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Trauma & Shock Scenarios. Use of critical thinking skills!! . When viewing the next slide consider the following priorities: 1. How would client have been managed initially at the scene of accident? 2.How would this patient have been prioritized in ER (rate as ESI-1 to ESI-5)

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trauma shock scenarios

Trauma & Shock Scenarios

Use of critical thinking skills!!

slide2

When viewing the next slide consider the following priorities:

1. How would client have been managed initially at the scene of accident?

2.How would this patient have been prioritized in ER (rate as ESI-1 to ESI-5)

3. What actions would trauma team take initially to stabilize this patient… what priorities?

4. What type of shock would this patient initially experience…what other type of shock do you anticipate for this patient?

5. What potential complications

scenario
Scenario
  • 63 yo male
  • Stab wounds to left upper abdomen
  • Fighting off intruder in his home

What questions come to mind?

Trauma.org

questions to ask yourself
Questions to ask yourself?
  • What will you expect to see on arrival?
  • What assessments will you complete?
assessment
ASSESSMENT
  • LOC:
    • No response to commands
  • Response to pain:
    • No response to pain
  • Vitals:
    • BP 72/52 -HR 114
    • RR 8, irreg, periods of apnea -Temp 97.8
slide7
Dr. G

Dr. G is the new medical resident in the ER, first day is today.

Which action by Dr. G would require you to intervene?

A. Orders for STAT ECG

B. Dr. G orders 1/2NS to run 200mls/hr

C. Dr. G orders urinary catheter placement

D. Dr. G orders STAT CBC, Mg, & COMP

WHY?

after arrival to ed
After arrival to ED
  • 2000ml LR infused before arrival
  • Taken to Surgery ----- 4 hr procedure
    • 3L LR & 6 units PRBC’s
    • Antibiotic therapy started
    • Right thoracotomy
      • Chest tube placement – 500mls bright blood noted
    • Right upper laparotomy
      • Liver & Duodenal laceration repaired
      • Cavity irrigated with antibiotic solution
      • 3 drains placed

Then transferred to ICU

labs after transfer to icu
LABS After transfer to ICU

Vitals

  • BP 92/52 RR 12
  • HR 114 Temp 97.1
  • PAWP 6 CO/CI 5/2.5
  • SVR 1040 CVP 4

CBC

  • WBC 13.6
  • Hgb 10
  • HCT 31

ABG

  • pH 7.34 PaCO2 36mmHg
  • HCO3 21mEq/L PaO2 84mmHG
  • O2 sats 88%
shock
SHOCK

Is this patient showing signs of shock?

What types of shock might he develop?

What are some signs & symptoms of each?

making assignments
Making Assignments
  • You must assign an ICU staff nurse to care for this patient. Who is most appropriate?

A. A temporary agency nurse, with extensive previous ICU experience, who has been in your ICU for 3 days

B. A LPN with 10 years of experience in your ICU, who is in the last semester of an RN program

C. A RN who has worked in your ICU for 2 1/2 years after transferring from the mother-baby unit

D. A RN who has 12 years experience in the ER and has been floated to ICU today

slide14
UhOh!!!!
  • Client remains stable until post-op day 2.
    • Vent Settings
      • Rate 12 FiO2 0.80 TV 800
    • NG drainage
      • 200ml/8hr
    • JP drains xs 3
      • Total 60ml/8hr
    • UO
      • 40-50ml/hr
    • LOC
      • agitation
    • Resp
      • SaO2 64
labs 2 days post op
LABS 2 days post op

Vitals

  • BP 90/62 RR 12
  • HR 126 Temp 101.4
  • PAWP 10 CO/CI 6.0/3.1
  • SVR 820

CBC

  • WBC 4.2
  • Hgb 9.4
  • HCT 27

ABG

  • pH 7.30 PaCO2 48mmHg
  • HCO3 25mEq/L PaO2 65mmHG
  • O2 sats 86%
what do you think is happening
What do you think is happening?
  • Wedge?
  • CO?
  • SVR?
  • WBC?
  • UO?
  • ABG’s?

What additional information do you want?

slide17

What do you expect the CXR to reveal?

  • What lung sounds do you anticipate?
post op day 3 assessment
Post op day 3 assessment
  • Resp
    • FiO2 inc. 1.00 (100%)
    • PEEP 7.5cm
  • CV
    • 4 fluid boluses of 250ml NS
    • NS IV @ 175ml/hr
  • GU
    • <30ml/hr
labs the next morning post op day 3
LabsThe next morningPost op day 3

Vitals

  • BP 80/50 RR 28
  • HR 132 Temp 104.8
  • PAWP 4 CO/CI 8.2/4.3
  • SVR 560 PAP 14/7
  • CVP 2

Coags & CBC

  • WBC 22 PT 22 PTT 98
  • Hgb 9.4 Platelets 75
  • HCT 27
  • Drain culture – gram negative bacilli

ABG

  • pH 7.14 PaCO2 49mmHg
  • HCO3 12mEq/L PaO2 46mmHG
  • O2 sats 83%

COMP & Enzymes

  • Na 152 K 5.9 Creat 3.4 BUN 104
  • Amylase 290 Lipase 3.9 AST 82 ALT 102
  • CK 640
what is happening
What is happening?
  • Diagnosis?
  • What orders do you expect?
  • Why these potential orders
    • IV Ceftin (cefuroxime) , Flagyl (metronidazole), Gentamycin
    • IV Xigris
    • IV Dopamine at 5-10mcg/kg/min (see next side - difference between dobutamine and dopamine)
    • Possible TPN, Tube feedings
post op day 6 assessment
Post Op day 6Assessment
  • Integ
    • cool clammy
  • HEENT
    • Sclera yellow tinged
  • LOC
    • Unresponsive to stimuli
  • GU
    • UO 3-5ml/hr
  • GI
    • Abdomen grossly distended & bowel sounds absent
  • Resp
    • Crackles in all fields
  • CV
    • Norepinephrine gtt, Lidocaine gtt,
    • Dobutamine gtt & dopamine gtt
    • ST w/ episodes of VT, with T wave inversion
labs post op day 6
LabsPost op day 6

Vitals

  • BP 72/46 RR 12
  • HR 140 Temp 95.9
  • PAWP 24 CO/CI 2.1/1/3
  • SVR 2015 PAP 44/26

Coags & CBC

  • WBC 2.2 PT 32 PTT 108
  • Hgb 8.4 Platlets 75
  • HCT 37

ABG

  • pH 7.10 PaCO2 49mmHg
  • HCO3 10mEq/L PaO2 46mmHG
  • O2 sats 80%

COMP & Enzymes

  • Na 152 K 5.9 Creat 4.2 BUN 104
  • Amylase 330 Lipase 5.2 AST 91 ALT 202
  • CK 1040
slide25

What stage of shock is present?

    • What info supports this?
  • Which organs are dysfunctional?
    • What info supports this?