1 / 42

ARDS in Trauma

ARDS in Trauma. 30 y/o male (note eyes covered to protect identity). 2 Dudes (Probably these two). H&P. CC: s/p MVA HPI: pt 30y/o male in comes to the ED after an MVA with multiple injuries PMHx/PSHx: insignificant Meds: none Allergies: none. Physcical Exam. BP 110/85, HR 115, RR 32

kenyon-anthony
Download Presentation

ARDS in Trauma

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. ARDS in Trauma

  2. 30 y/o male(note eyes covered to protect identity)

  3. 2 Dudes(Probably these two)

  4. H&P • CC: s/p MVA • HPI: pt 30y/o male in comes to the ED after an MVA with multiple injuries • PMHx/PSHx: insignificant • Meds: none • Allergies: none

  5. Physcical Exam • BP 110/85, HR 115, RR 32 • Neuro: in C-collar, GCS 10 (E3V3M4) • CVS: tachycardic, • Resp/chest: dyspnea, tachypneic, tenderness on right chest, CTA bilat, decreased inspiratory excursion • ABD: nondistended, soft, tender in right upper quadrant • EXT: 18g IV in left AC and 16g IV right AC, moves all 4 ext, deformity of left thigh, tender to palpation, pulses intact

  6. Glasgow Coma Scale • Eyes spontaneous, command, pain, none • Verbal oriented, confused, inappropriate, inconprehensible, none • Motor obeys, localizes, withdraws, flex, extension, none

  7. Physcical Exam • BP 110/85, HR 115, RR 32 • Neuro: in C-collar, GCS 10 (E3V3M4) • CVS: tachycardic, • Resp/chest: dyspnea, tachypneic, tenderness on right chest, CTA bilat, decreased inspiratory excursion • ABD: nondistended, soft, tender in right upper quadrant • EXT: 18g IV in left AC and 16g IV right AC, moves all 4 ext, deformity of left thigh, tender to palpation, pulses intact

  8. Injury Survey • Small subdural hematoma over right frontal lobe • Right sided rib fractures 5-8 • Lung contusion • Liver contusion • Left femur fracture

  9. Operating Room • Ventilator 10 cc/kg, 10 Resp/min • Isoflurane • Arterial line and introducer • Four units packed red blood cells • Conservative mx for liver • Off to SICU for continued mx

  10. All in a days work

  11. Lung Injury • Range of entities • Local not clinically significant • Unable to exchange gases across mebranes and participate in respiration • Somewhere in between

  12. Inflammation • Blunt injury • Neutrophiles • Cytokines • Macrophages • Complement Cascade • Coagulation Cascade

  13. Normal Lung Tissue

  14. Exudative Phase • Starts early. • Interstitial and alveolar edema • Hyaline membrane formation • Endothelial cell damage • Type I cell necrosis • Infiltration with neutrophiles

  15. Diffuse Alvolar Damage

  16. Proliferation Phase • Type II cells increase in number • Type II cells can become Type I cells

  17. Fibrotic Stage • Fibroblasts • Myofibroblasts • Collagenation • Arteriolar hypertrophy • Obliteration of pulmonary vasculature

  18. Late Diffuse Alveolar Damage

  19. Neutrophiles • Already there… • Secrete toxins… • Connected for activation… • Protected from deactivation… • Location, Location, Location…

  20. Map to the Neighborhood

  21. Macrophages • Killing machines • Keep going and going and going… • Complement • IL-1, -6, -8 • TNF • Impaired judgment?

  22. Endothelium • Express cytokines • Secrete vasoactive substance • Procoagulant • Metabolically active

  23. Phospholipids • On all cells • Great cellular messenger • Makes more cellular messengers • Arachadonic acid • Thromboxane • Prostacylin • PAF

  24. Pulmonary Edema • Hydrostatic pressure • Oncotic pressure • Lymph system • Increase distance from capillary lumen to alveolar lumen • Pulmonary hypertension • Hypoxemia • Lung compliance decreases

  25. Diffuse Alveolar Infultrates

  26. Patchy Densities

  27. Phase 1 • Dyspnea • Tachypnea • Normal CXR • Hypoxemia • Hypocarbia • Neutrophiles

  28. Phase 2 • Changes on CXR • Changes on PE • Pulmonary Hypertension • Change in pulmonary mechanics • Microscopic lung changes/damage

  29. Phase 3 • Worse CXR • Worse PE • Worse cardiopulmonary mechanics • Decreased hemoglobin oxygen extraction • Occlusion of vessels

  30. Phase 4 • Diffuse infiltrates with superimposed pneumonia • Sepsis • MOF • More lung impairment • Cellular changes in the lung

  31. Diagnosis of ARDS • Diffuse alveolar infiltrates on CXR • Noncardiogenic pulmonary edema • PaO2/FiO2 ratio <200 • 12-39% Trauma Population • Mortality 25-30%

  32. Shock Gastric aspiration Pulmonary contusion Near-drowning Fractures Smoke inhalation Multiple transfusions Fat embolism Pneumonia Sepsis Injury severity score > 16 Blunt injury Trauma score < 13 Surgery to head +/- admission lactate, pH, base deficit, serum bicarbonate Disseminated intravascular coagulation Risk Factors

  33. Injury Severity Score • Head and Neck • Face • Chest • Abdomen • Extremity • External

  34. Trauma Score • Glasgow Coma Scale • Systolic Blood Pressure • Respiratory Rate

  35. Strategy • Spontaneous respiration • Noninvasive positive pressure • Beware oxygen toxicity • Fluid balance • Treat underlying causes

  36. Ventilator Strategies • High PEEP early – 16 cm H2O • Watch plateau pressure <35 cm H2O • Low tidal volume – 6-8 cc/kg • Be careful with manual ventilation • Hypercapnia • Pressure controlled ventilation

  37. For Longer Term Care • Treat underlying infections • Proning • ECMO • Trach ‘em early • NO! • Steroids?

  38. Bibliography • 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 • 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. • 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.

  39. Bibliography continued • PEEP in ARDS – How much is enough? Levy M. M. N Engl J Med 2004; 351:389-391, Jul 22, 2004 •  Medical Progress: The Acute Respiratory Distress Syndrome. Kollef M. H., Schuster D. P. N Engl J Med 1995; 332:27-37, Jan 5, 1995. •  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

  40. More Bibliography • Medical Progress: The Acute Respiratory Distress Syndrome. Ware L. B., Matthay M. A. N Engl J Med 2000; 342:1334-1349, May 4, 2000. • Effect of age on the development of ARDS in trauma patients.Johnston CJ - Chest - 01-AUG-2003; 124(2): 653-9 • Glucocorticoids and acute lung injury.Thompson BT - Crit Care Med - 01-APR-2003; 31(4 Suppl): S253-7 • 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

  41. Bibliography Continued • Management of post traumatic respiratory failure.Michaels AJ - Crit Care Clin - 01-JAN-2004; 20(1): 83-99, vi – vii • Matox, Feliciano, Moore. Trauma Fouth Edition. McGraw-Hill 2000. Pages 1309-1339. • Beers and Berkow. The Merck Manual of Diagnosis and Therapy Seventeenth Edition. Merck and Co. 1999. Pages 551-555. • Fauci et al. Harrison’s Principles of Internal Medicine Fourteenth Edition. McGraw-Hill 1998. Pages 1483-1490. • WWW.ARDSNET.ORG • Medical pictures from Up To Date.

  42. Thanks for a fun morning!

More Related