VentWorld Case Studies

DB: Trauma and ARDS Development
Published August 17, 2001

William French and John Gallagher, CRT
Lakeland Community College, Kirtland, OH
www.lakeland.cc.oh.us/index.htm

Contents (click to jump directly to that section, or scroll down to read the case)


INTRODUCTION

DB, a 43-year-old-male, was admitted to the emergency department following an assault during which he was beaten with an aluminum baseball bat. He sustained injuries to the head, chest, and abdomen, but did not lose consciousness.


CASE PRESENTATION

Upon arrival at the ED, DB scored 13 on the Glasgow Coma Scale. His airway was patent and his breath sounds were clear and equal bilaterally. Heart rate was 92, respiratory rate was 20, blood pressure was 144/67, temperature was 37.1 C, and SpO2 on room air was 100%.

Initial physical examination revealed bruising and swelling around the left eye orbit and an opacified iris with no vision of the same eye. In addition, he complained of abdominal and chest pain, which correlated clinically with bruising and swelling of the same area. Chest radiograph and c-spine images did not show any signs of trauma. Following the initial exam, DB scored 15 on the GCS. However, he did exhibit gross hematuria, which prompted an irrigation of his bladder and CT scans of the head and abdomen.

DB was admitted to the hospital. CT scan suggested a spleen laceration, a kidney contusion, and splenic pseudoaneurysm, which would eventually require dialysis. Not long after admission, he experienced a large hypotensive event. Four units of blood were required to stabilize. Ativan and morphine were ordered for pain and anxiety.

Two days later, the patient’s chest radiograph showed right upper lobe collapse and bilateral infiltrates. This and his physical assessment suggested the development of adult respiratory distress syndrome. The decision was made to place the patient on ventilatory support via the Puritan-Bennett 7200 ventilator, with the following settings:

Mode CMV Rate 14
Tidal Volume 650 mL Flow 60 Lpm
FiO2 0.50 PEEP +5 cmH2O

The patient did not respond well to mechanical ventilation, with repeated episodes of refractory hypoxemia and general agitation. Therefore, he was given neuromuscular blocking agent and the ventilator settings were changed to:

Mode CMV Rate 28
Tidal Volume 420 mL Flow 60 Lpm
FiO2 0.40 PEEP +7.5 cmH2O

Within three days of initiation of mechanical ventilation, the PEEP level was increased, in gradual increments, to a maximum of 22.5 cmH2O, with an FiO2 of 0.80, in order to maintain a PaO2 of 90 mmHg and a SaO2 of 92%.

Over the next several days, the patient began to improve and the PEEP was eventually reduced to +5 and the FiO2 decreased to .40. Arterial blood gases drawn on these settings (tidal volume 420 mL, rate 28) were:

pH 7.38 PaO2 81
PaCO2 43 SaO2 95%
HCO3 25 base excess 0.1

A tracheostomy was performed after 26 days of ventilatory support. At this time, morphine and Ativan were reduced and the patient became more alert. In addition, injuries to his kidney and spleen appeared to be healing nicely and there was hope that he would successfully wean from ventilatory support and undergo rehabilitation.


DISCUSSION:

Do you think the staff recognized and managed the case appropriately? Post your thoughts or ask other questions related to this case.

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