Simulation 10: 27 Year-Old Male Trauma Patient

Simulation 10: 27 Year-Old Male Trauma Patient Flow Chart Opening Scenario Section 1 Type: IG Handed off 27 YO male with blunt chest trauma/pulmonary contusions on PC A/C ventilation; PIP = 30 cm H2O, set rate = 15/min, 60% O2, 10 cm H2O PEEP ABG = PO2 = 120 torr 80% O2; exp VT = 495 ml; Pplateau = 25 cm H2O Section 2 Type: DM 3 days later, pt stable and triggering @ 20 breaths/min; ABG on 40% O2 normal; -> spontaneous breathing trial (SBT) Section 3 Type: DM Select spontaneous breathing trial method (either 5 CPAP + 5 PS OR T-tube/trach mask) with 50% O2 Section 4 Type: IG Section 5 Type: DM 20 min into SBT ph = 7.33, PCO2 = 46 torr, PO2 = 71 torr, RR to 28/min; HR 113/min; no dyspnea or labored breathing Recommend D/C vent support, maintain pt on T-tube/trach mask and evaluate for decannulation End

Opening Scenario (Links to Section 1) During a shift change to cover ICU, you colleague hands-off a 27 year-old male patient who was intubated and placed on a ventilator after admission to the ED for blunt chest trauma and pulmonary contusions suffered in an industrial accident. The patient currently is receiving pressure control A/C ventilation with a PIP of 30 cm H2O, set rate of 15/min, 60% O2 and 10 cm H2O PEEP. (Click the Start button below when ready to begin) 2

Information-Gathering Section Simulation Section #: 1 Links from: Opening scenario Links to Section #(s): 2 On your initial patient rounds in ICU, your assessment of this patient would include which of the following? (SELECT AS MANY as you consider indicated in this Section, then click on the Go To Next Section button below to proceed.) Requested Information Data Recent arterial blood gas ph = 7.33, PCO2 = 51 torr, HCO3 = 26 meq/l, PO2 = 60 torr, SaO2 = 90% on 60% O2 and 10 cm H2O PEEP Negative inspiratory force/mip Not done -1 Level of consciousness Patient sedated on propofol (Diprivan) +2 drip; not triggering ventilator Breath sounds Course crackles in all lung fields; +1 decreased BS left lower lobe Recent chest X-ray Patchy peribronchial consolidation with air bronchograms and left lower lobe infiltrates +1 Airway status 8 mm trach tube, properly secured; cuff +2 pressure = 25 cm H2O Rapid shallow breathing index Not done -1 Expired tidal volume 395 ml +1 Deadspace to tidal volume ratio Not done -1 (VD/VT) Patient height and weight patient is 6 ft 2 inches tall, weighs 80 kg +2 Perfect Score: 11 Minimum Pass Score: 9 Score +2 3

Decision-Making Section Simulation Section #: 2 Links from Section #: 1 Links to Section #(s): 3 Three days later, the patient is stable on pressure-limited assist/control ventilation with a PIP = 25 cm H2O and actively triggering breaths at a rate of 20/min, PEEP = 5 cm H2O, FIO2 = 0.40. ph = 7.43, PCO2 = 34 torr, HCO3 = 23 meq/l, PO2 = 89 torr, SaO2 = 97%. Expired VT = 385 ml. Which of the following actions would you now recommend? (CHOOSE ONLY ONE unless you are directed to Make another. ) Action/Recommendation Discontinuing the PEEP Lowering the FIO2 to 0.35 Implementing a spontaneous Physician agrees recommendation breathing trial implemented Maintaining all current ventilator settings Reducing the tidal volume/pip by 1 ml/kg Perfect Score: 2 Minimum Pass Score: 1 Score -1 +2 3-1 Link to Section 4

Decision-Making Section Simulation Section #: 3 Links from Section #: 2 Links to Section #(s): 4 Which of the following methods would you select to initiate the spontaneous breathing trial? (CHOOSE ONLY ONE unless you are directed to Make another. ) Action/Recommendation Switching the ventilator mode to CPAP at 5 cm H2O with 5 cm H2O pressure support Switching the ventilator mode to pressure support at 15 cm H2O with 5 cm H2O PEEP Placing the patient on a trach collar with 50% O2 Switching the ventilator mode to SIMV at a rate of 6/min with 5 cm H2O pressure support Placing the patient on a T-tube with 50% O2 Physician agrees recommendation implemented Physician agrees recommendation implemented Physician agrees recommendation implemented Perfect Score: 2 Minimum Pass Score: 1 Link to Score Section +2 4-1 +2 4 +2 4 5

Information-Gathering Section Simulation Section #:4 Links from Section #: 3 Links to Section #(s): 5 20 minutes into the spontaneous breathing trial, you would evaluate which of the following? (SELECT AS MANY as you consider indicated in this Section, then click on the Go To Next Section button below to proceed.) Requested Information Data Score Pulse oximetry SpO2 = 92% +1 Negative inspiratory force/mip Not done -1 General appearance No dyspnea or diaphoresis evident; minor +2 accessory muscle use Vital capacity Not done -1 Spontaneous tidal volume 350 ml +2 Changes in vital signs RR increased from 19/min to 28/min; HR +2 increased from 98/min to 113/min Cardiac output Not done -1 Arterial blood gas ph = 7.33, PCO2 = 46 torr, HCO3 = 23 +2 meq/l, PO2 = 71 torr, SaO2 = 91% Tracheotomy tube cuff leakage Not done -1 Percent shunt Not done -1 Perfect Score: 9 Minimum Pass Score: 7 6

Decision-Making Section Simulation Section #: 5 Links from Section #: 4 Links to Section #(s): End 30 minutes later, the patient is breathing at a rate of 24/min with no evidence of respiratory distress. The SpO2 is 93% and his spontaneous tidal volume is averaging about 375 ml. Which of the following would you now recommend? (CHOOSE ONLY ONE unless you are directed to Make another. ) Action/Recommendation Discontinuing ventilatory support, removing the trach tube and providing 50% O2 via aerosol mask Providing pressure support ventilation at 10 cm H2O with 5 cm H2O PEEP Providing 10 cm H2O CPAP with 30% O2 and continuing close monitoring Restoring the patient to the preweaning ventilator settings Discontinuing ventilatory support, maintaining the patient on a T-tube or trach mask and evaluating him for decannulation Score Link to Section Physician agrees end of problem +2 End Perfect Score: 2 Minimum Pass Score: 2 7

RTBoardReview Simulation 10 27 Year-Old Male Trauma Patient Condition/Diagnosis: Blunt Chest Trauma (Weaning) Simulation Scoring Individual Scoring (Used for All RTBoardReview Simulations) Score Meaning +2 Essential/optimum to identifying or resolving problem +1 Likely helpful in identifying or resolving problem 0 Neither helpful nor harmful in identifying or resolving problem -1 Unnecessary or potentially harmful in identifying or resolving problem Wastes critical time in identifying problem or causes direct harm to patient -3 Results in life-threatening harm to patient Summary Scoring of Simulation 10 Section IG Max IG Min DM Max DM Min 1 11 9 2 2 1 3 2 1 4 9 7 5 2 2 TOTALS 20 16 6 4 MPL% 80% 66% Cut Score = IG Min + DM Min = 16 + 4 = 20 MPL% = Minimum Pass Level as a percent = (Min/Max) x 100 IG and DM MPL% vary by problem; typically ranges are 77-81% for IG and 60-70% for DM If the IG or DM raw score is negative (e.g., ) then the reported % score = 0 The Cut Score for a problem is the sum of IG Min + DM min To pass a problem, the sum of one s IG + DM raw scores must be the Cut Score 8

Take-Home Points RTBoardReview Simulation 10 27 Year-Old Male Trauma Patient Condition/Diagnosis: Blunt Chest Trauma (Weaning) Chest trauma may result from either penetrating or blunt injury Trauma can include injuries to the ribcage (e.g., flail chest), airways (e.g., laryngeal or tracheal crush injury/fractures), lung parenchyma (e.g., pulmonary contusions) and/or heart/great vessels (e.g., aortic tear) Penetrating chest trauma most commonly is due to knife or gunshot wounds o injury can occur to any thoracic structure o bleeding (e.g., hemothorax) and/or air leakage (e.g., pneumothorax) is common o "sucking" chest wounds initially should be covered with an occlusive dressing (e.g., Vaseline pad) to permit ventilation and help prevent tension pneumothorax o definitive treatment always involves surgical repair Most blunt chest trauma occurs in motor vehicle accidents (MVAs) o Other causes include falls, sports injuries, crush injuries and explosions o injuries are caused primarily by the rapid deceleration that occurs with direct impact or blow to the thorax Respiratory management pointers include the following: Assessment/Information Gathering Because the full effects of pulmonary contusion may not be apparent for 24-48 hours, patients should be admitted and closely monitored, especially for worsening hypoxemia (about 50% of these patients develop ARDS). Recommend diagnostic tests according to type of trauma described in th above table; in addition, recommend CBC, hemoglobin, hematocrit (to assess for blood loss or hemodilution), coagulation tests, and ABGs. Do not recommend chest X-ray or CT scan if clear signs of tension pneumothorax; instead recommend immediate treatment via needle decompression or tube thoracostomy (followed by imaging studies) Fractures of the lower "floating" ribs (11-12) often are associated with diaphragmatic tears and trauma to the liver and/or spleen; recommend abdominal ultrasound (for hemoperitoneum) and CT scan (to assess organ damage). Treatment/Decision-Making Indications for ET intubation in chest trauma patients include apnea, profound shock, and inadequate ventilation. Recommend epidural analgesia for rib cage fracture pain; epidurals allow painless deep breathing and coughing without depressing respiration. Adjunctive measures to recommend in the care of chest trauma patients include early mobilization and aggressive bronchial hygiene therapy (to prevent pneumonia). Do not recommend steroids for treatment of pulmonary contusion. 9

Only recommend mechanical ventilation to correct abnormal gas exchange (with pulmonary contusion), not to treat chest wall instability (flail chest). o Intubation and A/C or SIMV with PEEP is the standard approach. o Recommend trial of mask CPAP or BiPAP for the alert, compliant patient with marginal respiratory status. o Apply NHLBI ARDS protocol if ALI/ARDS develops o Recommend HFOV for patients failing A/C or SIMV with PEEP o Recommend independent lung ventilation for patients with severe unilateral contusion if (a) severe shunting persists or (b) "crossover" bleeding is affecting the good lung. Weaning from ventilatory support o if ALI/ARDS, follow NHLBI ARDS weaning protocol o otherwise apply standard evidence-based SBT weaning protocol Follow-up Resources Standard Text Resources: Des Jardins, T, & Burton, GG. (2011). Flail Chest (Chapter 21). In Clinical Manifestations and Assessment of Respiratory Disease, 6th Ed. Maryland Heights, MO: Mosby-Elsevier. Hicks, GH, & Eckrode, C. (2007). Chest Trauma (Chapter 12). In Wilkins, RL, Dexter, JR, & Gold, PM. (Eds). Respiratory Disease: A Case Study Approach to Patient Care. 3rd Ed. Philadelphia: F.A. Davis. Useful Web Links: American Association for Respiratory Care. (2002). Evidence-Based Guidelines for Weaning and Discontinuing Ventilatory Support. http://www.rcjournal.com/cpgs/pdf/ebgwdvscpg.pdf Eastern Association for the Surgery of Trauma (2012). Practice Management Guideline for Pulmonary Contusion and Flail Chest. http://www.east.org/content/documents/practicemanagementguidelines/management_of_pulmo nary_contusion_and_flail_chest_.13.pdf National Heart, Lung and Blood Institute, ARDS Clinical Network. (2008). Mechanical Ventilation Protocol Summary. http://www.ardsnet.org/system/files/6mlcardsmall_2008update_final_july2008.pdf 10