UBP 1.1 (Long Form): Trauma & Critical Care – Head Injury

Question 1

Intra-Operative Management:

Let’s assume there is an open femur fracture and the orthopedic surgeon wants to go straight to the OR.

Would you require ICP monitoring in this patient?

• (A 5’7”, 180 kg, 22-year-old male is brought to the trauma suite following a motor vehicle accident. He is somnolent, spontaneously breathing, withdraws from painful stimuli (does not localize), and is speaking inappropriately. The patient has an 18g IV in his left arm with D5LR hanging.*
• PE: VS: P = 134, R = 24, BP = 178/108, O2 sat = 96% on non-rebreathing mask, T = 33 °C*
• HEENT: There is an abrasion on his forehead. There is ecchymosis into the periorbital tissue and hemotympanum is noted. The patient has a C-collar in place.*
• Airway: There are multiple facial fractures, multiple loose teeth, and the patient is uncooperative for further examination.*
• Lower Extremities: The right leg is swollen with intact peripheral pulses.*
• Lab: Hgb = 13.6, Hct = 42%, Platelets = 163,000. Electrolytes: Normal.*
• CT scans of the abdomen and pelvis: negative*
• CT scan of the head shows a non-displaced basilar skull fracture*
• Radiographs show a right femoral fracture. Neck radiographs show no apparent injury.*
• EKG: sinus tachycardia*
• Drug screen: positive for amphetamines)*

Answer 1

I would NOT necessarily require ICP monitoring, but I would certainly discuss it with the surgeon, as the monitor may be very helpful in determining the mean arterial pressure required for adequate CPP.

Moreover, the placement of an intraventricular catheter would, in addition to providing a means for monitoring ICP, allow for the removal of CSF should it become necessary to lower ICP and improve cerebral perfusion.

Question 2

Intra-Operative Management:

What can you do to reduce increased ICP in the absence of an intraventricular catheter?

• (A 5’7”, 180 kg, 22-year-old male is brought to the trauma suite following a motor vehicle accident. He is somnolent, spontaneously breathing, withdraws from painful stimuli (does not localize), and is speaking inappropriately. The patient has an 18g IV in his left arm with D5LR hanging.*
• PE: VS: P = 134, R = 24, BP = 178/108, O2 sat = 96% on non-rebreathing mask, T = 33 °C*
• HEENT: There is an abrasion on his forehead. There is ecchymosis into the periorbital tissue and hemotympanum is noted. The patient has a C-collar in place.*
• Airway: There are multiple facial fractures, multiple loose teeth, and the patient is uncooperative for further examination.*
• Lower Extremities: The right leg is swollen with intact peripheral pulses.*
• Lab: Hgb = 13.6, Hct = 42%, Platelets = 163,000. Electrolytes: Normal.*
• CT scans of the abdomen and pelvis: negative*
• CT scan of the head shows a non-displaced basilar skull fracture*
• Radiographs show a right femoral fracture. Neck radiographs show no apparent injury.*
• EKG: sinus tachycardia*
• Drug screen: positive for amphetamines)*

Answer 2

Question Type – Wide River

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Xtra Q: – What are risks of mannitol? Are there any?

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There are several actions I can take to decrease ICP including:

1. making sure there is no venous obstruction, particularly in this patient with a c-collar in place;
2. elevating the patient’s head 15-30 degrees (if hemodynamically tolerated) to increase venous drainage;
3. administering mannitol, which reduces ICP by –
   
   1. osmotically shifting fluid from the brain compartment to the intravascular compartment, decreasing production of CSF (this affect is seen with hypertonic fluids), and
   2. inducing reflex cerebral vasoconstriction secondary to decreased blood viscosity (keep in mind that this drug may potentially worsen cerebral edema if the BBB is not intact, and/or result in the expansion of an intracranial hematoma as surrounding brain tissue shrinks with osmotic diuresis);
4. administering furosemide, recognizing that in the presence of hypovolemia, this diuretic could lead to hypotension and worsening cerebral ischemia; and
5. administering a barbiturate, which produces a beneficial effect by reducing ICP (secondary to cerebral vasoconstriction) and CMRO2 (although not globally), recognizing that there is a risk for hypotension when utilizing the large doses required for cerebral protection.

While hyperventilation would reduce his ICP by inducing cerebral vasoconstriction, this is no longer recommended in head trauma patients due to the risk of inducing cerebral ischemia (patients with head trauma often experience a reduction in cerebral blood flow during the first 24 hours following the injury).

Question 3

Intra-Operative Management:

So, would you ever hyperventilate a patient with head trauma?

What is the problem with hyperventilation?

• (A 5’7”, 180 kg, 22-year-old male is brought to the trauma suite following a motor vehicle accident. He is somnolent, spontaneously breathing, withdraws from painful stimuli (does not localize), and is speaking inappropriately. The patient has an 18g IV in his left arm with D5LR hanging.*
• PE: VS: P = 134, R = 24, BP = 178/108, O2 sat = 96% on non-rebreathing mask, T = 33 °C*
• HEENT: There is an abrasion on his forehead. There is ecchymosis into the periorbital tissue and hemotympanum is noted. The patient has a C-collar in place.*
• Airway: There are multiple facial fractures, multiple loose teeth, and the patient is uncooperative for further examination.*
• Lower Extremities: The right leg is swollen with intact peripheral pulses.*
• Lab: Hgb = 13.6, Hct = 42%, Platelets = 163,000. Electrolytes: Normal.*
• CT scans of the abdomen and pelvis: negative*
• CT scan of the head shows a non-displaced basilar skull fracture*
• Radiographs show a right femoral fracture. Neck radiographs show no apparent injury.*
• EKG: sinus tachycardia*
• Drug screen: positive for amphetamines)*

Answer 3

I would consider hyperventilation to a CO2 of 25-30 mmHg if other methods to reduce ICP were unsuccessful and I thought the elevated ICP was severe enough to place the patient at risk for brain stem herniation.

However, as mentioned before, there is a risk of exacerbating cerebral ischemia by inducing cerebral vasoconstriction in a patient with lower than normal cerebral blood flow following head trauma.

I would also keep in mind that the effects of hyperventilation are temporary (24-48 hours) because HCO3 levels in the CSF adjust to compensate for the change in PaCO2.

Question 4

Intra-Operative Management:

The patient’s temperature is 33 °C.

Does this concern you?

• (A 5’7”, 180 kg, 22-year-old male is brought to the trauma suite following a motor vehicle accident. He is somnolent, spontaneously breathing, withdraws from painful stimuli (does not localize), and is speaking inappropriately. The patient has an 18g IV in his left arm with D5LR hanging.*
• PE: VS: P = 134, R = 24, BP = 178/108, O2 sat = 96% on non-rebreathing mask, T = 33 °C*
• HEENT: There is an abrasion on his forehead. There is ecchymosis into the periorbital tissue and hemotympanum is noted. The patient has a C-collar in place.*
• Airway: There are multiple facial fractures, multiple loose teeth, and the patient is uncooperative for further examination.*
• Lower Extremities: The right leg is swollen with intact peripheral pulses.*
• Lab: Hgb = 13.6, Hct = 42%, Platelets = 163,000. Electrolytes: Normal.*
• CT scans of the abdomen and pelvis: negative*
• CT scan of the head shows a non-displaced basilar skull fracture*
• Radiographs show a right femoral fracture. Neck radiographs show no apparent injury.*
• EKG: sinus tachycardia*
• Drug screen: positive for amphetamines)*

Answer 4

This does concern me because hypothermia has several deleterious effects including – coagulopathy, cardiac dysrhythmias, impaired renal function, and poor wound healing.

Additionally, although the reduction of CMRO2 by 7%/ °C below 36 °C could theoretically provide some neuroprotection, the evidence has not shown improved neurologic outcome with mild hypothermia following traumatic brain injury.

Question 5

Intra-Operative Management:

Would you use N2O on a patient with traumatic brain injury (TBI) and elevated ICP?

• (A 5’7”, 180 kg, 22-year-old male is brought to the trauma suite following a motor vehicle accident. He is somnolent, spontaneously breathing, withdraws from painful stimuli (does not localize), and is speaking inappropriately. The patient has an 18g IV in his left arm with D5LR hanging.*
• PE: VS: P = 134, R = 24, BP = 178/108, O2 sat = 96% on non-rebreathing mask, T = 33 °C*
• HEENT: There is an abrasion on his forehead. There is ecchymosis into the periorbital tissue and hemotympanum is noted. The patient has a C-collar in place.*
• Airway: There are multiple facial fractures, multiple loose teeth, and the patient is uncooperative for further examination.*
• Lower Extremities: The right leg is swollen with intact peripheral pulses.*
• Lab: Hgb = 13.6, Hct = 42%, Platelets = 163,000. Electrolytes: Normal.*
• CT scans of the abdomen and pelvis: negative*
• CT scan of the head shows a non-displaced basilar skull fracture*
• Radiographs show a right femoral fracture. Neck radiographs show no apparent injury.*
• EKG: sinus tachycardia*
• Drug screen: positive for amphetamines)*

Answer 5

I would avoid the use of N2O for a patient with elevated ICP for several reasons.

1. FIrst, if cerebral perfusion were compromised, I would want the patient breathing 100% oxygen.
2. Second, if hyperemia was a problem, N2O has the potential to increase CBF when used alone or in conjunction with another volatile agent.
3. Finally, if there were air trapped within the cranium, N2O would expand the air pocket, further elevating ICP.

Question 6

Intra-Operative Management:

During the case the patient’s blood pressure progressively falls to 95/60 mmHg and peak inspiratory pressures increase to the mid 40’s. His oxygen saturation falls to the high 80’s.

What is your differential?

What are you going to do?

• (A 5’7”, 180 kg, 22-year-old male is brought to the trauma suite following a motor vehicle accident. He is somnolent, spontaneously breathing, withdraws from painful stimuli (does not localize), and is speaking inappropriately. The patient has an 18g IV in his left arm with D5LR hanging.*
• PE: VS: P = 134, R = 24, BP = 178/108, O2 sat = 96% on non-rebreathing mask, T = 33 °C*
• HEENT: There is an abrasion on his forehead. There is ecchymosis into the periorbital tissue and hemotympanum is noted. The patient has a C-collar in place.*
• Airway: There are multiple facial fractures, multiple loose teeth, and the patient is uncooperative for further examination.*
• Lower Extremities: The right leg is swollen with intact peripheral pulses.*
• Lab: Hgb = 13.6, Hct = 42%, Platelets = 163,000. Electrolytes: Normal.*
• CT scans of the abdomen and pelvis: negative*
• CT scan of the head shows a non-displaced basilar skull fracture*
• Radiographs show a right femoral fracture. Neck radiographs show no apparent injury.*
• EKG: sinus tachycardia*
• Drug screen: positive for amphetamines)*

Answer 6

My differential would include –

• migration of the ETT into the right mainstem,
• an unrecognized and expanding tension pneumothorax,
• cardiac tamponade, and
• fat emboli secondary to the patient’s fractured femur.

Moreover, given his increased risk for aspiration and my difficulty in securing his airway, I would consider the possibility that his hypoxia and decreased pulmonary compliance are secondary to –

• aspiration pneumonitis (an acute increase in pulmonary vascular resistance secondary to hypoxic pulmonary vasoconstriction could also be contributing to his decreased blood pressure).

–

In treating this patient, I would –

• hand ventilate,
• auscultate the chest,
• make sure the patient was breathing 100% O2,
• verify correct positioning of the ETT, and
• order a CXR.

I may – order an ABG, place a pulmonary catheter, and/or order an echocardiogram if the clinical picture is confusing.

Question 7

Intra-Operative Management:

A pulmonary artery catheter is inserted and shows a PA pressure of 55/47 mmHg, a PCWP of 16 mmHg, a mixed venous oxygen saturation of 65%, and a cardiac index is 1.7 L/min/m2.

Furthermore, on examination of the patient, you discover subconjunctival petechiae.

How do you interpret this data?

• (A 5’7”, 180 kg, 22-year-old male is brought to the trauma suite following a motor vehicle accident. He is somnolent, spontaneously breathing, withdraws from painful stimuli (does not localize), and is speaking inappropriately. The patient has an 18g IV in his left arm with D5LR hanging.*
• PE: VS: P = 134, R = 24, BP = 178/108, O2 sat = 96% on non-rebreathing mask, T = 33 °C*
• HEENT: There is an abrasion on his forehead. There is ecchymosis into the periorbital tissue and hemotympanum is noted. The patient has a C-collar in place.*
• Airway: There are multiple facial fractures, multiple loose teeth, and the patient is uncooperative for further examination.*
• Lower Extremities: The right leg is swollen with intact peripheral pulses.*
• Lab: Hgb = 13.6, Hct = 42%, Platelets = 163,000. Electrolytes: Normal.*
• CT scans of the abdomen and pelvis: negative*
• CT scan of the head shows a non-displaced basilar skull fracture*
• Radiographs show a right femoral fracture. Neck radiographs show no apparent injury.*
• EKG: sinus tachycardia*
• Drug screen: positive for amphetamines)*

Answer 7

(Per online UBP… sample way of answering – “All of these findings are consistent with – fat embolism syndrome… then maybe give more expanded differential.**)

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The combination of hypoxia, elevated pulmonary artery pressure, decreased cardiac index, and subconjunctival petechiae in a patient with a long bone fracture, is most consistent with fat embolism syndrome.

A definitive diagnosis, however, would require at least one major criterion and four minor criteria, as described by Gurd and Wilson*.

(Note – not expected to rattle off major & minor criteria on exam. Don’t need to memorize)

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Major criteria include:

1. a petechial rash, present on the conjunctiva, oral mucosa, axillae, and/or the skin folds of then eck;
2. hypoxemia, with a PaO2 < 60 mmHg on a Fio2 < 0.4;
3. central nervous system depression, unexplained by the patient’s hypoxia; and
4. pulmonary edema.

Minor criteria include:

1. tachycardia > 110 beats/minute;
2. pyrexia;
3. retinal fat emboli;
4. fat microglobulinemia;
5. fat globules in the sputum;
6. unexplained anemia;
7. unexplained thrombocytopenia;
8. increased erythrocyte sedimentation rate;
9. urinary fat globules; and
10. jaundice.

• Recognizing that many of these diagnostic criteria could be confounded by conditions associated with his recent trauma, (i.e. pain → tachycardia; hypovolemia → tachycardia; head injury → central nervous system depression ; bleeding → anemia and thrombocytopenia; etc.),*
• I would attempt to obtain a more definitive diagnosis by evaluating –*
• the patient’s temperature, ABGs, CXR, pulmonary catheter data, hemoglobin/hematocrit, platelets, sedimentation rate, and urine analysis.
• Moreover, I would consider obtaining an –*
• echocardiogram and perform a funduscopic examination, to look for the presence of retinal fat emboli.
• —*
• Clinical Notes:*
• Normal Values:*
• cardiac index = 2.6 - 4.2
• PCWP = 2 - 15 mmHg
• PA pressure = 15-30/4-12 mmHg
• venous oxygen saturation (internal jugular) = about 70-80%

Question 8

Intra-Operative Management:

Assuming this is fat emboli syndrome (FES), what would you do?

• (A 5’7”, 180 kg, 22-year-old male is brought to the trauma suite following a motor vehicle accident. He is somnolent, spontaneously breathing, withdraws from painful stimuli (does not localize), and is speaking inappropriately. The patient has an 18g IV in his left arm with D5LR hanging.*
• PE: VS: P = 134, R = 24, BP = 178/108, O2 sat = 96% on non-rebreathing mask, T = 33 °C*
• HEENT: There is an abrasion on his forehead. There is ecchymosis into the periorbital tissue and hemotympanum is noted. The patient has a C-collar in place.*
• Airway: There are multiple facial fractures, multiple loose teeth, and the patient is uncooperative for further examination.*
• Lower Extremities: The right leg is swollen with intact peripheral pulses.*
• Lab: Hgb = 13.6, Hct = 42%, Platelets = 163,000. Electrolytes: Normal.*
• CT scans of the abdomen and pelvis: negative*
• CT scan of the head shows a non-displaced basilar skull fracture*
• Radiographs show a right femoral fracture. Neck radiographs show no apparent injury.*
• EKG: sinus tachycardia*
• Drug screen: positive for amphetamines)*

Answer 8

I would –

• administer 100% oxygen,
• treat his hypotension,
• correct any hypovolemia,
• replace blood and platelets as required,
• continue mechanical ventilation,
• monitor the patient carefully for further deterioration, and
• inform the surgeon of his condition (i.e. the surgeon may choose to switch from intramedullary nailing to external fixation of the femur).

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Xtra Q – What could surgeon do in this situation?

Question 9

Post-Operative Management:

The following day the PaO2 is 88 mmHg with a Fio2 of 50% and the CXR shows bilateral diffuse infiltrates.

What do you think might be going on?

• (A 5’7”, 180 kg, 22-year-old male is brought to the trauma suite following a motor vehicle accident. He is somnolent, spontaneously breathing, withdraws from painful stimuli (does not localize), and is speaking inappropriately. The patient has an 18g IV in his left arm with D5LR hanging.*
• PE: VS: P = 134, R = 24, BP = 178/108, O2 sat = 96% on non-rebreathing mask, T = 33 °C*
• HEENT: There is an abrasion on his forehead. There is ecchymosis into the periorbital tissue and hemotympanum is noted. The patient has a C-collar in place.*
• Airway: There are multiple facial fractures, multiple loose teeth, and the patient is uncooperative for further examination.*
• Lower Extremities: The right leg is swollen with intact peripheral pulses.*
• Lab: Hgb = 13.6, Hct = 42%, Platelets = 163,000. Electrolytes: Normal.*
• CT scans of the abdomen and pelvis: negative*
• CT scan of the head shows a non-displaced basilar skull fracture*
• Radiographs show a right femoral fracture. Neck radiographs show no apparent injury.*
• EKG: sinus tachycardia*
• Drug screen: positive for amphetamines)*

Answer 9

Wide River Question-Type.

This clinical picture is consistent with:

1. aspiration pneumonitis;
2. cardiogenic pulmonary edema (possibly secondary to fluid overload during trauma resuscitation and/or surgery);
3. neurogenic pulmonary edema (may occur after any form of injury to the central nervous system); and
4. acute respiratory distress syndrome (possibly secondary to fat embolism syndrome, head trauma, or aspiration).
5. If blood had been transfused, I would also consider – transfusion related acute lung injury (TRALI) and
6. transfusion associated circulatory overload (TACO).

Question 10

Post-Operative Management:

What is the pathophysiology of ARDS?

• (A 5’7”, 180 kg, 22-year-old male is brought to the trauma suite following a motor vehicle accident. He is somnolent, spontaneously breathing, withdraws from painful stimuli (does not localize), and is speaking inappropriately. The patient has an 18g IV in his left arm with D5LR hanging.*
• PE: VS: P = 134, R = 24, BP = 178/108, O2 sat = 96% on non-rebreathing mask, T = 33 °C*
• HEENT: There is an abrasion on his forehead. There is ecchymosis into the periorbital tissue and hemotympanum is noted. The patient has a C-collar in place.*
• Airway: There are multiple facial fractures, multiple loose teeth, and the patient is uncooperative for further examination.*
• Lower Extremities: The right leg is swollen with intact peripheral pulses.*
• Lab: Hgb = 13.6, Hct = 42%, Platelets = 163,000. Electrolytes: Normal.*
• CT scans of the abdomen and pelvis: negative*
• CT scan of the head shows a non-displaced basilar skull fracture*
• Radiographs show a right femoral fracture. Neck radiographs show no apparent injury.*
• EKG: sinus tachycardia*
• Drug screen: positive for amphetamines)*

Answer 10

ARDS represents the pulmonary manifestation of the systemic inflammatory response syndrome (SIRS).

There is injury to the capillary alveolar membrane resulting in –

• bilateral diffuse infiltrates,
• severe dyspnea, and
• hypoxemia secondary to intrapulmonary shunting.

The syndrome may lead to – fibrosing alveolitis and permanent scarring of the lungs.

Question 11

Post-Operative Management:

What is required for the diagnosis of ARDS?

• (A 5’7”, 180 kg, 22-year-old male is brought to the trauma suite following a motor vehicle accident. He is somnolent, spontaneously breathing, withdraws from painful stimuli (does not localize), and is speaking inappropriately. The patient has an 18g IV in his left arm with D5LR hanging.*
• PE: VS: P = 134, R = 24, BP = 178/108, O2 sat = 96% on non-rebreathing mask, T = 33 °C*
• HEENT: There is an abrasion on his forehead. There is ecchymosis into the periorbital tissue and hemotympanum is noted. The patient has a C-collar in place.*
• Airway: There are multiple facial fractures, multiple loose teeth, and the patient is uncooperative for further examination.*
• Lower Extremities: The right leg is swollen with intact peripheral pulses.*
• Lab: Hgb = 13.6, Hct = 42%, Platelets = 163,000. Electrolytes: Normal.*
• CT scans of the abdomen and pelvis: negative*
• CT scan of the head shows a non-displaced basilar skull fracture*
• Radiographs show a right femoral fracture. Neck radiographs show no apparent injury.*
• EKG: sinus tachycardia*
• Drug screen: positive for amphetamines)*

Answer 11

Until recently, the diagnosis required an identifiable cause, acute onset, diffuse bilateral infiltrates on CXR, a PaO2 to Fio2 ratio of less than 200 , and a PAOP below 18 mmHg or no clinical evidence of left atrial hypertension.

A new set of criteria, with better predictive validity for mortality, has been proposed (“Berlin Definition”) including the following:

1. a PaO2/Fio2 ratio of < 300;
2. acute onset, defined as occurring within 7 days of the inciting event (i.e. sepsis, trauma, aspiration, or another accepted cause of ARDS);
3. bilateral infiltrates identified by chest radiography (CT or chest x-ray); and
4. respiratory failure that, in the physician’s best estimation, is “not fully explained by cardiac failure or fluid overload”.

Unlike the old diagnostic criteria, the Berlin Definition does NOT require the exclusion of heart failure.

However, if possible, it is recommended that an “objective assessment (i.e. echocardiogram) be performed to confirm that the patient’s respiratory condition is not fully explained by the presence of heart failure.

Moreover, the diagnosis of acute lung injury (PaO2/Fio2 ratio of 200-300) is eliminated and replaced with “mild” ARDS.

Clinical Note:

ARDS Severity Based on the Berlin Definition:

• Mild: PaO2/Fio2 = 200-300 (< 300)*
• Moderate:**PaO2/Fio2 = 100-200 (< 200)*
• Severe: PaO2/Fio2 = < 100*

Question 12

Post-Operative Management:

What is the recommended treatment (for ARDS)?

• (A 5’7”, 180 kg, 22-year-old male is brought to the trauma suite following a motor vehicle accident. He is somnolent, spontaneously breathing, withdraws from painful stimuli (does not localize), and is speaking inappropriately. The patient has an 18g IV in his left arm with D5LR hanging.*
• PE: VS: P = 134, R = 24, BP = 178/108, O2 sat = 96% on non-rebreathing mask, T = 33 °C*
• HEENT: There is an abrasion on his forehead. There is ecchymosis into the periorbital tissue and hemotympanum is noted. The patient has a C-collar in place.*
• Airway: There are multiple facial fractures, multiple loose teeth, and the patient is uncooperative for further examination.*
• Lower Extremities: The right leg is swollen with intact peripheral pulses.*
• Lab: Hgb = 13.6, Hct = 42%, Platelets = 163,000. Electrolytes: Normal.*
• CT scans of the abdomen and pelvis: negative*
• CT scan of the head shows a non-displaced basilar skull fracture*
• Radiographs show a right femoral fracture. Neck radiographs show no apparent injury.*
• EKG: sinus tachycardia*
• Drug screen: positive for amphetamines)*

Answer 12

Treatment includes – aggressively treating causative events and reversible pathology such as – DIC, sepsis, or hypotension; avoiding complications; and supportive mechanical ventilation.

Mechanical ventilation should provide sufficient PEEP to recruit collapsed alveoli and improve gas exchange while avoiding high airway pressures and large tidal volumes (tidal volumes = 6 ml/kg and static airway pressures < 30 cm H2O).

Permissive hypercapnia may be necessary to avoid higher tidal volumes and airway pressures.

The Fio2 should be less than 50% if possible to prevent iatrogenic lung injury.

While inhaled nitric oxide, inhaled prostacyclin, high-frequency ventilation, inverse ratio ventilation, and ventilation in the prone position have all been shown to temporarily improve oxygenation, none have provided significant long term outcome differences when compared with standard ventilation strategies.

Xtra Q – what is inverse ratio ventilation?

Question 13

Post-Operative Management:

The surgery resident recommends steroids, PEEP, and 10 ml/kg tidal volume.

What do you think of this recommendation?

• (A 5’7”, 180 kg, 22-year-old male is brought to the trauma suite following a motor vehicle accident. He is somnolent, spontaneously breathing, withdraws from painful stimuli (does not localize), and is speaking inappropriately. The patient has an 18g IV in his left arm with D5LR hanging.*
• PE: VS: P = 134, R = 24, BP = 178/108, O2 sat = 96% on non-rebreathing mask, T = 33 °C*
• HEENT: There is an abrasion on his forehead. There is ecchymosis into the periorbital tissue and hemotympanum is noted. The patient has a C-collar in place.*
• Airway: There are multiple facial fractures, multiple loose teeth, and the patient is uncooperative for further examination.*
• Lower Extremities: The right leg is swollen with intact peripheral pulses.*
• Lab: Hgb = 13.6, Hct = 42%, Platelets = 163,000. Electrolytes: Normal.*
• CT scans of the abdomen and pelvis: negative*
• CT scan of the head shows a non-displaced basilar skull fracture*
• Radiographs show a right femoral fracture. Neck radiographs show no apparent injury.*
• EKG: sinus tachycardia*
• Drug screen: positive for amphetamines)*

Answer 13

Giving steroids early in ARDS has been associated with an increase in mortality, although some small trials have shown reduced mortality when they are administered during the fibroproliferative phase of ARDS occurring around days 4-10.

PEEP may be helpful in recruiting healthy alveoli, although the long-term benefits are unproven.

A tidal volume of 10 ml/kg is too high and may result in volutrauma or barotrauma to healthy lung.

In fact, lower tidal volumes and airway pressures are the only intervention proven to reduce mortality in patients with ARDS.

Question 14

Post-Operative Management:

On post-op day 5 the patient’s serum sodium is 129 mEq/L and his urinary sodium is high.

What do you think might be going on?

• (A 5’7”, 180 kg, 22-year-old male is brought to the trauma suite following a motor vehicle accident. He is somnolent, spontaneously breathing, withdraws from painful stimuli (does not localize), and is speaking inappropriately. The patient has an 18g IV in his left arm with D5LR hanging.*
• PE: VS: P = 134, R = 24, BP = 178/108, O2 sat = 96% on non-rebreathing mask, T = 33 °C*
• HEENT: There is an abrasion on his forehead. There is ecchymosis into the periorbital tissue and hemotympanum is noted. The patient has a C-collar in place.*
• Airway: There are multiple facial fractures, multiple loose teeth, and the patient is uncooperative for further examination.*
• Lower Extremities: The right leg is swollen with intact peripheral pulses.*
• Lab: Hgb = 13.6, Hct = 42%, Platelets = 163,000. Electrolytes: Normal.*
• CT scans of the abdomen and pelvis: negative*
• CT scan of the head shows a non-displaced basilar skull fracture*
• Radiographs show a right femoral fracture. Neck radiographs show no apparent injury.*
• EKG: sinus tachycardia*
• Drug screen: positive for amphetamines)*

Answer 14

(Nice discussion in online UBP)

A high urinary sodium and serum hyponatremia are consistent with both cerebral salt wasting syndrome (CSWS) and syndrome of inappropriate antidiuretic hormone (SIADH).

Either of these two disorders may occur following TBI and may be best differentiated by –

the volume status of the patient.

CSWS is usually associated with hypovolemia, while patients with SIADH are usually euvolemic.

Question 15

Post-Operative Management:

How can you tell the difference between CSWS and SIADH?

• (A 5’7”, 180 kg, 22-year-old male is brought to the trauma suite following a motor vehicle accident. He is somnolent, spontaneously breathing, withdraws from painful stimuli (does not localize), and is speaking inappropriately. The patient has an 18g IV in his left arm with D5LR hanging.*
• PE: VS: P = 134, R = 24, BP = 178/108, O2 sat = 96% on non-rebreathing mask, T = 33 °C*
• HEENT: There is an abrasion on his forehead. There is ecchymosis into the periorbital tissue and hemotympanum is noted. The patient has a C-collar in place.*
• Airway: There are multiple facial fractures, multiple loose teeth, and the patient is uncooperative for further examination.*
• Lower Extremities: The right leg is swollen with intact peripheral pulses.*
• Lab: Hgb = 13.6, Hct = 42%, Platelets = 163,000. Electrolytes: Normal.*
• CT scans of the abdomen and pelvis: negative*
• CT scan of the head shows a non-displaced basilar skull fracture*
• Radiographs show a right femoral fracture. Neck radiographs show no apparent injury.*
• EKG: sinus tachycardia*
• Drug screen: positive for amphetamines)*

Answer 15

As I mentioned before, CSWS is usually associated with hypovolemia whereas patients with SIADH are euvolemic.

In addition, patients with SIADH exhibit elevated ADH levels and rarely develop urine sodium levels > 100 mEq/L.

Patients with CSWS usually have normal ADH levels and often develop urine sodium levels > 100 mEq/L.

Question 16

Post-Operative Management:

Is it important to distinguish between the two (CSWS and SIADH)?

• (A 5’7”, 180 kg, 22-year-old male is brought to the trauma suite following a motor vehicle accident. He is somnolent, spontaneously breathing, withdraws from painful stimuli (does not localize), and is speaking inappropriately. The patient has an 18g IV in his left arm with D5LR hanging.*
• PE: VS: P = 134, R = 24, BP = 178/108, O2 sat = 96% on non-rebreathing mask, T = 33 °C*
• HEENT: There is an abrasion on his forehead. There is ecchymosis into the periorbital tissue and hemotympanum is noted. The patient has a C-collar in place.*
• Airway: There are multiple facial fractures, multiple loose teeth, and the patient is uncooperative for further examination.*
• Lower Extremities: The right leg is swollen with intact peripheral pulses.*
• Lab: Hgb = 13.6, Hct = 42%, Platelets = 163,000. Electrolytes: Normal.*
• CT scans of the abdomen and pelvis: negative*
• CT scan of the head shows a non-displaced basilar skull fracture*
• Radiographs show a right femoral fracture. Neck radiographs show no apparent injury.*
• EKG: sinus tachycardia*
• Drug screen: positive for amphetamines)*

Answer 16

It is important because –

the treatment for SIADH includes –

• water restriction along with diuresis,
• demeclocycline (which inhibits ADH effects on renal tubules), and
• sodium replacement.

On the other hand, this treatment would be inappropriate for CSWS, as water restriction and diuresis could exacerbate the hypovolemia associated with this disorder.