A Collaborative Approach:

Overcoming the Challenges of

Treating Polytrauma

Rebecca Rosten, BSN, RN

Scott & White Memorial Hospital

Faculty Disclosure

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7. No conflict

Rebecca Rosten7. No conflict.

Accreditation StatementAORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019.

• Verbalize the response of the OR nursing staff when a trauma activation is received.

• Discuss the care provided by multidisciplinary teams and their ability to impact and improve outcomes of a polytrauma patient.

• Identify needed elements of communication for Level 1 trauma transfer to and from the OR

Objectives

•26 year old female in an MVA

•Small vehicle vs. 18 Wheeler

•Patient was a restrained driver.

•EMS on scene, GCS < 8

• Moving all four extremities

• Combative, unresponsive and incoherent

Case history

Phases

Pre Hospital

Hospital

Outpatient

EMS arrived:

• Driver's side severely damaged.

• Difficult extrication

• Jaws of Life used

• EMS contacted ED

• Aeromedical services called for

Pre-Hospital

25 miles , 42 minutes from Level 1

• Oxygen• Cervical collar placed• IV access-16 g left AC and 18g right AC.• Bolus with 2 L normal saline• Rapid Sequence Induction/Oral Intubation

• Etomidate

• Rocuronium

• Ativan

• Fentanyl

Pre-Hospital

ED

• 911 activated @ 2212.

• Patient arrives @ 2220 by Helicopter.

• Vital signs upon arrival:

• SBP in the 80mmHg

• HR 130

• Physical examination revealed significant pelvic instability.

• Resuscitated with 2 units Type O negative unmatched blood

Diagnostic imaging

• CXR revealed left pneumothorax: Chest tube placed

• AP films confirmed fractured pelvis: Sheet was utilized as pelvic binder

Hospital

Diagnostic Imaging cont:

• Positive FAST: pelvis and spleno-renal area

• Left subclavian introducer catheter placed

• Patient taken emergently to the operating room and IR called to meet in the OR

HospitalED cont

pelvis

2315 iStat:

CO2 14

pH 7.14

PO2 238

HCO3 13

BE -16

Remember this………….

• Exploratory Laparotomy: An upper midline incision was made and dissected down to the peritoneal cavity

• 500-600 ml of fresh blood was encountered

HospitalOperating Room

• Liver laceration which was controlled with electrocautery.

• Retroperitoneal hematoma (consistent with pelvic fracture). Pfannenstiel incision made (Bikini incision) to expose the pre-peritoneal space. Multiple packs placed within the pre-peritoneal space.

• Bleeding from the spleen (performed splenectomy).

HospitalOperating Room

Discoveries

10/29/12

• Attention turned to the bladder: bladder rupture . Repaired in two layers with suture.

• Requested Interventional Radiology- perform angiography to evaluate for arterial bleeding in the pelvis.

• Patient desaturates progressive hypotension and hypoxia

HospitalOR cont’d

Stat Chest X-ray was taken and revealed:

• Unevacuated blood in the left chest

• Widened pericardial and mediastinal silhouette

• Some displacement of endotracheal tube (to the right)

HospitalOR cont’d

Where is that bleeder????

Anesthesia performs a transesophagel echocardiogram

HospitalOR cont’d

Still searching

• Pericardial tamponade

• Subxiphoid pericardial window performed and produced 200cc

• Rapid left anterolateral thoracotomy (clamshell)

• 750-900 ml of blood was evacuated from left chest

• Multiple lacerations to the left lung (lower lobe)

• “Hole” in the HEART: Pericardium widely opened which showed a jagged 1 cm laceration on the left ventricle near the atrio-ventricular junction.

• Cardio surgeon in route!!

HospitalOR cont’d

BINGO!!!

The defect in the heart was closed utilizing pledgetedsutures for the repair.

HospitalOR cont’d

A fractured rib which had penetrated the lung and pierced the heart was found to be the culprit of the cardiac injury.

HospitalOR cont’d

• After cardiac repair, the patient again stabilized.

• Pelvic angiography was performed which revealed several bleeding branches of the internal iliac arteries bilaterally; these were gel-foam embolized.

• Patient then taken to the SICU.

HospitalOR cont’d

2315 iStat:

CO2 14, pH 7.14, PO2 238, HCO3 13, BE -16

Metabolic Acidosis, uncompensated

Normal valuespH 7.35-7.45

pCO2 35-45

pO2 80-100

O2 Sat 95-100%

HCO3 22-26

BE + or -2

Answer

29 units of RBC

23 units of FFP

5 units of platelets

750 ml of albumin

750 ml of cell saver

1 unit of cryoprecipitate

MBTP- 6 RBCs, 4 FFP, 1 platelet

PLEASE DONATE BLOOD!!!

FYIFluids Given

911 activated Pt arrived via helicopter

Incision iSTAT Leave OR

2212 2220 2303 2315 0445

• Re-exploration of packed open abdomen

• Repair of bladder laceration

• Copious irrigation

• Abdomen closed

Hospital

Back to the OR..3 days later

• Fractured pelvis was repaired

• Same Bikini incision was used

• Performed open reduction and internal fixation of anterior ring (screws for pelvic compression)

• Performed percutaneous fixation of bilateral posterior ring disruption (screws for sacral alignment)

HospitalPelvis Repair..6 days later

• Open reduction, internal fixation of atlantooccipitaland atlantoaxial dissociation

• Posterolateral arthrodesis- autograft (spinousprocesses) + 10ml of cancellous bone chips (donor)

• Screws , plate, and rods (instrumentation) performed, occiput to C3

HospitalCervical repair..7 days later

• Patient was unhappy with the stiffness and discomfort in her neck related to the fusion of the occipito-cervical joint.

• Cervical plate and C2-C3 screws were removed uneventfully

Outpatient6 Months from first surgery

The patient spent about 1 month in the hospital, then spent several weeks in a rehab facility, and was discharged home around 7 weeks after her accident completely neurologically normal

From Level 1 to Now

• 30 ICD-9 codes with in first 5 hours• Also she had sustained a small subdural hematoma and

several long-bone fractures.• ISS 66-The Injury Severity Score (ISS) is an anatomical

scoring system that provides an overall score for patients with multiple injuries. The ISS score takes values from 0 to 75.

• Team approach: EMS, ED, radiology, anesthesia, perfusion, nursing, respiratory, ancillary staff, surgical teams for-ETS, ortho, urology, neuro, and cardiac.

Recap

• Penetrating cardiac injury from a fractured rib is a rare occurrence with survival rarely reported.

• Survival of this extremely rare injury in combination with the often fatal occipito-cervical ligamentous injury and an Injury Severity Score of 66, has never been reported.

Discussion

• This case outlines how the modern, multidisciplinary approach to care at an advanced trauma center can enable optimal outcomes even in patients with such tremendous injury burden.

• It is important to remember that patient care is a team effort and that together we can save lives.

Teamwork!!!

THANK YOU

Arterial Blood Gases (ABGs). (n.d.). Arterial Blood Gases (ABGs). Retrieved December 3, 2012, from http://www.the-abg-site.comBaker SP et al, (1974). The Injury Severity Score: a method for describing patients with multiple injuries and evaluating emergency care, J Trauma 14:187-196;1974Chaput CD et al, (2011). Defining and detecting missed ligamentous injuries of the occipitocervical complex. SPINE, 36(9), 709-714.Davis, M. (Director) (2012, June 9). Fractured Rib Causing Cardiac Injury: A Case Illustration of the Teamwork and Multidisciplinary Approach of Trauma Care. Trauma Symposium. Lecture conducted from Scott & White, Temple.Surgeons, A. C. O. (2007). Resources for optimal care of the injured patient 2006.

References

Questions

rrosten@sw.org