Mr. Reynolds is a 35-year-old patient involved in a motor vehicle accident.
He was wearing a seat belt and driving at a high rate of speed when he lost control of the car and hit an abutment.
Read through the information below and then keep Mr. Reynolds in mind as you navigate through this site. You can quiz yourself on his care on the Bread Crumbs page.
He was wearing a seat belt and driving at a high rate of speed when he lost control of the car and hit an abutment.
Read through the information below and then keep Mr. Reynolds in mind as you navigate through this site. You can quiz yourself on his care on the Bread Crumbs page.
ON THE SCENE/TRANSPORT:
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- Initially awake at the scene
- Level of consciousness decreased while in transport
- He was intubated and received 2 L of normal saline
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UPON ARRIVAL AT HOSPITAL:
- Medical history was noncontributory except 15 yr smoking history and social drinking
- Family history negative for heart disease, diabetes, or cancer
- On a backboard with a cervical collar
- Vital signs were BP: 110/80 HR: 113 SpO2 95%
- Pupils 3 cm, equal, and reacted briskly to light; no Battle’s sign or raccoon eyes, no abnormalities (step-offs) were noted skull or down his spine
- Tympanic membranes were clear, trachea midline
- Chest exam: no flailing and no subQ emphysema; tachycardic with normal S1, S2; no murmurs, rubs, gallops; peripheral pulses 2+ bilaterally
- Breath sounds were diminished in the lower lobes bilaterally
- Abdomen soft and moderately distended with hypoactive BS, no palpable masses and no hepatosplenomegaly
- Pelvis stable; GU exam revealed no gross hematuria; Rectal tone was normal, and stool was guaiac negative
- Able to move all four extremities spontaneously
- Orientation to time, person, and place was difficult to assess because he had been sedated.
DIAGNOSTIC TESTING:
- CT scan which revealed a grade III liver laceration; No splenic or renal injuries were noted
- CT scan of the head revealed no hematoma
- Because of the patient’s unstable condition, his spine could not be fully evaluated.
- Chest XR revealed bilateral pulmonary contusion with bilateral rib fractures
- A toxicology screen was negative for drugs, but Mr. Reynold’s blood alcohol level was 171 mg/dL
- Labs results (see left).
PROBLEM LIST ON ADMISSION TO ICU:
1. Blunt abdominal trauma
2. No closed head injury as revealed by CT scan
3. Bilateral pulmonary contusions with bilateral rib fractures
4. Relative hypoxia with a PaO2 value of 80 on FiO2 of 100%
5. Metabolic acidosis
6. Hypovolemic shock
IN THE TRAUMA ICU:
1. Blunt abdominal trauma
2. No closed head injury as revealed by CT scan
3. Bilateral pulmonary contusions with bilateral rib fractures
4. Relative hypoxia with a PaO2 value of 80 on FiO2 of 100%
5. Metabolic acidosis
6. Hypovolemic shock
IN THE TRAUMA ICU:
- SIMV ventilation with PEEP and Pressure support (PS)
- PA catheter, NGT, and foley placed
- Fluid infusion changed from NS to LR solution b/c hyperchloremia
- Acidosis treated with 3 runs of sodium bicarbonate
OVER THE NEXT 12 HOURS:
Mr. Reynold’s abdomen became very firm and distended, with less than 300ml of drainage from the NGT. In addition, his peak inspiratory pressure (PIP) rose from 35 to 60mm Hg, and his bladder pressure rose to 35mm HG.
Vital signs were BP: 100/80 HR: 130 Respirations: 14
Mr. Reynold’s abdomen became very firm and distended, with less than 300ml of drainage from the NGT. In addition, his peak inspiratory pressure (PIP) rose from 35 to 60mm Hg, and his bladder pressure rose to 35mm HG.
Vital signs were BP: 100/80 HR: 130 Respirations: 14
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Abdominal Compartment Syndrome diagnosis was made.
UPON RETURN TO THE ICU:
CI: 5.5 SaO2: 97% SvO2: 83%
Day 2 (after initial surgery): Returned to the OR for re-exploration of his abdomen and assessment of his liver laceration. Packing was removed, hemostasis was maintained and there was no necrosis of the liver or any signs of active bleeding
Day 3: Started on enteral feedings of Perative 90ml/ hr
Day 6: Returned to OR-abdominal fascia closed w/ stay sutures. Note: The skin was not closed because the wound had been open for 6 days, instead the wound was packed with sterile wet to dry dressings
Day 6: Received trach
Day 8: Vent weaning started
Day 19: Pt transferred to rehab where he required only supplemental O2 through a trach collar with minimal suction every 2 hr
Keep Mr. Reynolds in mind as you navigate through this site. You can quiz yourself on his care on the Bread Crumbs page.
- Taken to OR and a compression celiotomy was performed; laceration of the right dome of the liver was assessed and packed
- No other injuries were noted, but the small bowel was edematous and distended. The abdomen could not be closed because of the edema, and the intestines were covered with a sterile towel and a large sterile transparent dressing was placed over the wound
UPON RETURN TO THE ICU:
- Vital signs were
CI: 5.5 SaO2: 97% SvO2: 83%
- Vent Settings: SIMV 14 Vt: 750 FiO2: 40% PEEP 10cm H2O PS 5
- Started antibiotics, Fentanyl, Pepcid, Ativan for conscious sedation
Day 2 (after initial surgery): Returned to the OR for re-exploration of his abdomen and assessment of his liver laceration. Packing was removed, hemostasis was maintained and there was no necrosis of the liver or any signs of active bleeding
Day 3: Started on enteral feedings of Perative 90ml/ hr
Day 6: Returned to OR-abdominal fascia closed w/ stay sutures. Note: The skin was not closed because the wound had been open for 6 days, instead the wound was packed with sterile wet to dry dressings
Day 6: Received trach
Day 8: Vent weaning started
Day 19: Pt transferred to rehab where he required only supplemental O2 through a trach collar with minimal suction every 2 hr
Keep Mr. Reynolds in mind as you navigate through this site. You can quiz yourself on his care on the Bread Crumbs page.