Download to read offline
More Related Content
Similar to Anguila panama connection
Anguila panama connection
- 1. ANGUILA-PANAMA The Critical CareConnection
- 2. TRAUMATIC BRAIN INJURY CASEREPORT #1 TJR Dr. Guillermo Castillo Abrego Medical Director Neuro and Critical Care Corp. Critical Care/Internal Medicine Panama
- 3. ABOUT US • Neuro& Critical Care (NCC) is based in Panama-City, Panama’, Neuro and Critical Care (NCC) is a one stop shop of critical care expertise. • Our mission is to supports and provide the highest quality critical care service to patients with life-threatening medical, surgical, neurological condition, promoting the highest standards of multidisciplinary care of critically ill patients and support their families through education, research and professional development. • We offer multidisciplinary professional team of board-certified physicians (intensivists), specialist critical care nurses, respiratory therapists, pharmacists, physical, nutritional and speech therapists, and social workers. • We excel in pro-active care that reduces the probability of complications. • NCC is a key provider to MDabroad Networks and Management in Panama. NEURO & CRITICAL CARE GROUP - NCC PANAMA' 303/11/16
- 5. OBJECTIVES • My goalis to explain our role in the continuum of care offered to critical care cases that begin in Anguilla. • Present our role in two recent trauma cases with different pathologies (Gunshot and Traumatic Brain Injury). • Offer observations & recommendations for improving this treatment relationship. NEURO & CRITICAL CARE GROUP - NCC PANAMA' 503/11/16
- 6. NEURO & CRITICALCARE GROUP - NCC PANAMA' 6 Method of Operation Ongoing Case Communications with all Members of the Care Team, MDabroad Case Manager in Panama’ and Daily Briefing of Family 03/11/16
- 8. CASE #1 • NAME: TJR • GENDER: male • AGE: 26 • ID: 707543706 • DATE: december 20 th
- 9. HX • 26 yearsold young man from Anguilla Islands , who after having a car accident crashing to a fixed object had a head trauma with concussion, periorbital edema, nose bleeding and oral bleeding and progressive lost of consciousness with short of breathiness. He arrived to the local medical facility Hospital in Anguilla, he was with respiratory and cardiovascular instability, tachycardia, tachypnea needing urgent tracheal intubation and with the help of Dra. Vonetta George and her team he had quick stabilization. Once stable and wounds bleedings on control, they prepare an urgent medical transfer. They activate the ICU air ambulance, and transferred to San Fernando´s General Hospital, in Panama that is a level II trauma center.
- 10. PMH: • Cardiopathy (NEG) •Hormon disorders (NEG) • Pneumopathy (NEG) • Gastric/bowel disorders (NEG) • Neuropathy (NEG) • Blood Diseases (NEG) • Allergies (NEG)
- 11. Airway maintenance and cervicalspine protection Breathing: ventilation and oxygenation Circulation and hemorrhage control Exposure/environmental control Disability: Brief Neurologic examinaition Primary survey Resucitation Secundary survey Management Head to toe Examination History: MVT (mechanism of ijnjury, treatment AMPLE Advanced Trauma Life Support algorithm A B C D E
- 12. PHYSICAL EXAM • BP=120/70HR=90 RR=14 Sat=100% • General: mechanical ventilation, well sedated, with IV fluids, and secured with a trauma collar and a hard spine board. • Head Facial edema, periorbital and facial swelling, and bleeding in the nose. • Neck no emphysema or abnormal sounds, no edema, • Thorax: no ribs fractures, no hematoma, no deformities or unstable thorax, Normal heart sounds, lungs with bilateral crackles • Abdomen: No defense and no hematoma. No blood in urinary catheter, no legs deformities. • Neurologic GC 4/15 • Sedated, reaction to pain, reactive pupils in the right eye, ocasionally move the leg • Cranial pair differed • Motor Force 1/5, Reflex0/4, sensorial no assessed.
- 13. ISS = INJURYSEVERITY SCORE Region Head / Neck Face Chest Abdomen Extremity External Injury 1. Minor 2. Moderate 3. serious 4. severe 5. critical 6. survivable ISS 1-8 Minor 9-15 modera 16-24 serious 25-49 Severe 50-74 critical 75 maximum ISS = A2 + B2 + C2
- 14.
- 15. FULL OUTLINE OFUNRESPONSIVENESS
- 16. TERTIARY SURVEY • ECG . normal • CHEST XRAY: Bilateral lungs infiltrates in the bases. Normal mediastinum, aortic arch normal. Cardiac arcs normal. No emphysema or ribs fractures. • CT SCAN HEAD: left Frontal brain contusion, with bilateral brain edema, bilateral subdural temporal hematomas, eye orbit fracture, nose fracture, cribose membrane fracture, zygomatic fracture. • CT THORAX: bilateral base infiltration, no hemothorax, no pneumothorax, small contusion. • CT ABDOMEN: no free air, no macroscopic injuries.
- 17. DIAGNOSTICS: • Brain traumaticInjury 800.00 / 801.9 • Brain Edema 348.5 • Refractary Intracraneal Hypertension • Frontol Parietal Isquemic- Deluxe Reperfusion Injury • syncope 780.2 • lung contusion 861.21 • broncho aspiration pneumonia 507 / 770.18 • Zygomatic-orbital fracture 802.8 • Nose septum fracture 802.0 • cribriform fracture • Hypoglicemia / Hyperglicemia • Burst suppresion brain activity • sinusitis 461 / 473
- 18.
- 19. EARLY CHANGES • DECEMBER21TH: intracranial sensor, ICP=14 • DECEMBER 23TH: EEG Also the Neurophysiologist (Evelia Gomez MD, Neurologist) did an Electroencephalogram EEG today showed occasional peaks and burst of abnormal cortical activity . No status epilepticus.
- 21.
- 22.
- 23. December 30th ICP=30mmHg and fever
- 24. INTRACRANIAL PRESSURE TREATMENTS •Head elevation • Centered head • Normocapnia • Mannitol 20%. • propofol • Hypertonic saline. • Temperature management therapy
- 25.
- 26. Dr. Sierra theNeuroradiologist “the results that the cerebral blood flow was compromised and the arteries has perfusion, but they are narrowed in the right Cerebral Hemisphere, than the left one. And there was a high risk of complete hemispheric infarction in the preliminary results.. There is brain edema , which narrowing the blood flow and is comprimising the penumbra tissue that could be saved.”
- 27.
- 28. THERMOMODULATION MANAGEMENT • Thebody core temperature is decreased to 33 degrees Celsius to decrease the inflammation and secondary injury in the brain. • It has to be very monitorized, and with electrolytes and ABG control to ensure maximum efficacy. • The metabolism is decreased and the acute inflammatory response is decreased.
- 29. MECHANISM Salazar-Reyes H, VaronJ: Hypoxic tissue damage and the protective effects of therapeutic hypothermia. Crit Care & Shock 2005;8:28-31 Abate MG, Cadore B, Citerio G: Hypothermia in adult neurocritical care patiients: a very “hot” strategy not to be hibernated yet. Minerva Anesthesiol 2008;74:425-30 Radicales Libres NT Exitatorios H T Reacciones Enzimáticas Destructivas Acidosis Intracelular Integridad de la Membrana Lipoproteíca
- 30.
- 31. MECANISMOS DE EDEMACEREBRAL DESPUES DE TRAUMA CRANEOENCEFÁLICO. MARMAROU PHD.
- 32. JANUARY 11TH • Theintracranial pressure after the hypothermia decrease in minutes from 30 to 9 and keep in nearly values until the rewarming process (36 hours). 33 grades 37 grades
- 33. CEREBRAL ANGIOTOMOGRAPHY: JAN15TH •Evidence of Deluxe Reperfusion circulation in Right frontoparietal, with some ischemic lesions in parietal area. With improve of narrowing of Right ACM artery in comparison with previous cerebral angiotomography. Distal cerebral blood flow of ACM . Decrease of brain Edema. No herniation sign. •
- 35. JANUARY 25TH • Endotrachealculture showed Pseudomona aeruginosa already treated with meropenem. Was assessed by Infectologist Dr. Ivan Toala.
- 37. APACHE II APACHE II=22 APACHE II =7 JANUARY 5TH FEBRUARY 15TH
- 38. PHYSICAL THERAPY/ RESPIRATORY THERAPY •The last weeks in january and the first of february tyrone had been improving his functions. The grapping function, the swallowing, and trying to stand up were promoted in the neurorehabilitation.5 5 3
- 39. RECOMMENDATIONS • The patientmust continue with physical therapy to ensure the most recovery in the first year. • The disability score must be assessed and recorded. • The physical therapy must be directed to neurological therapy and functional activities. Mainly with the 3 important function: grasp, language and standing. • He must continue with thrombosis prophylaxis until he start to move out of the bed. • The phonetics has to be practice, trying to name and identify, and vocalize words.
- 40.
- 42. CASE #2 • PatientName: AC • Date of Birth: April 27, 1992 • Age years old: 23yold • Hospital : San Fernando Hospital • Date of admission: December 23th
- 43. HX • Mr. A.C.is a 23 years old man who in December 22th received a gunshot injury through his neck with acute moderate bleeding and short of breathiness, he was received by the trauma team in The Princess Alexandria Hospital in Anguila by Dra. Vonetta George part of the trauma team, who secure the main airway, and evidenced a visible wound at superior⅓ portion of the medial border of the right sternocleidomastoid muscle , with evidence or air bubbles and crepitus on palpation. The surgical team quickly secure the thorax with a chest tube, It was transferred monitorized and with to Hospital San Fernando, directly to the ICU unit.
- 44. PMH: • Cardiopathy (NEG) •Hormon disorders (NEG) • Pneumopathy (NEG) • Gastric/bowel disorders (NEG) • Neuropathy (NEG) • Blood Diseases (NEG) • Allergies (NEG)
- 45. PHYSICAL EXAM • IntubatedSedated. with Benzodiacepine Drip. • GCS 4/15 NRPupils Not Neurological Deficit. Not focalization. Patient mobilized 4 extremities. • ORL: Sialorrea with blood. Neck and Facial Subcutaneos Enfisema . • Cardio: Sinusal Rhythm without vasopressor drip. • Respi: in Mechanical Ventilation Control Assist. • Chest: With Right Chest Tube with Oscillating water Column • Abdomen: Bowels Sounds normal. Without pain . • Renal: Urinary Catheter Foley with Adequate urinary output. • Neurologic: sedated, entubated, flexion to pain, not decortication, pupilary light response, réflex normal 2/4 and no pathologic réflex. No meningeal signs.
- 46. MEDICAL DIAGNOSIS: • NeckGun Shot Wound • Tracheal Injury T!- T2 • Esophageal Injury • Mechanical Ventilation • Massive left lung atelectasia • Right Neumotórax • Facial Subcutaneous Enfisema. • Left Pneumonia
- 47. Sequential Organ FailureAssessment (SOFA) APACHE: 16 SOFA: 4
- 48. ISS = INJURYSEVERITY SCORE Region Head / Neck Face Chest Abdomen Extremity External Injury 1. Minor 2. Moderate 3. serious 4. severe 5. critical 6. survivable ISS 1-8 Minor 9-15 modera 16-24 serious 25-49 Severe 50-74 critical 75 maximum ISS = A2 + B2 + C2
- 49. MANAGEMENT • December 24,2015 • Patient had been taken to Neck Angiotomography with Contrast: There was evidence of Tracheal injury from C7 to T2. Probably Esophageal Injury. • Gastroenterologist made a endoscopy with evidence of injury 4-5cm below Cricopharyngeal Cartilage, left and posterior side. Patient had been taken to operation Room with Cardiovascular (Dr Miguel Guerra) and General Surgeons (Dr. Jorge Martin). • The Tracheal Injury had been repaired and through transoperative esophagoscopy there was evidence of erythema but not perforation of the esophagus. Had been placed a periesophageal Drain. Surgical Gastrostomy and Tracheal repair.
- 51. MANAGEMENT • December 25,2015. • Patient sedated intubated on mechanical ventilation. • 125/60 HR=86 RR14 Sat 98% GCS 3/15 • ORL ok without secretions. • Cervical dress clean without bleeding spot • Chest: With chest tube oscillating column, some roncus. • Gastrostomy. Ok. • Abd: receiving omeprazole for ulcer prophylaxis. We discuss with the General Surgeon start the enteral.nutrition through gastrostomy with additional supplement of Vit C for healing Wound. • Renal: adequate urinary output more 0.5cc/kg/hr •
- 52. COMPLICATIONS: MASSIVE ATELECTASIS •December 27, 2015 • 146/60 fr 24 HR 98 sat 100 GCS 3/15 • Sedated intubated with midazolam and fentanyl drip. • ORL: Abundant secretions • Cardio sounds normal • Respi: Breathing sound decrease of left ventilatory sound. No air entrance • Respiratory Accessory muscles use and tachypnea.
- 53. COMPLICATIONS • Anesthesia (DrEspinosa and Russell Batista) and Cardiovascular has been consulted for massive left atelectasia. • Multiples active nebulization had been administered with SBT + atrovent+pulmicort, mucosolvan and oral n acetylcysteine • The endotracheal tube had been removed 2 cm. • And recruitment maneuver (40/40) had been administered without clinical improve. • Had been placed a consult to Pneumology (dr Victor Pinzon) for Bronchoscopy . • During Bronchoscopy there was evidence of mucus plug and abundant secretions + secretions culture had been taken. •
- 54. With evidence ofmucous plug left distal bronchial. After bronchoscopy improve of both segmentals bronchioles.
- 55. JANUARY 5TH: • thepatient is awake, collaborative, conscious, tolerating nutrition, and with less cough. He has no fever and the neck drainage was taken out. He is tolerating deambulation and eating by oral means. Wound healing normal and still with the gastrostomy. Lungs normal. • Assessment: the patient will continue Physical Therapy and Respiratory Therapy in the Ward Room and will continue with oral nutrition advancement . • He was transferred to the hospital room
- 56. RECOMMENDATIONS • The patientmust be seen with his doctor if presents dysarthria or chronic cough. • He needs phonoaudiology therapy if there are problems with breathing.
- 58.