Monday, September 08, 2003
SOMEDAYS YOU GET THE BEAR......
DocShazam has an excellent post about how a life can be saved during a trauma with a simple intervention.
Shortly after I posted my comment about her post, I had the not-so-simple intervention.
Young man, restrained passenger, death of other occupant. Transferred from referral facility with cerebral contusion, orthopedic injuries, right pneumothorax with chest tube in place and "very bad pulmonary contusions". No mention of hypoxia from referring MD. Arrests twice enroute, probably from hypoxia. Arrives with BP in 90's and SaO2 in the 40's, and it's not a technical problem. CT of abd/pelvis O.K. CT of chest shows two contusions. One takes up 100% of his right lung, the other takes up 90% of his left lung. SaO2 still in 40-50's. Turn the O2 up, increase the PEEP, invert the I:E ratio.....BP falls from adverse effect on cardiac output. "Pressure falling doctor...." Robbing Peter to pay Paul my response. Give some blood, fill the tank, change out a single lumen central line for a multi lumen....turn PEEP down....SaO2 falls. Got breath sounds on both sides....belly still soft. Start the dopamine...CVP in 15-18 range. PEEP back up. Call the intensivist..."Too unstable for the oscillator.." SaO2 70's with BP in low 100's. Now in DIC.... Dopamine to 20 mcgs...
All the while in the ED I'm thinking....
I don't have an operation to save this kid...
Not many things more frustrating for a surgeon than that....
Up to the unit...More packed cells, fresh-frozen, crystalloid.... PA catheter with PAD in the 20's. No SvO2 capability... Due to the Herculean efforts of the ICU team SaO2 in the low 90's on FiO2 of 85 %, Dopamine down to 8mcgs.
In my comment I wrote....
...the "What do I do now?!?" feeling will become more infrequent.....
But it can always come back. The little voices I heard were my trauma attendings ....fluid is your friend.....A then B then C......look for a surgical problem.
There are a lot of times when trauma is no fun at all. |
DocShazam has an excellent post about how a life can be saved during a trauma with a simple intervention.
Shortly after I posted my comment about her post, I had the not-so-simple intervention.
Young man, restrained passenger, death of other occupant. Transferred from referral facility with cerebral contusion, orthopedic injuries, right pneumothorax with chest tube in place and "very bad pulmonary contusions". No mention of hypoxia from referring MD. Arrests twice enroute, probably from hypoxia. Arrives with BP in 90's and SaO2 in the 40's, and it's not a technical problem. CT of abd/pelvis O.K. CT of chest shows two contusions. One takes up 100% of his right lung, the other takes up 90% of his left lung. SaO2 still in 40-50's. Turn the O2 up, increase the PEEP, invert the I:E ratio.....BP falls from adverse effect on cardiac output. "Pressure falling doctor...." Robbing Peter to pay Paul my response. Give some blood, fill the tank, change out a single lumen central line for a multi lumen....turn PEEP down....SaO2 falls. Got breath sounds on both sides....belly still soft. Start the dopamine...CVP in 15-18 range. PEEP back up. Call the intensivist..."Too unstable for the oscillator.." SaO2 70's with BP in low 100's. Now in DIC.... Dopamine to 20 mcgs...
All the while in the ED I'm thinking....
I don't have an operation to save this kid...
Not many things more frustrating for a surgeon than that....
Up to the unit...More packed cells, fresh-frozen, crystalloid.... PA catheter with PAD in the 20's. No SvO2 capability... Due to the Herculean efforts of the ICU team SaO2 in the low 90's on FiO2 of 85 %, Dopamine down to 8mcgs.
In my comment I wrote....
...the "What do I do now?!?" feeling will become more infrequent.....
But it can always come back. The little voices I heard were my trauma attendings ....fluid is your friend.....A then B then C......look for a surgical problem.
There are a lot of times when trauma is no fun at all. |
