10/27/2014. An experience that causes physical, emotional, or psychological distress or harm.
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1 Ann Marie Szoke, DNP, CRNP Supervisor Advanced Practitioners St. Luke s University Hospital To review multiple traumatic events through case presentations Discuss the concept of the Hybrid Operating Room Discuss the role of the Advanced Practitioner in caring for the Trauma patient with multiple injuries as a member of the trauma team. An experience that causes physical, emotional, or psychological distress or harm. It is an event that is perceived as a threat to one s safety or to the stability of one s world. U.S. National Library of Medicine 1
2 As we men in medicine grow in learning we more justly appreciate our dependence on each other. The sum total of medical knowledge is now so great and wide spreading that it would be futile for any one man to assume that he has even a working knowledge of any part of the whole THE BEST INTEREST OF THE PATIENT IS THE ONLY INTEREST TO BE CONSIDERED, AND IN ORDER THAT THE SICK MAY HAVE THE BENEFIT OF ADVANCING KNOWLEDGE, UNION OF FORCES IS NECESSARY it has become necessary to develop medicine as a cooperative science; the clinician, the specialist, and the laboratory workers uniting for the good of the patient, each assisting in the elucidation of the problem at hand, and each dependent upon the other for support. Dr. Wm. Mayo, Rush Medical College 1910 None I have received permission form all four patients to discuss their events and utilize their radiographic findings for educational purposes. 2
3 Trauma Alert : 2/4/14 8:00 a.m. 22 y/o female MVC Level B arrival 7 minutes Restrained Driver Head on collision, involving another car One of multiple trauma s in the bay at the same time Prolonged Extrication Flown in by Pennstar Vitals stable during flight A: patent B: CTA C: 2+ carotid, 2+ femoral D: GCS 15-4/5/6, positive C spine, T spine and L spine tenderness E: + seatbelt signs, Discoloration of right foot. 3
4 FAST: negative CXR multiple rib fractures b/l. Right Knee Xray Tender: + Chest, and rib cage + Abdomen in all 4 quadrants + Entire T/L spine + Left Hip + Right Knee Abrasions: Seat Belt sign Laceration: Right Lateral Knee Discoloration: Right Foot, + PT 4
5 Allergies: NKDA Medications: MVI PMHx: None PSHx: s/p tonsillectomy Last meal: 2/13/14 at 10:30 pm pasta Events: Head on collision, LOC? 5 cars involved. Restrained driver. SHx: No smoking/drinking/drugs Vital signs: HR 99 BP 143/80 RR 20 SpO2 98% on 2L Awake and talking with us as going to cat scan. 5
6 6
7 Team assembly Trauma Laparotomy -Packing/Explore - Findings: Small Bowel Perforation Resection : Grade 2 Splenic Laceration Splenectomy : Transverse colon serosal tear Primary repair ****Zone 1 Retroperitoneal hematoma - Vascular 7
8 8
9 Extubated Pain Control Hemoglobin/Hematocrit 11/34 Cr 0.5 ASA/Plavix Diet Advanced Pain Control ASA/Plavix Held Platelets: 1 unit TLSO Brace - Cast Shoe 9
10 Psych Consult Acute Stress Disorder Pain optimization Diet TLSO Cast shoe Ortho-Outpatient Right Calcaneal Fracture repair 2/17/14 Discharge 2/15/14 10
11 11
12 Post-op day 16 since Trauma Alert Dispositon Planning Plavix/ASA TLSO Brace WBAT on LLE, NWB RLE F/U with Trauma/Neuro/Vascular/Ortho/Psych Preop Diagnosis: MVC Level B Alert Hospital Diagnosis: 1. Abdominal Aortic transection s/p EVAR 2. Grade 2 Splenic Laceration s/p Splenectomy 3. Small Bowel Perforation s/p resection 4. Transverse colon serosal tear s/p primary repair 5. T12 Vertebral body fracture: s/p Min Perc T11-L1 instrumentation 12
13 6. B/L ribs R 3-7, L 4-6 fractures: Nonpain, pain control 7. Right calcaneal fracture s/p ORIF 8. Sternal fracture non-op 9. B/l occult PTX Resolved Phalanx fractures Left 1 st /4 th non-op 11. Acute Stress Disorder stress relief techniques 12. Abdominal wall hematoma / abrasions: resolving NONE SO FAR ****** MVC s and SBS in 2yr period 671 patients 11.3% SBS in MVC s Restraints 20% Sharma et al. AM surg
14 SBS/Restraints vs Control ISS Mortality 1.1% 5.7% Rib fx 26% 11% HVI/SOI 8/17% 1/3% Splenic Trauma 9.7% 0.4% 14
15 It is a surgical theatre equipped with advanced medical imaging, ie: CT scanners, C-arm, MRI capabilities Allows different areas of problems and concerns to be addressed at the same time. Combination of IR suite and OR State of the art operating room providing a modern OR, interventional radiology lab, vascular, orthopedic and complex cardiac procedures. Interventions done Splenectomy Small Bowel Resection TVAR of Abdominal Aorta ORIF of T-spine ORIF of Right Calcaneous 15
16 Discharge Instructions: Patient sent home with patients with home services Fractures all healing well Follow up visits with Orthopedics, Neurosurgery, Trauma and Vascular Surgery Long term issue of Pain Management. 22 y/o male S/P MVC Unrestrained passenger, Fatality at scene Trauma admission 8/23/14 Prolonged extrication 16
17 One of multiple Trauma s, 3 total in the bay One other was fiancé of brother (fatality) Third patient was driver of opposite car B/P 136/86 HR 134 RR 22 O2 sat 94% GCS - E=4 V=5 M=6 Alert and oriented Scalp Laceration Dentition intact Tachycardia C-collar on C-spine non-tender Abdomen soft 17
18 FAST neg CXR neg HCT neg CT C-spine neg Right Femur xray positive fracture Pelvis xray Left acetabular fracture CT Chest/Abdomen/Pelvis: Right Pneumothorax, Left Hemothorax, Adrenal Hematoma, Splenic laceration, Liver Laceration, Left Kidney Laceration, Thoracic Aortic Injury 18
19 Echo 55% to 65% Ct Chest thoracic aortic dissection 19
20 Transfer from ICU to Trauma Floor Pain Management Physical Therapy / Occupational Therapy Temperature Spikes overnight only Numerous sets of blood cultures and urine cultures, repeat chest xrays over a 2 weeks period Almost ready for transfer to Acute Rehab 20
21 Duplex done Repeat CT scans, especially of the abdomen and pelvis ALL results come back Negative. Decision to transfer to Acute Rehab Fevers have resumed, chills present Doesn t feel well Orthopedics consulted to see patient Wounds re-evaluated Ct scan of abdomen and pelvis re-ordered (last scan 3 days prior) ***Different reading: Hyperdense focus Left Iliopsoas muscle 14 x 19 mm adjacent to acetabular fixation hardware. Radiology asked to re-read CT scan done 3 days prior to discharge, On review, same conclusion obtained. Ortho takes T.L. to Or for a washout and closure. Therapy resumed, and discharged home 4 days later Seen in outpatient office in 1 week, doing well. 21
22 J.T. 18 y/o Female, student 7/27/14 Level A trama c/o I can t breathe Was sitting on an inner tube while being pulled by a boat on a river Came around a turn, she flew off the tube and into a tree Initial GCS had been a 15 and then declined to 13,12 Felt nauseous and confused Very anxious, unable to follow simple commands PMH, PSH, allergies, medications, social hx, family fx all unable to attain. 22
23 ABC s intact GCS 13 E4 V4 M5 122/ temp 100% O2 sat Alert C-collar is on Tachycardia, crepitus right chest wall Guarding of upper abdomen Tenderness in suprapubic region Pelvis stable Accurate N/V exam difficult due to mental status Distal pulses palpable HCT neg for hemorrhage, air in right lateral neck and retropharyngeal tissue FAST -? Free fluid CXR PTX, Pneumomediastinum, right posterior rib fractures, right midlung contusion CT C-spine neg CT Chest right 5-8 rib fractures, right pneumothorax, right kidney contusion, Grade IV liver laceration 23
24 24
25 Utilized the IR portion of the room with the ability to do emergency surgery should something have progressed during the procedure Able to be discharged 7 days later Solid organ injury restrictions Unable to return to school 24 y/o male Motorcycle vs auto Level B trauma Vital signs stable in the field and trauma bay 25
26 GCS 15, E4 V5 M6 Airway intact, however some difficulty with deep breaths on left side, slightly decreased breath sounds on left Deformity left arm and severe deformity of Left leg. Neurovascular status intact. CXR left pneumothorax, midlung contusion CT Left arm comminuted fracture of the humerus L tib/fib xray non-displaced left fibular diaphysis fracture HCT neg CT C-spine neg CT abd/pelvis splenic laceration, b/l acetabular fractures CTA splenic laceration with active extravasation and multiple intussescptions and no bowel obstruction. CTA of Lower extremity diffuse spasm of left superficial femoral artery with 3 vessel continuous run off. 26
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28 Use of C-arm left hand had a closed reduction of 4 th & 5 th metacarpal fractures Fixation of L femur Splenectomy Plan of care since still hospitalized is Physical therapy, Occupational therapy Place in SNF rehab NWB left upper extremity and b/l lower extremities 28
29 You have the marrying of two areas with distinct and different problems and concerns. This room gives you the integration of interventional and surgical techniques such as angiography and imaging capabilities. The Hybrid Room combines a conventional surgical part including a skin incision with an interventional part using some sort of catheter based procedure guided with fluoroscopic of MRI imaging with interruption. 29
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