Trauma Case Studies: Teamwork

Leading to Great Saves

Presented by: Rex Chung, MD
Trauma & Surgical Critical Care
 Objectives

Describe one decision making challenge that can arise

in caring for the patient with multiple traumatic
injuries.
Name one decision point where nursing can have an
impact on helping save a trauma patients life.
List one diagnostic challenge in caring for trauma
patients.
Case 1
 29F brought in by ambulance after MVC on
freeway requiring extrication, GCS 10 in the field,
complaining of abdominal pain:
-Upon Arrival
-GCS 10 6
-BP 121/85
-RR 21, SpO2: 97%
-Abdominal tenderness and guarding
In ED:
- Intubated
- IV access confirmed
- Secondary survey
- RUQ punctate contusion on exam
- CXR neg
- Pelvic Xray neg
- FAST: + fluid in RUQ

Where should we go?

 Head CT: No acute findings
Chest CT: No acute findings
Abdominal CT:
Liver: AAST Grade V
Pancreas: AAST Grade V
Spleen: AAST Grade I
Duodenum: Laceration with adjacent
hematoma
Management

Taken to the Operating Room

Complete pancreatic transection through head
and neck
Significant segment 4B laceration
3cm hole in D1-2, mesenteric side
Intraoperative consultation with liver transplant
surgeon
Traumatic Pancreatic Transection
Whipple s/p Traumatic Injury
Post Operative Course

- Extubated POD 0
- Bile leak on POD 5
- Taken back to OR on POD 7 for washout,
jejunostomy tube placement and omental patch
to leak from pancreatojejunostomy
- Remained in hospital an additional 3 weeks
with wound infection, intrabdominal fluid
collections
- 3 months after injury, back to baseline
 Whipple s/p Traumatic Injury

Management in the Unit

Nursing care
Examples of teamwork
Outcome
Challenges
Case 2
19M brought in by ambulance after GSW to right flank,
GCS 6 in the field, went into cardiac arrest 1 minute into
transport. Arrived within 4 minutes.
-In field:
- GCS 6 3
- Agonal respirations
- King Airway placed
- BP palpable femoral no palpable pulses
- ETA 5 minutes
- Update, HR went asystolic after 1 minute of
transport

What should we prepare?

 Arrived to ED within 4 minutes in cardiac arrest,
compressions being performed, bagging via King
airway.
-Upon Arrival to ED
- GCS: 3
- BP: no palp pulses carotid pulses
- HR: asystolic
-SpO2: undetectable
-In ED:
- Airway management w ETT intubation
- ED thoracotomy performed
- Massive Transfusion activated
- Level 1 prepped
- L subclavian Cordis CVL placed
- Transfused PRBCs
- Intracardiac Epinephrine
- ROSC
- Communicated to OR of our arrival
 Overview of Aortic Anatomy

-In SICU:
- Ventilator
- s/p ED thoracotomy, chest left open
- Massive Transfusion ongoing
- Level 1 utilized
- Warming measures
- Transfused PRBCs
- ACLS
- Coagulopathic, Acidotic, Hypothermic
- Went into heart failure and expired
approximately 6 hours after initial call.
 Penetrating Aortic Injury

Case overview
Overall management
Overview of important aortic anatomy
 Penetrating Aortic Injury

OR management
Nursing care
Examples of teamwork
Outcome
Challenges
Case 3
 39M Auto vs Pedestrian, reportedly assaulted w
car in parking lot and pinned him against wall,
left leg near-complete amputation. No LOC
reported.
-In field:
- GCS 15
- BP 140/85
- SpO2: 97%
- Isolated left leg mangled extremity
- Thigh tourniquet placed
-In ED:
- GCS 15, responsive and appropriate
- BP: 98/68
- HR: 128
- SpO2: 100% on RA
- Left leg w large bleeding wound, exposed bone
and muscle, no sensation, no movement.
- Left thigh tourniquet in place and wound
hemostatic.
Traumatic Amputation
-In ED:
- Patient judged to be able to protect airway
- IVs placed
- Started blood
- Secondary Survey performed without signs of
other injuries
- CXR, PXR, FAST neg
- Communicated to OR of our arrival
- Communicated to Ortho to meet in OR
-In OR:
- Discussed w patient the possibility of having
amputation
- Placed pneumatic tourniquet above field tourniquet
- Removed the field tourniquet prior to prep and drape
- 3 main arteries to foot completely lacerated
- Popliteal artery exposed and confirmed intact
- Tibeal nerve was completely transected/shredded
- Discussed case w Ortho attending and another
trauma attending and formed a consensus agreement to
proceed w completion amputation.
 Traumatic Amputations

Nursing care
Examples of teamwork
Outcome
Challenges
 Summary

Decision making challenges can complicate patient

care.
Nursing can have an impact on helping save a trauma
patients life.
Teamwork is crucial for improved outcomes.
Questions