Friday, January 06, 2006

Tales From the Trauma Service XIV.....
Twenty-ish year old unrestrained driver in MVC. Airlifted from the scene. Intubated with difficulty in the ED. Difficult to oxygenate with a O2 saturation in the 40 to 50 percent range. Here is the CXR:

After some vent maneuvers such as increasing PEEP and using pressure control ventilation we are able to raise his saturation to the 70 percent range so we can go to CT:

As you can see there were severe contusions bilaterally. No fluid in the posterior and there is no evidence of a pneumothorax. To add to this young man's woes:

He has a severe subdural and subarachnoid hemorrhage (yellow) and a midline shift (blue. The enemies of head injuries are hypotension and hypoxia. After discussion with the neurosurgeon and anesthesiologist the decsion is made to take him to the OR for a craniotomy and chest tube placement. Chest tubes were placed because of the potential for barotrauma with high pressure ventilation. Try as we might, it took about 16 hours to correct his hypoxia. When oxygen is restored to a previously hypoxic organ (or blood flow is re-established) you can get what is known as a repefusion injury. As oxygen is restored there evolved into what could be described as a body wide re-prefusion injury with hypotension that required high levels of pressor support. His neurologic status continued to decline and his family decided to de-escalate his care and he expired on the fourth hospital day.
Again, somedays you get the bear, somedays the bear gets you.


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