Polytrauma Case 6 AOTrauma Masters courseSDL Polytrauma course
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Polytrauma Case 6 AOTrauma Masters course—SDL Polytrauma course
Case description • 20 -year-old man • Motor vehicle crash into a tree • At the scene: – Glasgow Coma Scale: 3, intubation at the scene – Stable hemodynamics – Rescue time: 60 minutes
Admission to external hospital • Infusion of 8 units of packed cells and 8 units of plasma • Chest tube on the right side • Deterioration of respiration Helicopter transfer to level I hospital
On admission • Stable hemodynamics • Hemoglobin: 13. 1 g/L • p. O 2/Fi. O 2: 80 • Core temperature: 33°C • Unstable grade 2 open left forearm (3 cm) • Right midshaft femoral fracture • Focused Abdominal Sonography for Trauma (FAST): no free fluid
Initial chest x-ray
Initial computed tomographic scan of chest taken at external hospital
Initial computed tomographic scan of chest taken at external hospital
Now in level I hospital External hospital
Diagnosis: Bilateral lung contusion and hemathorax Femoral shaft fracture Moderate contusion (frontal, occipital) Forearm fracture (grade 2 open)
Initial surgical treatment? • External fixation of right femur • Debridement and external fixation of the forearm fracture on the left side
Admission to intensive care unit (ICU) • p. O 2/Fi. O 2: 50 mm Hg • Bilateral chest tubes
Clinical course on ICU—day 1– 3 • p. O 2/Fi. O 2 50 mm Hg • Supine/prone positioning • Oxygenation maintained
Clinical course on ICU—day 4– 14 • Acute respiratory distress syndrome (ARDS) and relapsing pneumothoraces • Up to three chest tubes bilateral • Intermittent prone/supine positioning Improvement of respiratory situation by day 14
Secondary surgical treatment? ? 1. According to lung function only? 2. According to physiological parameters? 3. Combination 1 and 2? 4. Ask anesthesist?
Secondary surgical treatment? ! 1. p. O 2/Fi. O 2 > 300 2. Negative indoor/outdoor (I/O) ratio 3. Platelets > 100, 000 and rising 4. No need for pressors 5. No local/systemic infection (pneumonia!)
Definitive fracture stabilization • At 4 weeks, nailing of femur and plating of ulna
Course of p. O 2/Fi. O 2
Course of IL-6 concentrations
Complications during clinical course 1. Decubiti in right groin caused by external fixation of right femur 2. Deep vein thrombosis 3. Ossification of left elbow and impairments of ROM revision surgery
Summary • Mechanical ventilation: 38 days • ICU: 42 days • Transfer to neurorehabilitation facility • Development of ARDS • No multiorgan failure, no sepsis
Follow-up 3 years after trauma
Follow-up 3 years after trauma
Take-home messages • Severe chest injury prevents early total care • Good ICU care helps with resuscitation • p. O 2/Fi. O 2 ratio is very helpful in determining who is ready for the operating room • Delayed fixation is very reasonable • External fixation can be done in ICU if patient is too sick to go to the operating room
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