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ARDS in Trauma Karl Wagner MD 11/30/04
30 y/o male (note eyes covered to protect identity)
2 Dudes (Probably these two)
H&P <ul><li>CC:  s/p MVA </li></ul><ul><li>HPI:  pt 30y/o male in comes to the ED after an MVA with multiple injuries </li...
Physcical Exam <ul><li>BP 110/85, HR 115, RR 32 </li></ul><ul><li>Neuro:  in C-collar, GCS 10 (E3V3M4) </li></ul><ul><li>C...
Glasgow Coma Scale <ul><li>Eyes spontaneous, command, pain, none </li></ul><ul><li>Verbal oriented, confused, inappropriat...
Physcical Exam <ul><li>BP 110/85, HR 115, RR 32 </li></ul><ul><li>Neuro:  in C-collar, GCS 10 (E3V3M4) </li></ul><ul><li>C...
Injury Survey <ul><li>Small subdural hematoma over right frontal lobe </li></ul><ul><li>Right sided rib fractures 5-8 </li...
Operating Room <ul><li>Ventilator 10 cc/kg, 10 Resp/min </li></ul><ul><li>Isoflurane </li></ul><ul><li>Arterial line and i...
All in a days work
Lung Injury <ul><li>Range of entities </li></ul><ul><li>Local not clinically significant </li></ul><ul><li>Unable to excha...
Inflammation <ul><li>Blunt injury </li></ul><ul><li>Neutrophiles </li></ul><ul><li>Cytokines </li></ul><ul><li>Macrophages...
Normal Lung Tissue
Exudative Phase <ul><li>Starts early. </li></ul><ul><li>Interstitial and alveolar edema </li></ul><ul><li>Hyaline membrane...
Diffuse Alvolar Damage
Proliferation Phase <ul><li>Type II cells increase in number </li></ul><ul><li>Type II cells can become Type I cells </li>...
Fibrotic Stage <ul><li>Fibroblasts </li></ul><ul><li>Myofibroblasts </li></ul><ul><li>Collagenation </li></ul><ul><li>Arte...
Late Diffuse Alveolar Damage
Neutrophiles <ul><li>Already there… </li></ul><ul><li>Secrete toxins… </li></ul><ul><li>Connected for activation… </li></u...
Map to the Neighborhood
Macrophages <ul><li>Killing machines </li></ul><ul><li>Keep going and going and going… </li></ul><ul><li>Complement </li><...
Endothelium <ul><li>Express cytokines </li></ul><ul><li>Secrete vasoactive substance </li></ul><ul><li>Procoagulant </li><...
Phospholipids <ul><li>On all cells </li></ul><ul><li>Great cellular messenger </li></ul><ul><li>Makes more cellular messen...
Pulmonary Edema <ul><li>Hydrostatic pressure </li></ul><ul><li>Oncotic pressure </li></ul><ul><li>Lymph system </li></ul><...
Diffuse Alveolar Infultrates
Patchy Densities
Phase 1 <ul><li>Dyspnea </li></ul><ul><li>Tachypnea </li></ul><ul><li>Normal CXR </li></ul><ul><li>Hypoxemia </li></ul><ul...
Phase 2 <ul><li>Changes on CXR </li></ul><ul><li>Changes on PE </li></ul><ul><li>Pulmonary Hypertension </li></ul><ul><li>...
Phase 3 <ul><li>Worse CXR </li></ul><ul><li>Worse PE </li></ul><ul><li>Worse cardiopulmonary mechanics </li></ul><ul><li>D...
Phase 4 <ul><li>Diffuse infiltrates with superimposed pneumonia </li></ul><ul><li>Sepsis </li></ul><ul><li>MOF </li></ul><...
Diagnosis of ARDS <ul><li>Diffuse alveolar infiltrates on CXR </li></ul><ul><li>Noncardiogenic pulmonary edema </li></ul><...
Risk Factors <ul><li>Shock </li></ul><ul><li>Gastric aspiration </li></ul><ul><li>Pulmonary contusion </li></ul><ul><li>Ne...
Injury Severity Score <ul><li>Head and Neck </li></ul><ul><li>Face </li></ul><ul><li>Chest </li></ul><ul><li>Abdomen </li>...
Trauma Score <ul><li>Glasgow Coma Scale </li></ul><ul><li>Systolic Blood Pressure </li></ul><ul><li>Respiratory Rate </li>...
Strategy <ul><li>Spontaneous respiration </li></ul><ul><li>Noninvasive positive pressure </li></ul><ul><li>Beware oxygen t...
Ventilator Strategies <ul><li>High PEEP early – 16 cm H2O </li></ul><ul><li>Watch plateau pressure  <35 cm H2O </li></ul><...
For Longer Term Care <ul><li>Treat underlying infections </li></ul><ul><li>Proning </li></ul><ul><li>ECMO </li></ul><ul><l...
Bibliography <ul><li>Amato MBP, Barbas CSV, Medeiros DM,  et al : Effect of a protective ventilation strategy on mortality...
Bibliography continued <ul><li>PEEP in ARDS – How much is enough?  Levy M. M.  N Engl J Med 2004; 351:389-391, Jul 22, 200...
More Bibliography <ul><li>Medical Progress: The Acute Respiratory Distress Syndrome .  Ware L. B., Matthay M. A.  N Engl J...
Bibliography Continued <ul><li>Management of post traumatic respiratory failure. Michaels AJ -  Crit Care Clin  - 01-JAN-2...
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Transcript of "Ards in trauma wagner"

  1. 1. ARDS in Trauma Karl Wagner MD 11/30/04
  2. 2. 30 y/o male (note eyes covered to protect identity)
  3. 3. 2 Dudes (Probably these two)
  4. 4. H&P <ul><li>CC: s/p MVA </li></ul><ul><li>HPI: pt 30y/o male in comes to the ED after an MVA with multiple injuries </li></ul><ul><li>PMHx/PSHx: insignificant </li></ul><ul><li>Meds: none </li></ul><ul><li>Allergies: none </li></ul>
  5. 5. Physcical Exam <ul><li>BP 110/85, HR 115, RR 32 </li></ul><ul><li>Neuro: in C-collar, GCS 10 (E3V3M4) </li></ul><ul><li>CVS: tachycardic, </li></ul><ul><li>Resp/chest: dyspnea, tachypneic, tenderness on right chest, CTA bilat, decreased inspiratory excursion </li></ul><ul><li>ABD: nondistended, soft, tender in right upper quadrant </li></ul><ul><li>EXT: 18g IV in left AC and 16g IV right AC, moves all 4 ext, deformity of left thigh, tender to palpation, pulses intact </li></ul>
  6. 6. Glasgow Coma Scale <ul><li>Eyes spontaneous, command, pain, none </li></ul><ul><li>Verbal oriented, confused, inappropriate, inconprehensible, none </li></ul><ul><li>Motor obeys, localizes, withdraws, flex, extension, none </li></ul>
  7. 7. Physcical Exam <ul><li>BP 110/85, HR 115, RR 32 </li></ul><ul><li>Neuro: in C-collar, GCS 10 (E3V3M4) </li></ul><ul><li>CVS: tachycardic, </li></ul><ul><li>Resp/chest: dyspnea, tachypneic, tenderness on right chest, CTA bilat, decreased inspiratory excursion </li></ul><ul><li>ABD: nondistended, soft, tender in right upper quadrant </li></ul><ul><li>EXT: 18g IV in left AC and 16g IV right AC, moves all 4 ext, deformity of left thigh, tender to palpation, pulses intact </li></ul>
  8. 8. Injury Survey <ul><li>Small subdural hematoma over right frontal lobe </li></ul><ul><li>Right sided rib fractures 5-8 </li></ul><ul><li>Lung contusion </li></ul><ul><li>Liver contusion </li></ul><ul><li>Left femur fracture </li></ul>
  9. 9. Operating Room <ul><li>Ventilator 10 cc/kg, 10 Resp/min </li></ul><ul><li>Isoflurane </li></ul><ul><li>Arterial line and introducer </li></ul><ul><li>Four units packed red blood cells </li></ul><ul><li>Conservative mx for liver </li></ul><ul><li>Off to SICU for continued mx </li></ul>
  10. 10. All in a days work
  11. 11. Lung Injury <ul><li>Range of entities </li></ul><ul><li>Local not clinically significant </li></ul><ul><li>Unable to exchange gases across mebranes and participate in respiration </li></ul><ul><li>Somewhere in between </li></ul>
  12. 12. Inflammation <ul><li>Blunt injury </li></ul><ul><li>Neutrophiles </li></ul><ul><li>Cytokines </li></ul><ul><li>Macrophages </li></ul><ul><li>Complement Cascade </li></ul><ul><li>Coagulation Cascade </li></ul>
  13. 13. Normal Lung Tissue
  14. 14. Exudative Phase <ul><li>Starts early. </li></ul><ul><li>Interstitial and alveolar edema </li></ul><ul><li>Hyaline membrane formation </li></ul><ul><li>Endothelial cell damage </li></ul><ul><li>Type I cell necrosis </li></ul><ul><li>Infiltration with neutrophiles </li></ul>
  15. 15. Diffuse Alvolar Damage
  16. 16. Proliferation Phase <ul><li>Type II cells increase in number </li></ul><ul><li>Type II cells can become Type I cells </li></ul>
  17. 17. Fibrotic Stage <ul><li>Fibroblasts </li></ul><ul><li>Myofibroblasts </li></ul><ul><li>Collagenation </li></ul><ul><li>Arteriolar hypertrophy </li></ul><ul><li>Obliteration of pulmonary vasculature </li></ul>
  18. 18. Late Diffuse Alveolar Damage
  19. 19. Neutrophiles <ul><li>Already there… </li></ul><ul><li>Secrete toxins… </li></ul><ul><li>Connected for activation… </li></ul><ul><li>Protected from deactivation… </li></ul><ul><li>Location, Location, Location… </li></ul>
  20. 20. Map to the Neighborhood
  21. 21. Macrophages <ul><li>Killing machines </li></ul><ul><li>Keep going and going and going… </li></ul><ul><li>Complement </li></ul><ul><li>IL-1, -6, -8 </li></ul><ul><li>TNF </li></ul><ul><li>Impaired judgment? </li></ul>
  22. 22. Endothelium <ul><li>Express cytokines </li></ul><ul><li>Secrete vasoactive substance </li></ul><ul><li>Procoagulant </li></ul><ul><li>Metabolically active </li></ul>
  23. 23. Phospholipids <ul><li>On all cells </li></ul><ul><li>Great cellular messenger </li></ul><ul><li>Makes more cellular messengers </li></ul><ul><li>Arachadonic acid </li></ul><ul><li>Thromboxane </li></ul><ul><li>Prostacylin </li></ul><ul><li>PAF </li></ul>
  24. 24. Pulmonary Edema <ul><li>Hydrostatic pressure </li></ul><ul><li>Oncotic pressure </li></ul><ul><li>Lymph system </li></ul><ul><li>Increase distance from capillary lumen to alveolar lumen </li></ul><ul><li>Pulmonary hypertension </li></ul><ul><li>Hypoxemia </li></ul><ul><li>Lung compliance decreases </li></ul>
  25. 25. Diffuse Alveolar Infultrates
  26. 26. Patchy Densities
  27. 27. Phase 1 <ul><li>Dyspnea </li></ul><ul><li>Tachypnea </li></ul><ul><li>Normal CXR </li></ul><ul><li>Hypoxemia </li></ul><ul><li>Hypocarbia </li></ul><ul><li>Neutrophiles </li></ul>
  28. 28. Phase 2 <ul><li>Changes on CXR </li></ul><ul><li>Changes on PE </li></ul><ul><li>Pulmonary Hypertension </li></ul><ul><li>Change in pulmonary mechanics </li></ul><ul><li>Microscopic lung changes/damage </li></ul>
  29. 29. Phase 3 <ul><li>Worse CXR </li></ul><ul><li>Worse PE </li></ul><ul><li>Worse cardiopulmonary mechanics </li></ul><ul><li>Decreased hemoglobin oxygen extraction </li></ul><ul><li>Occlusion of vessels </li></ul>
  30. 30. Phase 4 <ul><li>Diffuse infiltrates with superimposed pneumonia </li></ul><ul><li>Sepsis </li></ul><ul><li>MOF </li></ul><ul><li>More lung impairment </li></ul><ul><li>Cellular changes in the lung </li></ul>
  31. 31. Diagnosis of ARDS <ul><li>Diffuse alveolar infiltrates on CXR </li></ul><ul><li>Noncardiogenic pulmonary edema </li></ul><ul><li>PaO2/FiO2 ratio <200 </li></ul><ul><li>12-39% Trauma Population </li></ul><ul><li>Mortality 25-30% </li></ul>
  32. 32. Risk Factors <ul><li>Shock </li></ul><ul><li>Gastric aspiration </li></ul><ul><li>Pulmonary contusion </li></ul><ul><li>Near-drowning </li></ul><ul><li>Fractures </li></ul><ul><li>Smoke inhalation </li></ul><ul><li>Multiple transfusions </li></ul><ul><li>Fat embolism </li></ul><ul><li>Pneumonia </li></ul><ul><li>Sepsis </li></ul><ul><li>Injury severity score > 16 </li></ul><ul><li>Blunt injury </li></ul><ul><li>Trauma score < 13 </li></ul><ul><li>Surgery to head </li></ul><ul><li>+/- admission lactate, pH, base </li></ul><ul><li>deficit, serum bicarbonate </li></ul><ul><li>Disseminated intravascular coagulation </li></ul>
  33. 33. Injury Severity Score <ul><li>Head and Neck </li></ul><ul><li>Face </li></ul><ul><li>Chest </li></ul><ul><li>Abdomen </li></ul><ul><li>Extremity </li></ul><ul><li>External </li></ul>
  34. 34. Trauma Score <ul><li>Glasgow Coma Scale </li></ul><ul><li>Systolic Blood Pressure </li></ul><ul><li>Respiratory Rate </li></ul>
  35. 35. Strategy <ul><li>Spontaneous respiration </li></ul><ul><li>Noninvasive positive pressure </li></ul><ul><li>Beware oxygen toxicity </li></ul><ul><li>Fluid balance </li></ul><ul><li>Treat underlying causes </li></ul>
  36. 36. Ventilator Strategies <ul><li>High PEEP early – 16 cm H2O </li></ul><ul><li>Watch plateau pressure <35 cm H2O </li></ul><ul><li>Low tidal volume – 6-8 cc/kg </li></ul><ul><li>Be careful with manual ventilation </li></ul><ul><li>Hypercapnia </li></ul><ul><li>Pressure controlled ventilation </li></ul>
  37. 37. For Longer Term Care <ul><li>Treat underlying infections </li></ul><ul><li>Proning </li></ul><ul><li>ECMO </li></ul><ul><li>Trach ‘em early </li></ul><ul><li>NO! </li></ul><ul><li>Steroids? </li></ul>
  38. 38. Bibliography <ul><li>Amato MBP, Barbas CSV, Medeiros DM, et al : Effect of a protective ventilation strategy on mortality in the acute respiratory distress syndrome. NEJM 1998; 338: 347 354 </li></ul><ul><li>The Acute Respiratory Distress Syndrome Network: Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. NEJM 2000; 342. </li></ul><ul><li>M McCunn, MD, MIPP, A Sutcliffe, MBChB, W Mauritz, MD, PhD and the ITACCS Critical Care Committee: Guidelines for Management of Mechanical Ventilation for Critically Injured Patients. </li></ul>
  39. 39. Bibliography continued <ul><li>PEEP in ARDS – How much is enough? Levy M. M. N Engl J Med 2004; 351:389-391, Jul 22, 2004 </li></ul><ul><li>  Medical Progress: The Acute Respiratory Distress Syndrome. Kollef M. H., Schuster D. P. N Engl J Med 1995; 332:27-37, Jan 5, 1995. </li></ul><ul><li>  Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome. The National Heart, Lung, and Blood Institute ARDS clinical Trials Network. N Engl J Med 2004; 351: 327-336, Jul 22, 200 </li></ul>
  40. 40. More Bibliography <ul><li>Medical Progress: The Acute Respiratory Distress Syndrome . Ware L. B., Matthay M. A. N Engl J Med 2000; 342:1334-1349, May 4, 2000. </li></ul><ul><li>  Effect of age on the development of ARDS in trauma patients. Johnston CJ - Chest - 01-AUG-2003; 124(2): 653-9 </li></ul><ul><li>  Glucocorticoids and acute lung injury. Thompson BT - Crit Care Med - 01-APR-2003; 31(4 Suppl): S253-7 </li></ul><ul><li>  Effect of acute lung injury and acute respiratory distress syndrome on outcome in critically ill trauma patients. Treggiari MM - Crit Care Med - 01-FEB-2004; 32(2): 327-31 </li></ul>
  41. 41. Bibliography Continued <ul><li>Management of post traumatic respiratory failure. Michaels AJ - Crit Care Clin - 01-JAN-2004; 20(1): 83-99, vi – vii </li></ul><ul><li>Matox, Feliciano, Moore. Trauma Fouth Edition. McGraw-Hill 2000. Pages 1309-1339. </li></ul><ul><li>Beers and Berkow. The Merck Manual of Diagnosis and Therapy Seventeenth Edition. Merck and Co. 1999. Pages 551-555. </li></ul><ul><li>Fauci et al. Harrison’s Principles of Internal Medicine Fourteenth Edition. McGraw-Hill 1998. Pages 1483-1490. </li></ul><ul><li>WWW.ARDSNET.ORG   </li></ul><ul><li>Medical pictures from Up To Date. </li></ul>
  42. 42. Thanks for a fun morning!
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