2013 congress sw
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In a surgical setting, a patient's life depends on a well-functioning multidisciplinary team. A polytruama patient presents with multifaceted complexities that only a strong collaborative effort can handle. The team approach offers critical and specialized diversities in medicine that promote fast competent care for our patients. Polytruamas present with the unique opportunity for teams to partner together and display the epitome of collaboration-saving lives. This presentation will recall the journey of the integrated care one patient received. Various disciplines such as; cardiothoracic, urology, anesthesia, orthopedics, spine, emergency trauma services (ETS), and nursing pulled together to provide exceptional care, in turn produced exceptional outcomes.
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- 1. A Collaborative Approach: Overcoming the Challenges of Treating Polytrauma Rebecca Rosten, BSN, RN Scott & White Memorial Hospital
- 2. Faculty Disclosure Rebecca Rosten 7. No conflict. Scott & White’s policy is that the subject matter experts must disclose any financial relationship in a company providing grant funds and/or a company whose product(s) may be discussed or used during the educational activity. Financial disclosure will include the name of the company and/or product and the type of financial relationship, and includes relationships that are in place at the time of the activity or were in place in the 12 months preceding the activity. Disclosures for this activity are indicated according to the following numeric categories: 1. Consultant/Speaker’s Bureau 2. Employee 3. Stockholder 5. Grant/Research Support 4. Product Designer 6. Other relationship (specify) 7. No conflict Accreditation Statement AORN 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.
- 3. Objectives • 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
- 4. Case history •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
- 12. Pre-Hospital EMS arrived: • Driver's side severely damaged. • Difficult extrication • Jaws of Life used • EMS contacted ED • Aeromedical services called for
- 13. 25 miles , 42 minutes from Level 1
- 14. Pre-Hospital • • • • • 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
- 16. 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
- 17. Hospital ED cont 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
- 18. pelvis
- 20. Remember this…………. 2315 iStat: CO2 14 pH 7.14 PO2 238 HCO3 13 BE -16
- 21. Hospital Operating Room • • Exploratory Laparotomy: An upper midline incision was made and dissected down to the peritoneal cavity 500-600 ml of fresh blood was encountered
- 22. Hospital Operating Room Discoveries • • • 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).
- 24. 10/29/12
- 25. Hospital OR cont’d • • • 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
- 26. Hospital OR cont’d Where is that bleeder???? 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)
- 27. Hospital OR cont’d Still searching Anesthesia performs a transesophagel echocardiogram
- 28. Hospital OR cont’d BINGO!!! • • • • • • • 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!!
- 30. Hospital OR cont’d The defect in the heart was closed utilizing pledgeted sutures for the repair.
- 32. Hospital OR cont’d A fractured rib which had penetrated the lung and pierced the heart was found to be the culprit of the cardiac injury.
- 34. Hospital OR 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.
- 35. Answer 2315 iStat: CO2 14, pH 7.14, PO2 238, HCO3 13, BE -16 Metabolic Acidosis, uncompensated Normal values pH 7.35-7.45 pCO2 35-45 pO2 80-100 O2 Sat 95-100% HCO3 22-26 BE + or -2
- 36. FYI Fluids Given 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!!!
- 37. 911 activated Pt arrived via Incision helicopter iSTAT Leave OR 2212 2220 2315 0445 2303
- 38. Hospital Back to the OR..3 days later • • • • Re-exploration of packed open abdomen Repair of bladder laceration Copious irrigation Abdomen closed
- 39. Hospital Pelvis Repair..6 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)
- 40. Hospital Cervical repair..7 days later • • • Open reduction, internal fixation of atlantooccipital and atlantoaxial dissociation Posterolateral arthrodesis- autograft (spinous processes) + 10ml of cancellous bone chips (donor) Screws , plate, and rods (instrumentation) performed, occiput to C3
- 43. Outpatient 6 Months from first surgery • • 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
- 44. From Level 1 to Now 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
- 46. Recap • 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, respirat ory, ancillary staff, surgical teams forETS, ortho, urology, neuro, and cardiac.
- 47. Discussion • 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.
- 48. Teamwork!!! • 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.
- 49. THANK YOU
- 50. References Arterial Blood Gases (ABGs). (n.d.). Arterial Blood Gases (ABGs). Retrieved December 3, 2012, from http://www.the-abg-site.com Baker 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;1974 Chaput 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.
Editor's Notes
- Generally , when we get the EMS report we activate if one of the criteria is met. Sometimes it doesn’t happen that way (poor report or pt status changes enroute generally) and we don’t realize pt meets criteria until they get here. Activating early is important to ensure that resources are ready when the pt arrives. The ED activates a pager group in InfoRad with the alert. Generally , when we get the EMS report we activate if one of the criteria is met. Sometimes it doesn’t happen that way (poor report or pt status changes enroute generally) and we don’t realize pt meets criteria until they get here. Activating early is important to ensure that resources are ready when the pt arrives. The ED activates a pager group in InfoRad with the alert.
- The trauma team performed a FAST . FAST is an acronym for Focused Assessment with Sonography in Trauma. This is quick and available way to access for significant bleeding into the peritoneal, pleural, or pericardial spaces. The FAST was positive for bleeding in the pelvis and spleno-renal area. These discoveries lead to the decision to emergently take the patient directly to the operating room. At the same time the decision was made to have Interventional Radiology meet the patient for an angiography.
- The OR has designated rooms set up for trauma. Scott & White has an on call OR team 24 hours 7 days a week. When a 911 or 922 activation is called from the EMS, the OR gets a page from the ED. Promptly, a RN from the OR is sent to the ED. The OR nurse at that time hears report from EMS staff and collects information that is verbalized from trauma team. The OR nurse has a cell phone that is utilized for communication to the OR control Desk. Constant communication between the OR nurse and control desk provides timely accommodations to the surgical trauma team and patient care. Given the current status of the patient Interventional Radiology, perfusion, anthologist resident, ancillary staff, and OR surgical team were alerted and dispatched to OR 7. Without haste, the patient was delivered to OR 7.
- By definition, a grade I liver laceration involves capsular tear no more than 1 cm in depth. Keep in mind, the liver has double vascular supply with a rate of blood flow of 1.5 liters per minute.
- . A grade II splenic laceration entails capsular tear of 1-3 cm depth which does not involve a trabecular vessel.
- Interventional radiology started to move their equipment in the room to perform an angiography to evaluate the patient for any possible arterial bleeding in the pelvis. Without missing a beat, the surgeons continue to explore. In addition to the midline incision, a pfannenstiel incision was made and discovered that the bladder was ruptured. Care was taken to repair the bladder but the attention suddenly was turned to the progressive hypotension and hypoxia that the anesthesia was trying to correct. Struggling, the anesthesia resident paged for the anesthesia attending. Immediately, the angiography was canceled and instead a chest x-ray was performed.
- Left chest tube had 800 cc of drainage since placement; empiric placement of right chest tube performed with minimal return of blood.
- In search for the cause of the hypotension and hypoxia, the chest x-ray reveals the presence of Unevacuated blood in her left chest and a widen pericardial and mediastinal silhouette and some displacement of in the endotracheal tube. The Cardiac Anesthesiologist arrives and performs a TEE (transesphogeal echocardiogram). A transesophagel echocardiogram is performed by inserting a probe with a transducer down the esophagus rather than placing the transducer on the chest. The transducer picks up the reflected waves and sends them to a computer. The computer interprets the echoes into an image of the heart walls and valves.
- The left chest tube drained 800ml since placement and empiric right chest tube was placed with minimal return of blood. As if the situation could not get worse, then the discovery was made that the patient had a pericardial tamponade. Instinctively, a clam shell incision was performed and 750 to900 ml of blood evacuated from the left chest. At the same time, a pericardial window was performed for a brisk evacuation of blood from the pericardial space. Bleeding also came from the left lower lung due to multiple lacerations. The heart was inspected and the surgeon discovered a hole in the myocardium on the left side near the artioventricular junction. Intense bleeding was occurring at this site, the surgeon instinctively placed his finger over the hole in the heart. The OR nurse remembers the vitals improving once the surgeon placed his finger in the hole of the myocardium. Keep in mind, a continuous supply of blood and blood products were delivered throughout this procedure.Clamshell incision allows easy access for the surgeon to the heart, lungs and major vessels.
- Cutting edge medical care: nothing says love like a finger in your heart. The Cardiac Surgeon on call was notified. All together the surgeons, anesthesiologists, residents, nurses, scrub techs, radiology, perfusionists, and ancillary staff pulled together and collaborated effectively.
- The culprit was a sharp rib fragment which caused the penetrating wounds to the lung and heart. The rib was trimmed back and made round. The full-thickness lacerations involving the left lower lung were dealt with by performing a wedge resection. Due to the nature of the injuries sustained, the patient was coagulopathic. One dose of Factor VII was administered. Factor VII is glycoprotein that is part of the coagulation casacade. Synthesized by the liver, this little single-chain glycoprotein is depenant on an enyzyme called serine protease. Remember hypothermia slows and/or inhibits enzyme activity, thus we keep the room warm. Factor VII is indicated for bleeding or immediately prior to an invasive procedure in patients with significant hypofibrinogenemia (<100 mg/dL).
- Chest tube was placed and the clamshell incision was closed. Patient’s abdomen was packed open and a JP drain placed. Once the patient was stabilized, a pelvic angiogram was performed which revealed several bleeding branches of the internal iliac arties bilaterally; these were gel-foam embolized. The patient was then taken to the surgical ICU.
- BE= Base Excess which denotes an acid/base disturbance
- Incision to close: 2303-0445
- Three days later, the patient was brought back to the operating room. Re-exploration determined that there was no gross contamination in the abdomen, however, an extraperitoneal bladder injury needed to be dealt with. The urologist was requested and repaired the injured bladder. Prior to closing the abdomen, copious irrigation was used and confirmed hemostasis. Confidently the surgeon closed her abdomen with JP drain still in place.
- Because of the high energy impact of the the collision, the patient suffered a soft tissue injury at the Occipitaocervical complex (OCC). The seventh day the patient was returned to the OR. The ligamentous injury to the occipital and atlas region (Atlanto-Occipital Dissociation) was corrected with an open reduction and internal fixation. This injury was intially missed due to previously defined criteria which was disruption over 16mm. The orthopedic spine surgeon and his associates performed a retrospective study and concluded that new criteria of disruption over 9mm would alarm for soft tissue injury. Posterolateral arthrodesis-fusion between two adjacent vertebrae across the lamina and transverse processes.The uppermost cervical vertebra (the atlas) rotates about the odontoid process of the second cervical vertebra (the axis). The joint between the axis and atlas is a pivot type of joint that allows the head turn.
- Survivial of AOD isdependant on prompt diagnosis and adequatetreatment. Failure to recognize AOD will lead to neurologicdeterioration.An article written by orthopedicspine surgeon whowasinvovledwithher care wrote an article suggesting the criteria for AOD diagnosisbechangedfrom 16mm to 9mm
- Patient stayed in the ICU for 2 weeks then transferred to continuing care hospital where she was weaned off the ventilator. Then received aggressive rehab which entails of physical therapists and nurses
- I got to meet the patient. Pateint admitted, while she still had the hardware in, she raced and went into a theme park were she did bungee jumping (5 months after her accident)
- From the day of her accident to the day she returned back to work was 8 WEEKS!!!In retrospect, this recovery is short compared to others, however it was very painful process. She remembers waking up on the fifth week. Frustrated with herself, not able to answer simple questions, not able to walk, and not able to operate her phone.She received excellent care through out all phases: Pre-hospital, ED,OR, ICU, Continuing care, and Neuro rehab. It was said to her during her out-patient phase, “You need to come to terms that you cant do what you used to do.” This statement burn within her and motivated her to push herself harder. She confessed she a rebel and very independent.She shared with me some kind gestures that are etched in her family’s memory forever, like with the ICU nurse took the time to wash and comb her hair and polish her nails. Erin reflected that her life was in other peoples hands…”what if they had a bad day?” “how would that impact my care?” She stated, “I glad everyone worked together for me.”
- She is a dirt racer and mechanic for leisure time. 7 months after her accident she went back and raced, her hardware still in. One of her doctors told her, ”I am not in this business to just to keep you alive…I am in this business to help you return to your normal life again.”
- What makes this case unique is the fact her ISS was 66, not the highest, however this is the highest score assigned to a patient that is walking and talking with no deficits. Actually the Trauma surgeon in charge of her care stated there nothing like this found in medical literature.
- Dr Davis stated that there is nothing like this in the medical literature
- Team work, communication, and collaboration are the reason this young woman is alive today. Despite of the serious injuries, multidisciplinary approach enabled optimal outcomes. Pre-hospital, hospital, and outpatient continuity of care outlines the benefit, which is savings lives and returning quality of life to human being.