When Bad Things Happen To Good Patients: Managing The Complications of Trauma

1. When Bad Things Happen To Good Patients: Managing The Complications of Trauma Janice Delgiorno MSN, CCRN, ACNP-BC Acute Care Nurse Practitioner Department of Surgery Division of Trauma and Surgical Critical Care Cooper University Medical Center

2. Cooper Trauma

3. Typical Trauma Patient • 37 Y/O male • ETOH • Intubated, L SC TLC, NGT, Flexiseal • Grade II Liver, Grade III Spleen • L Traumatic AKA • R Grade 3-4 C Open Tibia fx with external fixator • OR Q Other Day for Wash outs

4. Airway • Emergent Airways/ Loss of Airway • Obstruction from loss of consciousness is the most common cause • Facial Fractures • Burns • Laryngeal Fracture

5. Laryngeal Fracture

6. Cricothyroidotomy

7. Inappropriate NGT • Raccoon eyes suggest basilar skull fracture • NGT placed • Could go through cribiform plate!!

8. Respiratory • ARDS • Pneumonia/ VAP • Atelectasis • Respiratory Failure • Iatrogenic Pneumothorax • Empyema

9. Empyema • Collection of pus in pleural space • Caused by infection in the lung • Fluid builds up to a pint or more and puts pressure on the lung • Causes SOB and pain • TX: thoracentesis

10. Iatrogenic Pneumothorax • Air in the pleural space • Caused by: Trans-thoracic needle aspiration procedures (37%), central line insertion, mechanical ventilation, thoracentesis • Can cause substantial morbidity: rarely death

11. ARDS

12. ARDS • Causes: Injury (inhalation, trauma), or as a result of MODS • Causes lung swelling and fluid build up in the alveoli • Lungs become “stiff” and unable to ventilate • Fluid build up inhibits oxygen passing into the bloodstream • Mechanical ventilation with PEEP, diuretics

13. Respiratory Infection • Primary loss of defense when patient is intubated • Flail Chest, rib fractures, surgical incisions…can’t cough and deep breathe • Aspiration : Streptococcus most common

14. Respiratory Infection • NG tubes and Nasal-tracheal tubes can obstruct the drainage of the sinuses and result in nosocomial sinusitis • Can obstruct eustachian tubes and cause otitis media • Chest tubes have been shown to be a factor in developing nosocomialempyema

15. VAP • ETT/ Trach provide a direct route to the lungs for bacteria • Gram negative bacilli and Staph aureus are the most common bacteria

16. Compartment Syndrome • Chest • Abdomen • Extremities

17. Compartment Syndrome

18. Compartment Syndrome • Can affect any body compartment • Most commonly affected are the lower leg and forearm • Body has 46 compartments, 36 are found in the extremities • Closed spaces containing muscles, nerves, vascular structures enclosed within bone or fascia • Can result from internal or external forces increasing compartment pressures

19. Abdominal Compartment Syndrome • Secondary to resuscitation edema, ileus, bowel obstruction, post op hemorrhage or abdominal packing • Increased abdominal pressure affects ventilation, urinary output, and the CV system (hypotension, decrease CO) • Normal IAP is 0 IAP >20 produces adverse physiologic effects

20. Abdominal Compartment Syndrome

21. Compartment Syndrome

22. Compartment Syndrome • Any injury to an extremity has the potential to cause a compartment sydrome • Tibial and forearm fractures • Severe crush injury to muscle • Localized, prolonged external pressure to an extremity • Increased capillary permeability secondary to ischemic muscle • Burns • Excessive exercise

23. Compartment Sydrome: 6 P’s • Pain • Parasthesia • Pallor • Paralysis • Pulse loss (late sign) • Tissue Pressures >35 to 45 mmHg

24. Management • All constricting dressings, casts, and splints applied over the affected extremity must be released • Patient must be carefully monitored for the next 30-60min • Anticipate OR for muscle compartment pressures greater than 35-45mm Hg • Fasciotomy

25. Compartment Syndrome

26. Compartment Syndrome

27. Compartment Syndrome

28. Compartment Syndrome

29. Rhabdomylosis • From crush injuries, electrical shock, severe burns, excessive muscle use, drugs (ethanol, cocaine, ecstacy, snake venom, tetanus) • Damaged muscle cells release potassium and Phosphorus • High myoglobin levels in the urine • CK climbs to > 5x normal

30. Rhabdomyolysis • Most common muscles involved are the calves and lower back • Signs/ Symptoms: Tachycardia, pain, malaise, nausea/ vomiting, and fever

31. Rhabdomyolysis • Aggressive IVF administration to “flush” kidneys • NaHCO3, Insulin, and Glucose to alkalinize urine and push potassium back into cells • Maintain urine output by using mannitol or lasix • CRRT if necessary

32. Infection • Sepsis • Sinusitis • Osteomylitis • Urinary Tract Infection • VAP • Skin/ Wound Infection

33. Infection… • Trauma patients are a breeding ground…think of all the tubes…tube in every orifice… • Sepsis, urinary tract infection, blood stream infection, wound/ skin infection… • Skeevy…

34. Infection • Pathogens bypass the first line defense, when broken skin and mucosal membranes are contaminated during injury and later by surgery and debridement • Surgical Drains, external fixators, IV catheters, ICP monitors, urinary catheters, wounds • Nosocomial Infections

35. SIRS • Caused by endogenous mediators • Overall inflammatory response that effects multiple organs with or without infection • SIRS can compromise the function of various organ systems resulting in MODS • SIRS with a confirmed infection is Sepsis

36. SIRS • 2 or more of the following: • Fever >38 c or < 36 c • HR >90 • RR >20 or CO2 <32 • WBC > 12K or < 4K or > 10% bands

37. Sepsis • High Mortality Rates: 40% for uncomplicated sepsis…80% for cases of septic shock and MODS • Severe Sepsis: Sepsis with organ hypoperfusion • Septic Shock: Severe sepsis with hypotension…requires fuids, vasopressors

38. Sepsis • Early, Goal Directed Therapy • Oxygenate • Central Venous Oximetry monitor and A-line • CVP <8 Crystalloid, Colloid • MAP <65 or >90 Vasoactive agents • ScVO2 <70% Transfuse PRBC’s to Hct >30 • ScVO2 still <70% start Dobutamine • Antibiotics within one hour

39. Spleen

40. Spleen • Filtration of aging or deformed blood cells • Antibody synthesis • Promotion of phagocytosis • Asplenic patients have significantly decreased levels of IgM, lack the ability to swithch from IgM to IgG antibody production

41. Spleen • The net effect is a decrease in opsonization • Opsonization facilitates the adherence of a phagocyte to a bacteria • Important for phagocytosis of encapsulated bacteria such as pneumococci, salmonellae, haemophilus, meningococci and staph aureus

42. Post Splenectomy Sepsis • Well documented in children and becoming more common in adults • Fulminant and usually fatal • 1.4% of patients • Early antibiotics and hemodynamic support • Prevention is imperative • Pneumococcal Vaccine (Pneumovax) within 72hrs of splenectomy

43. Post Splenectomy Infection • Encapsulated bacteria: S. pneumoniae, H. influenza, N. meningitidis • · S. aureus • · Numerous gram negatives including E. coli, K. pneumoniae,Salmonella sp. and Capnotcytophagia sp. (the latter usually acquired from a dog bite)

44. Post Splenectomy Infections • · Malaria • · Babesia (acquired from ticks in the Eastern seaboard particularly Cape Cod, Martha’s Vineyard, Nantucket, Block Island)

45. Vaccinations • Pneumococcal • Meningococcal • H Influenza • As soon as possible after splenectomy

46. Osteomylitis • Lots of ortho injuries…almost 80% of trauma patients have an ortho injury • Open fractures, fixators, procrastination of amputation

47. Osteomyelitis • Infection involving bone and marrow • Can occur weeks, months or years after injury • Infected hardware, overlying wound infection, inadequate debridement of a hematoma at the time of injury • Pain, erythema, heat, tenderness, drainage

48. Osteomyelitis • Remove infected hardware • Surgical debridement • IV antibiotics for a minimum of 4 weeks

49. Deep Vein Thrombosis • Approximately 630,000 pts develop DVT annually resulting in 200,000 deaths • In surgical patients over the age of 40 DVT occurs in 16%-30% with PE episodes in 1.6% Fatal PE..1% • 20% of young trauma patients develop DVT • More than 40% of elderly trauma patients with hip fractures develop DVT and 14% have a fatal PE episode

50. Deep Vein Thrombosis • Head and Spinal Cord Patients 40% and fatal PE of 5% • Prevention is key • Pre disposing factors: Venous stasis, vascular damage, hyper-coagulability • Examples: Sepsis, bed rest, long bone or pelvic fractures, spinal cord injuries, obesity, age >40, previous DVT or PE, prolonged use of MAST trousers