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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.
MEDICAL HISTORY AND DIAGNOSIS
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
MEDICAL HISTORY AND DIAGNOSIS
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.
MEDICAL HISTORY AND DIAGNOSIS
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
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
ABGs and Ventilator Settings
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
ABGs and Ventilator Settings
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
ABGs and Ventilator Settings
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
ABGs and Ventilator Settings
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
ABGs and Ventilator Settings
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
ABGs and Ventilator Settings
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.