A case to spread Holiday cheer

40+ yo male ejected through windshield after a high speed (90+ mph) mva. Intubated at OSH, wrapped in a big red bow, and the sent to us for further eval. In ED, BP's noted to be in the toilet ie 50-60's systolic. Left chest tube placed for hemothorax on CXR. After about 10 u prbc's, 10 L crystalloid mean bp's staying 60-70's on no support. Pt with multiple facial abrasions/lacertions, open tib/fib fractue, obvious femur fractue. Pt moving right side but not really left. CT'ed from head to toe.
Head: no bleed, mild cerebral edema, no shift
Neck: Cspine ok, lots of sub Q air
Chest: bilateral pulmonary contusions, no residual PTX on L, no PTX on R, L chest tube in good postition
Abdomen/pelvis: some peripancreatic edema, no fluid no blood

Pt continues to need blood in large quantities because his hemoglobin continued to drop over the course of morning (he came in about 3 am). At some point pt gets sent for aortic arteriogram which was also negative. Pt also gets re CT'ed (head/chest/abdomen/pelvis) which showed no change from the first ones.

This is about the time I come to work hoping for a nice quiet holiday weekend. Ortho wants to bring him down and ex fix femur and exfix/washout of his open tib/fib. Brain surgeon/ general surgeon has seen the guy (who has stabalized over the last few hours) and said it was ok to take him. I go see the guy, hgb 9, ph 7.25, pco2 50, BE-8, Sats 98-100%, BP's stable (aline placed earlier). Vent wise on ACVC 600 tv's, 5 peep, peaks pressures in the 40's.

Look at it, think about it, gotta go to a code will continue later.

We see this fairly regularly...

I think that his femur/thigh compartment is bleeding like stink, I have seen 5+L come out of a femoral compartment..

Obviously this guy needs to be resurveyed and assesed, his clinical staus is telling you that something has been missed.

I agree about the femoral compartment bleeding.

I'd also be concerned about those peak pressures and the hypercapnea/acidosis... that's not going to help your BP either. Looks like a good candidate for either ARDS.net protocol or APRV/Bilevel (depending on your vents..) and maybe some bicarb (if it is a treatment that you agree with). Of course if he is hypovolemic (probably) then the APRV will expose that rather quickly. I'm going to guess that the airway pressures are going to be attributed to the pulmonary contusions, and the beginning of ARDS (or TRALI?). What's your FIO2?

Anywhoo... I would think that getting that femur fx fixed would be a good thing...

But this is coming from an RT... Just interested in fun cases, sorry for the intrusion.

Hope everybody has a happy holidays.

I am assuming that there is no retro-peritoneal hemorrhage because you mentioned that the CT and aortogram were negative.
You can have a huge collection of blood in the femoral compartment, but because of the large hematoma you also need to R/O DIC and hemolysis, Were the coagulation tests normal?

I agree on the femur bleeding and probably bleeding from the open tib fib site. I talked to both the neurosurgeon and general surgeon both of whom think his blood loss is from these fractures. Femur fracture is mid to low to mid shaft and ortho is not worried about a femoral artery injury (the guy also had an arteriogram with the arteriogram sheath in the affected leg).
So I see the guy in the ICU, BP's stable with three numbers over two numbers on no pressors. hgb is 8 or 9 with a hct of 26. Gases as above and had been about the same for the last few hours. Base deficits have been improving from -14 to -8. His pulmonary status is not great with vent settings as above, on 100% fio2 and a Pao2 in the high 80's but I feel that is about as good as it is gonna get for a while. We take him to the OR. Ortho gets started, exfixes the tibia, and is starting on the femur when the pt starts to desat. I do all the usual things, hand bag, check the tube, suction the tube, listen to the chest, everything checks out, left sided chest tube was OK and in good working order hooked to suction. Fiberoptic revealed that the tube was patent, above the carina and he had no mainstem plugs. He is now harder to bag. Sat is still decreasing, he now looks like he is in a junctional rythm with his pressure dropping. We support his BP, but can't get his sats above 60 with continued peak pressures in the 50's only moving 200-300 cc's of air. I was on the lookout for a PTX on the right side and got a CXR when things were going south (the xray tech was already in the room). It was back much quicker than I expected and up on the big flat screen tv in the OR I did not find an answer to our problem (I love living in the digital age). There was no PTX on the CXR and he still had equal breath sounds on both sides. What next?

You said that you suctioned the tube... did you get anything (pulm edema)? How were breath sounds? Desats could be because of a PE (either blood or fat), or ARDS... any infiltrates on the Xray? He did get blood and had pulm contusions.

On a somewhat related note... are there any anesthesia machines that do any other kind of ventilation than just plain old volume or pressure?

that's what patients with ARDS do when you put them on anesthesia machine ventilators.....

but you got to rule out the other routine stuff....pneumo, hemo, mucus plug, embolism, etc.

TRALI could fit time course, too.

militarymd said:

that's what patients with ARDS do when you put them on anesthesia machine ventilators.....

but you got to rule out the other routine stuff....pneumo, hemo, mucus plug, embolism, etc.

Click to expand...

DrDre' said:

TRALI could fit time course, too.

Click to expand...

ARDS is an inclusive diagnosis

militarymd said:

that's what patients with ARDS do when you put them on anesthesia machine ventilators.....

but you got to rule out the other routine stuff....pneumo, hemo, mucus plug, embolism, etc.

Click to expand...

Just a general question to anybody out there: How routine is it that you bring the vent down to the OR that the pt is on in the ICU? The reason that I ask is that there have been several pt's that I have taken to the OR when they require APRV for an ARDS picture (and we keep them on their ICU Draeger). I know that there aren't really any studies that address this issue (or at least any that I know of), but it seems to make sense to me. If the patient has good recruitment from the APRV, but are then changed to conventional ventilation and de-recruits... you could get the picture described above, correct?

Very interested to hear what happened with the patient in the OP.

Thanks.

What was his lactate and was he evaluated for rhabdo?

ARDS is surely present but this may very well be a fat embolism from the long bone (femur) fx. Check the ECG. Look at the p waves. Supportive care. Very bad situation.

RT2MD said:

Just a general question to anybody out there: How routine is it that you bring the vent down to the OR that the pt is on in the ICU? The reason that I ask is that there have been several pt's that I have taken to the OR when they require APRV for an ARDS picture (and we keep them on their ICU Draeger). I know that there aren't really any studies that address this issue (or at least any that I know of), but it seems to make sense to me. If the patient has good recruitment from the APRV, but are then changed to conventional ventilation and de-recruits... you could get the picture described above, correct?

Very interested to hear what happened with the patient in the OP.

Thanks.

Click to expand...

I thought about keeping him on his vent and bringing him down. In hindsight I probably would have. But we did not because he was not on super
high peep and I did not feel he was really going to derecruit or had a full blown ARDS picture (even though he was headed that way). Our machines in the OR are fairly new and we are able to use PCV and peep with the vent on our machine. This guy was intubated and paralyzed so there was not going to be much difference between our vent and theirs. If this guy was totally peep dependent then he would have went down with his vent. You probably know this but you really don't want to unhook those people from their peep. They immediately derecruit the few alveoli that are actually exchanging gases and their sats drop like a stone.

toughlife said:

What was his lactate and was he evaluated for rhabdo?

Click to expand...

Lactate was normal, no CPK's, urine looked ok.

militarymd said:

that's what patients with ARDS do when you put them on anesthesia machine ventilators.....

but you got to rule out the other routine stuff....pneumo, hemo, mucus plug, embolism, etc.

Click to expand...

CXR had no PTX, did have diffuse infiltrates which were no big surprise. This drop in sat was not a gradual thing. It happened pretty fast (over 5 minutes accompanied by a drop in BP) and nothing I did from a ventilation standpoint helped (ie sats stayed in 60-70's for a good 10-15 minutes). I kinda was thinking embolism all along. But the fact that he was so hard to ventilate and seemed to get that way over such a short time bugged me. Then I remembered someone telling me at some point that no trauma patient should die without at least bilateral chest tubes. I figured what the hey I am about out of options. We put in a right sided chest tube, got no air, but did get about 500 cc's of blood. The patients sats slowly came up back into a range compatable with life. His peaks were still high but at least after the chest tube we were getting decent tidal volumes. I went back and looked at the CXR later and still could not see the hemothorax.

RT2MD said:

Just a general question to anybody out there: How routine is it that you bring the vent down to the OR that the pt is on in the ICU? The reason that I ask is that there have been several pt's that I have taken to the OR when they require APRV for an ARDS picture (and we keep them on their ICU Draeger). I know that there aren't really any studies that address this issue (or at least any that I know of), but it seems to make sense to me. If the patient has good recruitment from the APRV, but are then changed to conventional ventilation and de-recruits... you could get the picture described above, correct?

Very interested to hear what happened with the patient in the OP.

Thanks.

Click to expand...

I bring the ICU vent down when the settings are above the performance envelope of the OR machines.....

My arbitary cutoff:

1) minute ventilation > 10 liter per minute
2) mean airway pressure > 20 cm H20

&

3) patient doesn't pass the "x-mmd" eye ball test

pd4emergence said:

CXR had no PTX, did have diffuse infiltrates which were no big surprise. This drop in sat was not a gradual thing. It happened pretty fast (over 5 minutes accompanied by a drop in BP) and nothing I did from a ventilation standpoint helped (ie sats stayed in 60-70's for a good 10-15 minutes). I kinda was thinking embolism all along. But the fact that he was so hard to ventilate and seemed to get that way over such a short time bugged me. Then I remembered someone telling me at some point that no trauma patient should die without at least bilateral chest tubes. I figured what the hey I am about out of options. We put in a right sided chest tube, got no air, but did get about 500 cc's of blood. The patients sats slowly came up back into a range compatable with life. His peaks were still high but at least after the chest tube we were getting decent tidal volumes. I went back and looked at the CXR later and still could not see the hemothorax.

Click to expand...

Frequently people forget to do Chest x rays in the sitting position or as close to it as possible, the result of that is missing fluid collections unless they are really huge and missing some pneumo's as well.