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Department of Critical Care Medicine Royal Care Super Speciality Hospital Neelambur, Coimbatore

Department of Critical Care Medicine Royal Care Super Speciality Hospital Neelambur, Coimbatore. PANEL DISCUSSION. CASE SCENARIO-1. A 25 years old male admitted with h/o RTA (2w vs 2w) No LOC, ENT bleed, Vomiting On evaluation Primary survey is unremarkable

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Department of Critical Care Medicine Royal Care Super Speciality Hospital Neelambur, Coimbatore

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  1. Department of Critical Care Medicine Royal Care Super Speciality Hospital Neelambur, Coimbatore

  2. PANEL DISCUSSION

  3. CASE SCENARIO-1 • A 25 years old male admitted with h/o RTA (2w vs 2w) • No LOC, ENT bleed, Vomiting • On evaluation Primary survey is unremarkable • HR-90/min, BP-110/70 mmHg, RR-18/min • GCS is 15/15 • His Hb is 9.8 gm/dl and Normal Lactate Institute of Critical Care Medicine, Royal care Super Speciality Hospital, CBE

  4. Forearm fracture (closed) and few lacerations all over the body Institute of Critical Care Medicine, Royal care Super Speciality Hospital, CBE

  5. What is the fluid of choice for this patient ? • Crystalloids • Colloids • Blood and blood products Institute of Critical Care Medicine, Royal care Super Speciality Hospital, CBE

  6. CASE SCENARIO - 2 • A 60 year old male admitted with h/o RTA (2w vs 4w) • No LOC, ENT bleed, Vomiting • On Primary survey evaluation, he has signs of shock • HR-145/min, BP-90/60 mmHg,RR-28/min, Temp -34 deg c • FAST is negative • Identified to have pelvis fracture • Hb – 8.0 gm/dl, Lactate is 4.5 mmol/l Institute of Critical Care Medicine, Royal care Super Speciality Hospital, CBE

  7. Institute of Critical Care Medicine, Royal care Super Speciality Hospital, CBE

  8. Can we give colloids? • How much? • What colloid is safe? Institute of Critical Care Medicine, Royal care Super Speciality Hospital, CBE

  9. CASE SCENARIO -3 • A 40 year old male met with RTA • Sustained severe crush injury his right leg • On evaluation HR -150/min, RR-28/min,BP-70/40 mm Hg, temp is 34 deg c • GCS 13/15 • FAST is negative • Hb-7.0 gm/dl • 3000 ml crystaloids given • 2 units of whole blood and 4 units of FFP transfused • Bp is 78/50 mmHg and HR is 150/min. Institute of Critical Care Medicine, Royal care Super Speciality Hospital, CBE

  10. Institute of Critical Care Medicine, Royal care Super Speciality Hospital, CBE

  11. What is the fluid of choice for initial resuscitation? Can we use albumin? Institute of Critical Care Medicine, Royal care Super Speciality Hospital, CBE

  12. CASE SCENARIO - 4 • A 40 years old male,admitted with stab injury to his abdomen • Admitted with signs of severe shock • Intial GCS is 13/15,drowsy looking • FAST is positive • Bp 60/40 mmHg,HR is 160/min • 3000 ml warmed crystaloids and 2 units of blood were given • Bp now improved to 130/80 (96) • Wheeled in to OT for an emergency laparotomy Institute of Critical Care Medicine, Royal care Super Speciality Hospital, CBE

  13. What is the role of Permissive hypotension / Balanced resuscitation? Institute of Critical Care Medicine, Royal care Super Speciality Hospital, CBE

  14. What is your end point of resuscitation in all these three cases? Institute of Critical Care Medicine, Royal care Super Speciality Hospital, CBE

  15. DECOMPRESSIVE CRANIECTOMY Institute of Critical Care Medicine, Royal care Super Speciality Hospital, CBE

  16. 22 yrs male • No comorbidities • RTA 2wh vs 2wh • LOC+, ear bleed + • Brought to our casualty within an hour • GCS on arrival E3V2M5, pupils b/l 2mm R • Moving right side > left • Intubated for airway protection • Isolated head injury Institute of Critical Care Medicine, Royal care Super Speciality Hospital, CBE

  17. CT BRAIN Institute of Critical Care Medicine, Royal care Super Speciality Hospital, CBE

  18. DAY 2 CT BRAINON SEDATION , RELAXANT, ANTI EDEMA , PUPILS RT 3SR/ LT 2R Institute of Critical Care Medicine, Royal care Super Speciality Hospital, CBE

  19. DAY 3 : POST DECOMPRESSION Institute of Critical Care Medicine, Royal care Super Speciality Hospital, CBE

  20. DAY 4: ASSESSMENT • E2VTM5 • Pupils 2mm R both sides Institute of Critical Care Medicine, Royal care Super Speciality Hospital, CBE

  21. Day 7 • Fever • Neck stiffness • GCS E1VTM3 • Pupils 2mm R both sides • no hypoxia/ purulent ET secretion • Urine looks sterile Institute of Critical Care Medicine, Royal care Super Speciality Hospital, CBE

  22. CSF • Glucose – 40 (250) • TC – 2500 ( 90% poly) • RBC – 2000 • Protein - 200 • Lactate – 4 • Gram stain –GNB Started on meropenem 2 gm q8h Institute of Critical Care Medicine, Royal care Super Speciality Hospital, CBE

  23. DAY 14 • Patient improved • Afebrile • GCS E2VTM5 • Tracheostomised • Weaned and shifted to ward Institute of Critical Care Medicine, Royal care Super Speciality Hospital, CBE

  24. DAY 25 • In ward • Drop in GCS- E1VTM3 • Pupils RT 3 SR, LT 2 R • CT done Institute of Critical Care Medicine, Royal care Super Speciality Hospital, CBE

  25. Institute of Critical Care Medicine, Royal care Super Speciality Hospital, CBE

  26. DAY 26 Institute of Critical Care Medicine, Royal care Super Speciality Hospital, CBE

  27. DAY 45 • Patient improved • Decannulated • Discharged Institute of Critical Care Medicine, Royal care Super Speciality Hospital, CBE

  28. TRAUMATIC CSF LEAK Institute of Critical Care Medicine, Royal care Super Speciality Hospital, CBE

  29. CASE DISCUSSION • Mr.R, 56 years, presented with history of fall from a two wheeler on 07/05/2019 and went to near by hospital with • Right Ear blood stained discharge, • Good GCS-15/15 Institute of Critical Care Medicine, Royal care Super Speciality Hospital, CBE

  30. CT BRAIN WAS TAKEN Institute of Critical Care Medicine, Royal care Super Speciality Hospital, CBE

  31. With extensive Pneumocephalus • Shifted to another hospital on the same day, with GCS -15/15, • Repeat CT Brain was done(07/05/2019). Institute of Critical Care Medicine, Royal care Super Speciality Hospital, CBE

  32. Treated with supplement O2, Acetazolamide, Antiepileptics, Dexamethasone and Ceftriaxone Institute of Critical Care Medicine, Royal care Super Speciality Hospital, CBE

  33. On 8/5/19 with Persistent ear discharge, repeat CT brain done • Continued treatment with • O2, • Acetazolamide, • Ceftrioxone, • Dexamethasone • added T. Sodium bicarbonate Institute of Critical Care Medicine, Royal care Super Speciality Hospital, CBE

  34. On day 3 ( 9/5/19) • GCS -15/15, • Oxygenation and hemodynamic stable. • Persisted right ear discharge, with headache. • So escalated antibiotic to Piperacillin Tazobactum and Vancomycin empirically. Institute of Critical Care Medicine, Royal care Super Speciality Hospital, CBE

  35. Repeated CT on 4th and 5th day 10/05/2019 11/05/2019 Institute of Critical Care Medicine, Royal care Super Speciality Hospital, CBE

  36. OUTSIDE ESCALATION OF TREATMENT • After 11th (5th day) CT Brain • Escalated antibiotics to Meropenem Institute of Critical Care Medicine, Royal care Super Speciality Hospital, CBE

  37. OUTSIDE HOSPITAL INVESTIGATION AND SUMMARY Investigation Summary Institute of Critical Care Medicine, Royal care Super Speciality Hospital, CBE

  38. On 13th (7th day) patient shifted to our hospital with Irritability, Obeying commands, Severe headache and Right ear discharge Institute of Critical Care Medicine, Royal care Super Speciality Hospital, CBE

  39. On admission GCS 14-15/15 , severe headache, cranial nerves intact, pupil-2mm reacting, oxygenation and vitals- Stable. • Investigation- complete haemogram, S.Electrolytes, RFT, LFT, Urine complete and blood culture. Institute of Critical Care Medicine, Royal care Super Speciality Hospital, CBE Institute of Critical Care Medicine, Royal care Super Speciality Hospital, CBE

  40. After MDT discussion, oxygen Lumbar drain placed, Treated with Head end elevation, Analgesia, Stool softener and Planned for antibiotic after CSF complete. Institute of Critical Care Medicine, Royal care Super Speciality Hospital, CBE

  41. INVESTIGATIONS Institute of Critical Care Medicine, Royal care Super Speciality Hospital, CBE

  42. CSF SEND THROUGH AEROBIC BLOOD CULTURE BLOOD GROWN Institute of Critical Care Medicine, Royal care Super Speciality Hospital, CBE

  43. The preferred laboratory test to confirm CSF rhinorrhea or otorrhea is: a. Bedside glucose strip test b. β2-transferrin test c. CSF profile d. S100B Institute of Critical Care Medicine, Royal care Super Speciality Hospital, CBE

  44. 2. A standard 5 mm slice head CT did not reveal any calvarial or skull base fractures in a patient with rhinorrhea and suspected traumatic CSF leak. What is the next best diagnostic step? a. No further diagnostic work-up is needed. The patient does not have a CSF leak on CT because there was no fracture identified on the CT. b. No further diagnostic work-up is needed. A halo staining pattern is pathognomonic and diagnostic for the presence of CSF in nasal discharge fluid. c. CT cisternography d. High-resolution (1-2 mm slice) head CT. Institute of Critical Care Medicine, Royal care Super Speciality Hospital, CBE

  45. 3. An anterior skull base CSF leak has been confirmed clinically and radiographically. Which conservative measures are most appropriate to institute? a. Strict bedrest and raising the head of the bed to 30 to 45 degrees. b. Avoiding nose blowing, coughing, or sneezing. c. Avoiding the use of straws or incentive spirometers. d. Ordering stool softeners, laxatives, anti-emetics, and antitussives. e. All of the above. Institute of Critical Care Medicine, Royal care Super Speciality Hospital, CBE

  46. 4. Which of the following statements is true regarding the use of antibiotics for CSF leaks? a. The routine use of prophylactic antibiotic administration to decrease the rate of meningitis following blunt traumatic CSF leaks is not supported by current evidence. b. Use of prophylactic antibiotics carries no risk of selecting for more virulent organisms. c.Useof perioperative antibiotics for patients undergoing surgical repair of a CSF leak is not recommended. d. Prophylactic antibiotics should not be given for CSF leaks arising from penetrating head injuries, like gunshot wounds. Institute of Critical Care Medicine, Royal care Super Speciality Hospital, CBE

  47. 5.The patient with a documented traumatic CSF leak and an ethmoid sinus fracture on high-resolution CT still has intermittent low-volume rhinorrhea following 3 d of conservative therapy. He is afebrile, feels well, and is inquiring about discharge home. What is the most appropriate next stop? a. Repair via an endoscopic endonasal approach. b. Repair via a transcranial approach. c. Augment conservative management with CSF diversion through placement of a lumbar drain. d. Discharge the patient home with outpatient follow-up. Institute of Critical Care Medicine, Royal care Super Speciality Hospital, CBE

  48. Blunt injury of anterior cranial fossa • Blunt injury of middle and posterior cranial fossa • Penetrating injury Institute of Critical Care Medicine, Royal care Super Speciality Hospital, CBE

  49. Thank you ! Institute of Critical Care Medicine, Royal care Super Speciality Hospital, CBE

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