A Collaborative Approach:
Overcoming the Challenges of
Treating Polytrauma
Rebecca Rosten, BSN, RN
Scott & White Memorial Hospital
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Rebecca Rosten7. No conflict.
Accreditation StatementAORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019.
• Verbalize the response of the OR nursing staff when a trauma activation is received.
• Discuss the care provided by multidisciplinary teams and their ability to impact and improve outcomes of a polytrauma patient.
• Identify needed elements of communication for Level 1 trauma transfer to and from the OR
Objectives
•26 year old female in an MVA
•Small vehicle vs. 18 Wheeler
•Patient was a restrained driver.
•EMS on scene, GCS < 8
• Moving all four extremities
• Combative, unresponsive and incoherent
Case history
Phases
Pre Hospital
Hospital
Outpatient
EMS arrived:
• Driver's side severely damaged.
• Difficult extrication
• Jaws of Life used
• EMS contacted ED
• Aeromedical services called for
Pre-Hospital
25 miles , 42 minutes from Level 1
• Oxygen• Cervical collar placed• IV access-16 g left AC and 18g right AC.• Bolus with 2 L normal saline• Rapid Sequence Induction/Oral Intubation
• Etomidate
• Rocuronium
• Ativan
• Fentanyl
Pre-Hospital
ED
• 911 activated @ 2212.
• Patient arrives @ 2220 by Helicopter.
• Vital signs upon arrival:
• SBP in the 80mmHg
• HR 130
• Physical examination revealed significant pelvic instability.
• Resuscitated with 2 units Type O negative unmatched blood
Diagnostic imaging
• CXR revealed left pneumothorax: Chest tube placed
• AP films confirmed fractured pelvis: Sheet was utilized as pelvic binder
Hospital
Diagnostic Imaging cont:
• Positive FAST: pelvis and spleno-renal area
• Left subclavian introducer catheter placed
• Patient taken emergently to the operating room and IR called to meet in the OR
HospitalED cont
pelvis
2315 iStat:
CO2 14
pH 7.14
PO2 238
HCO3 13
BE -16
Remember this………….
• Exploratory Laparotomy: An upper midline incision was made and dissected down to the peritoneal cavity
• 500-600 ml of fresh blood was encountered
HospitalOperating Room
• Liver laceration which was controlled with electrocautery.
• Retroperitoneal hematoma (consistent with pelvic fracture). Pfannenstiel incision made (Bikini incision) to expose the pre-peritoneal space. Multiple packs placed within the pre-peritoneal space.
• Bleeding from the spleen (performed splenectomy).
HospitalOperating Room
Discoveries
10/29/12
• Attention turned to the bladder: bladder rupture . Repaired in two layers with suture.
• Requested Interventional Radiology- perform angiography to evaluate for arterial bleeding in the pelvis.
• Patient desaturates progressive hypotension and hypoxia
HospitalOR cont’d
Stat Chest X-ray was taken and revealed:
• Unevacuated blood in the left chest
• Widened pericardial and mediastinal silhouette
• Some displacement of endotracheal tube (to the right)
HospitalOR cont’d
Where is that bleeder????
Anesthesia performs a transesophagel echocardiogram
HospitalOR cont’d
Still searching
• Pericardial tamponade
• Subxiphoid pericardial window performed and produced 200cc
• Rapid left anterolateral thoracotomy (clamshell)
• 750-900 ml of blood was evacuated from left chest
• Multiple lacerations to the left lung (lower lobe)
• “Hole” in the HEART: Pericardium widely opened which showed a jagged 1 cm laceration on the left ventricle near the atrio-ventricular junction.
• Cardio surgeon in route!!
HospitalOR cont’d
BINGO!!!
The defect in the heart was closed utilizing pledgetedsutures for the repair.
HospitalOR cont’d
A fractured rib which had penetrated the lung and pierced the heart was found to be the culprit of the cardiac injury.
HospitalOR cont’d
• After cardiac repair, the patient again stabilized.
• Pelvic angiography was performed which revealed several bleeding branches of the internal iliac arteries bilaterally; these were gel-foam embolized.
• Patient then taken to the SICU.
HospitalOR cont’d
2315 iStat:
CO2 14, pH 7.14, PO2 238, HCO3 13, BE -16
Metabolic Acidosis, uncompensated
Normal valuespH 7.35-7.45
pCO2 35-45
pO2 80-100
O2 Sat 95-100%
HCO3 22-26
BE + or -2
Answer
29 units of RBC
23 units of FFP
5 units of platelets
750 ml of albumin
750 ml of cell saver
1 unit of cryoprecipitate
MBTP- 6 RBCs, 4 FFP, 1 platelet
PLEASE DONATE BLOOD!!!
FYIFluids Given
911 activated Pt arrived via helicopter
Incision iSTAT Leave OR
2212 2220 2303 2315 0445
• Re-exploration of packed open abdomen
• Repair of bladder laceration
• Copious irrigation
• Abdomen closed
Hospital
Back to the OR..3 days later
• Fractured pelvis was repaired
• Same Bikini incision was used
• Performed open reduction and internal fixation of anterior ring (screws for pelvic compression)
• Performed percutaneous fixation of bilateral posterior ring disruption (screws for sacral alignment)
HospitalPelvis Repair..6 days later
• Open reduction, internal fixation of atlantooccipitaland atlantoaxial dissociation
• Posterolateral arthrodesis- autograft (spinousprocesses) + 10ml of cancellous bone chips (donor)
• Screws , plate, and rods (instrumentation) performed, occiput to C3
HospitalCervical repair..7 days later
• Patient was unhappy with the stiffness and discomfort in her neck related to the fusion of the occipito-cervical joint.
• Cervical plate and C2-C3 screws were removed uneventfully
Outpatient6 Months from first surgery
The patient spent about 1 month in the hospital, then spent several weeks in a rehab facility, and was discharged home around 7 weeks after her accident completely neurologically normal
From Level 1 to Now
• 30 ICD-9 codes with in first 5 hours• Also she had sustained a small subdural hematoma and
several long-bone fractures.• ISS 66-The Injury Severity Score (ISS) is an anatomical
scoring system that provides an overall score for patients with multiple injuries. The ISS score takes values from 0 to 75.
• Team approach: EMS, ED, radiology, anesthesia, perfusion, nursing, respiratory, ancillary staff, surgical teams for-ETS, ortho, urology, neuro, and cardiac.
Recap
• Penetrating cardiac injury from a fractured rib is a rare occurrence with survival rarely reported.
• Survival of this extremely rare injury in combination with the often fatal occipito-cervical ligamentous injury and an Injury Severity Score of 66, has never been reported.
Discussion
• This case outlines how the modern, multidisciplinary approach to care at an advanced trauma center can enable optimal outcomes even in patients with such tremendous injury burden.
• It is important to remember that patient care is a team effort and that together we can save lives.
Teamwork!!!
THANK YOU
Arterial Blood Gases (ABGs). (n.d.). Arterial Blood Gases (ABGs). Retrieved December 3, 2012, from http://www.the-abg-site.comBaker SP et al, (1974). The Injury Severity Score: a method for describing patients with multiple injuries and evaluating emergency care, J Trauma 14:187-196;1974Chaput CD et al, (2011). Defining and detecting missed ligamentous injuries of the occipitocervical complex. SPINE, 36(9), 709-714.Davis, M. (Director) (2012, June 9). Fractured Rib Causing Cardiac Injury: A Case Illustration of the Teamwork and Multidisciplinary Approach of Trauma Care. Trauma Symposium. Lecture conducted from Scott & White, Temple.Surgeons, A. C. O. (2007). Resources for optimal care of the injured patient 2006.
References
Questions