a subclavian cordis from the ER but the damn thing was kinking as the placement was less than great so we ended up placing a RIC catheter 7.5 fr in the AC of her left arm and the belmont hooked to that.

My attending started with the lasix I guess to diuresis the pulmonary fluid off?? Not entirely sure, just did what was asked at that point. Doesn't make a lot of sense after the fact.

Heard the girl is still in the ICU, has been back for the perineal repair in the last couple of days, aparently she straddled the the dash and windshield as she was ejected.
 
neuroride said:
We had a subclavian cordis from the ER but the damn thing was kinking as the placement was less than great so we ended up placing a RIC catheter 7.5 fr in the AC of her left arm and the belmont hooked to that.

My attending started with the lasix I guess to diuresis the pulmonary fluid off?? Not entirely sure, just did what was asked at that point. Doesn't make a lot of sense after the fact.

Heard the girl is still in the ICU, has been back for the perineal repair in the last couple of days, aparently she straddled the the dash and windshield as she was ejected.
Click to expand...

i may be missing some details (abg, case hemodynamic values), but if your attending gave lasix to the patient you described in my trauma hospital, he would have been asked to attend both the anesthesia and surgery M&M's to present and defend his case.

a fairly common board question - the neurosurgeon's demand you give their fresh head-injured multi-trauma patient mannitol for an increased ICP - if you do you fail and pee the patient to death...
 
slavin said:
i may be missing some details (abg, case hemodynamic values), but if your attending gave lasix to the patient you described in my trauma hospital, he would have been asked to attend both the anesthesia and surgery M&M's to present and defend his case.

a fairly common board question - the neurosurgeon's demand you give their fresh head-injured multi-trauma patient mannitol for an increased ICP - if you do you fail and pee the patient to death...
Click to expand...

Death from over-urination, only could be contrived in the hallowed halls of world class academic medicine :)
 
i dont know, it depends on the situation. lasix does venodilate acutely, and this could be beneficial in dealing with a life-threatening pulmonary edema.

could be especially valuable if the patient is acutely oliguric, as you may need to give blood to help with tissue oxygenation but could be volume overloaded (see hematocrit of 10). i dont know, but i certainly dont think its as ridiculous as some of you do, especially not with what seem like obvious signs of left/right heart dysfunction.

with that said, id probably want to see TEE/PA evidence of what was going on, but if that wasnt an option...
 
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Idiopathic said:
i dont know, it depends on the situation. lasix does venodilate acutely, and this could be beneficial in dealing with a life-threatening pulmonary edema.

could be especially valuable if the patient is acutely oliguric, as you may need to give blood to help with tissue oxygenation but could be volume overloaded (see hematocrit of 10). i dont know, but i certainly dont think its as ridiculous as some of you do, especially not with what seem like obvious signs of left/right heart dysfunction.

with that said, id probably want to see TEE/PA evidence of what was going on, but if that wasnt an option...
Click to expand...

i agree, but given the info the OP gave, this was not life-threatening pulmonary edema. we still haven't been given an abg, or any indication that there was severe difficulty in oxygenating or ventilating. just that there were copious amounts of fluid coming outta the ett.

my take was that this is life-threatening hemorrhage, with hypovolemic shock (look at the number of units of blood/products given), and that the edema was a TRALI or TACO or whatnot - from the rescuscitation. giving lasix for that is a bad idea in my book.

all that said, it is academic. if the patient was dry/shocky, the lasix probably wouldn't cause much diuresis anyway.
 
yeah i think we can make a leap of faith here and suggest that if there is that much pulmonary fluid, then there is significant difficulty ventilating, at the very least, and likely oxygenating as well.
 
sevoflurane said:
I would re-scan her lungs looking for injury or misplaced line.
Click to expand...

neuroride said:
We had a subclavian cordis from the ER but the damn thing was kinking as the placement was less than great so we ended up placing a RIC catheter 7.5 fr in the AC of her left arm and the belmont hooked to that.
Click to expand...

Hmmm... sounds a bit suspicious, especially since you guys were not there to place it. A cordis that backwalled the sc and ended up piercing the lung can most certainly give you that kind of pulmonary edema.


Slide3.jpg


Not pointing fingers here btw (and only in the differential).... just adding to the discussion.

How is she doing? I bet her pulm. edema is better today + ex-lap, spleenectomy + pelvic ring fx (depending on type) are not necessarily devastating injuries. Massive resuscitation is another story though (trali, taco, coagulopathy, decrease end organ perfussion initially, etc).

381-0550x0475.jpg
 
I had a case a few months back very similar (different mechanism of injury). Young guy came in with "viral illness", ends up with an acute abdomen - gets to OR with multiple units of blood and product already transfused. About 15 minutes into the case after the abdomen was open and we continued to transfuse to keep him stable, we see a HUGE amount of pulmonary edema from the ETT. It was frothing all over the place.

Don't know how much blood was in your patients abdomen/pelvis but, the surgeon in our case suggested that it could be due to pressure differences in the abdomen and lung changing accutely. Couldn't really find any evidence to back this up (I personally think that it was TRALI). Impressive how much fluid can come from the lung. Patient ended up doing well and walked out of the hopsital a few weeks later.

Apparently he had EBV and developed spleen enlargement leading to rupture.
 
sevoflurane said:
Hmmm... sounds a bit suspicious, especially since you guys were not there to place it. A cordis that backwalled the sc and ended up piercing the lung can most certainly give you that kind of pulmonary edema.
Click to expand...

would be pretty low on my diff as i think you would encounter other more serious problems sooner, but should be considered, i agree
 
gtb said:
TTE might be easier if you don't want to drop a probe, and you can get access to the chest. Especially useful in this particular case where I think the clinical questions are right heart function and volume status.
Click to expand...


i'm a big fan of thinking of right heart function but there is no way that you will ever have access to the chest for TTE in a trauma. this patient is probably filleted from stem to stern. this is just a guess, but i bet the surgeons could have given the best assessment of cardiac function via palpation or even direct visualization...also, RV failure does not cause massive pulmonary edema.
 
Wow, went by yesterday and she is extubated to 2L NC and doing great it looks like, still requiring surgery for that perineal lac but seems to be doing well.

The cords problem looked more like an intern went nearly perpendicular to the skin when first inserted the needle and then flattened out so the path wS more like a 90 degree angle than a nice smooth angle which is probably why it kinked.

Again, thanks for the comments for my own benefit and maybe others as well.
 
Robert Loblaw said:
i'm a big fan of thinking of right heart function but there is no way that you will ever have access to the chest for TTE in a trauma. this patient is probably filleted from stem to stern. this is just a guess, but i bet the surgeons could have given the best assessment of cardiac function via palpation or even direct visualization...also, RV failure does not cause massive pulmonary edema.
Click to expand...

i wouldnt expect right sided failure to give you the picture described

edit: oh i guess you said that
 
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