Question

Brief Patient History

Mr. A is an 18-year-old 80-kg African American man admitted to the intensive care unit after emergency surgery

for gunshot wounds to the abdomen. The surgical procedure was extensive and involved repair of a perforated

bowel, splenectomy, and hemostasis. Mr. A’s mean arterial pressure (MAP) dropped below 65 mm Hg during

resuscitation, and he received 9 units of packed red blood cells and 4 L of lactated Ringer solution intravenously

(IV) to achieve hemodynamic stability.

Clinical Assessment

Within 24 hours of admission to the unit, Mr. A becomes extremely short of breath with an increase in respiratory

rate of 44 breaths/min. Crackles, rhonchi, and bronchial breath sounds are heard bilaterally, whereas on

admission, breath sounds were clear with a few crackles in the bases. Arterial blood gas (ABG) analysis reveals a

PaO

2

of 56 mm Hg, PaCO

2

of 33 mm Hg, pH of 7.52, HCO

3

-

level of 34, and O

2

saturation of 84%. Mr. A was

intubated and placed on synchronized intermittent mandatory ventilation (SIMV) with an FiO

2

(fraction of

inspired oxygen) of 60%, tidal volume (VT) of 400 mL, and 5 cm of positive end-expiration pressure (PEEP).

Despite sedation, Mr. A becomes extremely restless, diaphoretic, and tachypneic at 36 to 44 breaths/min. His

breathing is not synchronous with the ventilator, which is causing him to fight, or “buck,” the ventilator. The

high-pressure alarm on the ventilator sounds frequently, and he steadily becomes more hypoxic. His FiO2 is increased to 80%, and PEEP is increased to 10 cm to keep his PaO2 above 60 mm Hg. Mr. A is started on a Norcuron (vecuronium) and Ativan (lorazepam) IV infusion.

Diagnostic Procedures

The current chest radiograph reveals complete opacity or a “white-out” appearance of the lungs. The chest

radiograph in the emergency department was clear, and the chest radiograph immediately after surgery revealed

bilateral patchy infiltrates that had a “ground-glass appearance.” ABG analysis: pH of 7.48, PaO2 of 60 mm Hg, PaCO2 of 65 mm Hg, HCO3- level of 28 mEq/L, and O2 saturation of 90% on an FiO2 of 80%. Current vital signs are blood pressure of 118/76 mm Hg, heart rate of 112 beats/min (sinus tachycardia), respiratory rate of 16 breaths/min, and temperature of 100.8F. Urine output is 30 mL/h, and peripheral pulses are palpable. Hematocrit is 24%, hemoglobin is 8 g/dL, lactate level is 3 mmol/L, and white blood count is 12,000/mcL.

Medical Diagnosis

• Gunshot wound to abdomen; bowel resection

• Splenectomy

• Acute respiratory distress syndrome (ARDS)

• Patient-ventilator dyssynchrony

Question

1. What interventions must be initiated to monitor, prevent, manage, or eliminate the problems and risks identified?

Answer 1

1. What interventions must be initiated to monitor, prevent, manage, or eliminate the problems and risks identified?

Ans:-

Depending on Medical Diagnosis it describes complete intervention. Prevention, eliminate the problems, Management and Risk factors.

1.Gunshot Wound to the Abdomen

How are injuries from a GSW diagnosed?

A gunshot wound (GSW) to your abdomen may cause damage to your liver, stomach, intestines, colon, or spine. It may also cause damage to your kidneys, bladder, or other structures in your abdomen. Your healthcare provider will examine your body to check for injury. He will look to see if there are an entrance and exit wound from the bullet. You may need any of the following tests to diagnose the damage caused by your GSW:

• An x-ray, ultrasound, CT, or MRI may show damage to your heart, lungs, spine, abdominal organs, or blood vessels. It may also show where the bullet is. You may be given contrast liquid to help your organs or blood vessels show up better in the pictures. Tell the healthcare provider if you have ever had an allergic reaction to contrast liquid. Do not enter the MRI room with anything metal. Metal can cause serious injury. Tell the healthcare provider if you have any metal in or on your body.
• Blood and urine tests will show infection and kidney function, and give healthcare providers information about your overall condition.
• An endoscopy may show damage to your esophagus, stomach, or small intestines. Small damages may be repaired during an endoscopy.
• Surgery may be needed to find damage or where you are bleeding from.

How is a minor GSW treated?

A GSW may be minor if it does not go deep into your skin or damage any of your organs. Your healthcare provider may or may not remove the bullet. He may clean your wound and close it with stitches or staples.

How is a severe GSW treated?

You may need any of the following:

• Medicines may be given to treat pain and prevent infection. You may be given a tetanus shot. Tetanus is a severe infection caused by bacteria. Tell your healthcare provider if you have had the tetanus vaccine or a tetanus booster within the last 5 years.
• A blood transfusion may be given if you have bled heavily from your GSW.
• IV fluids may be given to prevent dehydration and increase blood flow to major organs.
• A nasogastric tube may be inserted to remove air, fluid, or blood from your stomach. A nasogastric (NG) tube is a long, thin, flexible tube inserted through your nose and down into your stomach or small intestine.
• An endotracheal tube may be inserted to help protect your airway and help you breathe. An endotracheal (ET) tube is a hollow plastic tube that is placed in your trachea through your mouth. The trachea is also called the windpipe or airway. The ET tube is attached to a machine called a respirator. A respirator gives you oxygen and breathes for you when you cannot breathe on your own.
• Surgery may be needed to repair damage to organs or blood vessels. It may also be needed to clean your GSW or remove the bullet. Your healthcare provider can close your GSW with stitches or staples, or leave it open. Your GSW may need to be left open to allow swelling to decrease and tissues to heal.

How can I care for myself after a GSW to the abdomen?

• Take short walks. Walk two to three times per day. This may help prevent blood clots and help you heal faster.
• Do not lift anything heavy. Heavy lifting may place too much stress on your wound. Ask your healthcare provider how much weight you can lift.
• Sleep in a comfortable position. Do not lie on your injured side. Sleep with your head propped up on pillows. This may make breathing more comfortable.
• Use a pillow when coughing or moving. Press a pillow gently against your wound when you need to cough or move. This may decrease your pain.
• Perform wound care as directed. Remove your dressing before showering unless your healthcare provider tells you not to. Do not soak your GSW. Let your wound air dry. Apply a clean bandage as directed. Change your bandage if it becomes dirty or wet. Monitor your wound for signs of infection such as redness, swelling, or pus.
• Get support. It is normal to have difficult and unexpected feelings after a GSW. You may have feelings such as anger, depression, fear, or anxiety. You may have nightmares or continue to think about what has happened. Talk to your healthcare provider if you have any of these feelings. Treatments are available to help you.

How can I care for myself after a GSW to the abdomen?

· Take short walks. Walk two to three times per day. This may help prevent blood clots and help you heal faster. Do not lift anything heavy. Heavy lifting may place too much stress on your wound. Ask your healthcare provider how much weight you can lift.

· Sleep in a comfortable position. Do not lie on your injured side. Sleep with your head propped up on pillows. This may make breathing more comfortable. Use a pillow when coughing or moving. Press a pillow gently against your wound when you need to cough or move. This may decrease your pain.

· Perform wound care as directed. Remove your dressing before showering unless your healthcare provider tells you not to. Do not soak your GSW. Let your wound air dry. Apply a clean bandage as directed. Change your bandage if it becomes dirty or wet. Monitor your wound for signs of infection such as redness, swelling, or pus. Get support. It is normal to have difficult and unexpected feelings after a GSW. You may have feelings such as anger, depression, fear, or anxiety. You may have nightmares or continue to think about what has happened. Talk to your healthcare provider if you have any of these feelings. Treatments are available to help you.

Management:-

· Eat foods that are easy to swallow and digest. These usually consist of soft, moist foods such as soup, gelatin, pudding, and yogurt.

· Avoid gummy foods such as bread and tough meats, as well as spicy, fried, or gas-producing foods.

· Bowel Function. After surgery, your caregivers will frequently ask whether you have passed gas. This is because passing gas is a sign that your bowels are returning to normal. You may not have a bowel movement for four to five days following surgery.

Treatment:-

Treatment of a gunshot wound to the abdomen may include bandaging, direct pressure and use of an occlusive dressing. The location of the wound and the patient's overall condition will influence specific treatment, including fluid administration

A gunshot wound (GSW) is physical trauma caused by a bullet from a firearm. Damage may include bleeding, broken bones, organ damage, infection of the wound, or loss of the ability to move part of the body.

Prevention:-

Body armour

Body armour offers some protection against injury from high-velocity weapons but has considerable limitations. The protection offered is graded I to IV. By and large, I and II will protect against handguns but assault rifles and other high-power weapons require ceramic tiles to give grade III or IV. Like mediaeval armour, they are rather heavy and cumbersome.

Important Points to Remember Do not elevate legs to treat for shock if the gunshot wound is above the waist (unless the gunshot wound is in the arm). Gunshot wounds to the abdomen and chest will bleed more quickly once the legs are elevated, making it harder for the patient to breathe. Let conscious patients sit or lie in a position most comfortable for them. Unconscious patients should be placed in the recovery position. Never give the patient anything to eat or drink, including water. Gunshot wounds are puncture wounds and are typically treated the same. Don't expect to be able to tell the difference between entrance and exit gunshot wounds. There's a myth that one type is significantly worse than the other. There's no reliable way to tell and it doesn't matter.

2. Splenectomy

Splenectomy is a surgical procedure to remove your spleen. The spleen is an organ that sits under your rib cage on the upper left side of your abdomen. It helps fight infection and filters unneeded material, such as old or damaged blood cells, from your blood.

The most common reason for splenectomy is to treat a ruptured spleen, which is often caused by an abdominal injury. Splenectomy may be used to treat other conditions, including an enlarged spleen that is causing discomfort (splenomegaly), some blood disorders, certain cancers, infection, and noncancerous cysts or tumors.

Splenectomy is most commonly performed using a tiny video camera and special surgical tools (laparoscopic splenectomy). With this type of surgery, you may be able to leave the hospital the same day and recover fully in two weeks.

Why it's done

Splenectomy is used to treat a wide variety of diseases and conditions. Your doctor may recommend splenectomy if you have one of the following:

• Ruptured spleen. If your spleen ruptures due to a severe abdominal injury or because of an enlarged spleen (splenomegaly), the result may be life-threatening, internal bleeding.
• Enlarged spleen. Splenectomy may be done to ease the symptoms of an enlarged spleen, which include pain and a feeling of fullness.
• Blood disorder. Blood disorders that may be treated with splenectomy include idiopathic thrombocytopenic purpura, polycythemia vera and thalassemia. But splenectomy is typically performed only after other treatments have failed to reduce the symptoms of these disorders.
• Cancer. Cancers that may be treated with splenectomy include chronic lymphocytic leukemia, Hodgkin's lymphoma, non-Hodgkin's lymphoma and hairy cell leukemia.
• Infection. A severe infection or the development of a large collection of pus surrounded by inflammation (abscess) in your spleen may require spleen removal if it doesn't respond to other treatment.
• Cyst or tumor. Noncancerous cysts or tumors inside the spleen may require splenectomy if they become large or are difficult to remove completely.

Your doctor may also remove your spleen to help diagnose a condition, especially if you have an enlarged spleen and he or she can't determine why.

Risks

Splenectomy is generally a safe procedure. But as with any surgery, splenectomy carries the potential risk of complications, including:

• Bleeding
• Blood clots
• Infection
• Injury to nearby organs, including your stomach, pancreas and colon

Long-term risk of infection

After spleen removal, you're more likely to contract serious or life-threatening infections. Your doctor may recommend that you receive vaccines against pneumonia, influenza, Haemophilus influenzae type b (Hib) and meningococci. He or she may also recommend that you take preventive antibiotics, especially if you have other conditions that increase your risk of serious infections.

How you prepare

Food and medications

Before your procedure, you may need to temporarily stop taking certain medications and supplements. You may also need to avoid eating or drinking for a certain amount of time. Your doctor will give you specific instructions to help you prepare.

Other precautions

If you have time before the surgery, you may need to receive blood transfusions to ensure that you have enough blood cells after your spleen is removed.

Your doctor may also recommend that you receive a pneumococcal vaccine and possibly other vaccines to help prevent infection after your spleen is removed.

What you can expect

Before the procedure

Right before your surgery, you will be given a general anesthetic. The anesthesiologist or anesthetist gives you an anesthetic medication such as a gas — to breathe through a mask — or as a liquid injected into a vein. The surgical team monitors your heart rate, blood pressure and blood oxygen throughout the procedure. You will have heart monitor leads attached to your chest and a blood pressure cuff on your arm.

During the procedure

After you're unconscious, your surgeon begins the surgery using either a minimally invasive (laparoscopic) or open (traditional) procedure. The method used often depends on the size of the spleen. The larger the spleen, the more likely your surgeon will choose to do an open splenectomy.

• Laparoscopic splenectomy. During laparoscopic splenectomy, the surgeon makes four small incisions in your abdomen. He or she then inserts a tube with a tiny video camera into your abdomen through one of the incisions. Your surgeon watches the video images on a monitor and removes the spleen with special surgical tools that are put in the other three incisions. Then he or she closes the incisions.
• Laparoscopic splenectomy isn't appropriate for everyone. A ruptured spleen usually requires open splenectomy. In some cases a surgeon may begin with a laparoscopic approach and find it necessary to make a larger incision because of scar tissue from previous operations or other complications.
• Open splenectomy. During open splenectomy, the surgeon makes an incision in the middle of your abdomen and moves aside muscle and other tissue to reveal your spleen. He or she then removes the spleen and closes the incision.

After the procedure

• In the hospital. After surgery, you're moved to a recovery room. If you had laparoscopic surgery, you'll likely go home the same day or the day after. If you had open surgery, you may be able to go home after two to six days.
• After you go home. Talk to your doctor about how long to wait until resuming your daily activities. If you had laparoscopic surgery, it may be two weeks. After open surgery, it may be six weeks.

Results

If you had splenectomy due to a ruptured spleen, further treatment usually isn't necessary. If it was done to treat another disorder, additional treatment may be required.

Life without a spleen

After splenectomy, other organs in your body take over most of the functions previously performed by your spleen. You can be active without a spleen, but you're at increased risk of becoming sick or getting serious infections. This risk is highest shortly after surgery. People without a spleen may also have a harder time recovering from an illness or injury.

To reduce your risk of infection, your doctor may recommend vaccines against pneumonia, influenza, Haemophilus influenzae type b (Hib) and meningococci. In some cases, he or she may also recommend preventive antibiotics, especially for children under 5 and those with other conditions that increase the risk of serious infections.

After splenectomy, notify your doctor at the first sign of an infection, such as:

• A fever of 100.4 F (38 C) or higher
• Redness or tender spots anywhere on the body
• A sore throat
• Chills that cause you to shake or shiver
• A cold that lasts longer than usual

Make sure anyone caring for you knows that you've had your spleen removed. Consider wearing a medical alert bracelet that indicates that you don't have a spleen.

3. What is acute respiratory distress syndrome[ARDS]?

Acute respiratory distress syndrome (ARDS) is a severe lung condition. It occurs when fluid fills up the air sacs in your lungs. Too much fluid in your lungs can lower the amount of oxygen or increase the amount of carbon dioxide in your bloodstream. ARDS can prevent your organs from getting the oxygen they need to function, and it can eventually cause organ failure.

ARDS most commonly affects hospitalized people who are very ill. It can also be caused by serious trauma. Symptoms usually occur within a day or two of the original illness or trauma, and they may include extreme shortness of breath and gasping for air.

ARDS is a medical emergency and a potentially life-threatening condition.

Symptoms of acute respiratory distress syndrome

The symptoms of ARDS typically appear between one to three days after the injury or trauma.

Common symptoms and signs of ARDS include:

• labored and rapid breathing
• muscle fatigue and general weakness
• low blood pressure
• discolored skin or nails
• a dry, hacking cough
• a fever
• headaches
• a fast pulse rate
• mental confusion

What causes acute respiratory distress syndrome?

ARDS is primarily caused by damage to the tiny blood vessels in your lungs. Fluid from these vessels leaks into the air sacs of the lungs. These air sacs are where oxygen enters and carbon dioxide is removed from your blood. When these air sacs fill with fluid, less oxygen gets to your blood.

Some common things that may lead to this type of lung damage include:

• inhaling toxic substances, such as salt water, chemicals, smoke, and vomit
• developing a severe blood infection
• developing a severe infection of the lungs, such as pneumonia
• receiving an injury to the chest or head, such as during a car wreck or contact sports
• overdosing on sedatives or tricyclic antidepressants

Risk factors for acute respiratory distress syndrome

ARDS is usually a complication of another condition. These factors increase the risk of developing ARDS:

• age over 65 years
• chronic lung disease
• a history of alcohol misuse or cigarette smoking

ARDS can be a more serious condition for people who:

• have toxic shock
• are older
• have liver failure
• have a history of alcohol misuse

Diagnosing acute respiratory distress syndrome

If you suspect that someone you know has ARDS, you should call 911 or take them to the emergency room. ARDS is a medical emergency, and an early diagnosis may help them survive the condition.

A doctor can diagnose ARDS in several different ways. There’s no one definitive test for diagnosing this condition. The doctor may take a blood pressure reading, perform a physical exam, and recommend any of the following tests:

• a blood test
• a chest X-ray
• a CT scan
• throat and nose swabs
• an electrocardiogram
• an echocardiogram
• an airway examination

Low blood pressure and low blood oxygen can be signs of ARDS. The doctor may rely on an electrocardiogram and echocardiogram to rule out a heart condition. If a chest X-ray or CT scan then reveals fluid-filled air sacs in the lungs, a diagnosis for ARDS is confirmed.

A lung biopsy can also be conducted to rule out other lung diseases. However, this is rarely done.

Treating acute respiratory distress syndrome

Oxygen

The primary goal of ARDS treatment is to ensure a person has enough oxygen to prevent organ failure. A doctor may administer oxygen by mask. A mechanical ventilation machine can also be used to force air into the lungs and reduce fluid in the air sacs.

Management of fluids

Management of fluid intake is another ARDS treatment strategy. This can help ensure an adequate fluid balance. Too much fluid in the body can lead to fluid buildup in the lungs. However, too little fluid can cause the organs and heart to become strained.

Medication

People with ARDS are often given medication to deal with side effects. These include the following types of medications:

• pain medication to relieve discomfort
• antibiotics to treat an infection
• blood thinners to keep clots from forming in the lungs or legs

Pulmonary rehabilitation

People recovering from ARDS may need pulmonary rehabilitation. This is a way to strengthen the respiratory system and increase lung capacity. Such programs can include exercise training, lifestyle classes, and support teams to aid in recovery from ARDS.

What is the outlook?

The American Lung Association estimates that 30 to 50 percent of people with ARDS die from it. However, the risk of death isn’t the same for all people who develop ARDS. The death rate is linked to both the cause of ARDS and the person’s overall health. For example, a young person with trauma-induced ARDS will have a better outlook than an older person with a widespread blood infection.

Many survivors of ARDS fully recover within a few months. However, some people may have lifelong lung damage. Other side effects may include:

• muscle weakness
• fatigue
• an impaired quality of life
• compromised mental health

Preventing acute respiratory distress syndrome

There’s no way to prevent ARDS completely. However, you may be able to lower your risk of ARDS by doing the following:

• Seek prompt medical assistance for any trauma, infection, or illness.
• Stop smoking cigarettes, and stay away from secondhand smoke.
• Give up alcohol. Chronic alcohol use may increase your mortality risk and prevent proper lung function.
• Get your flu vaccine annually and pneumonia vaccine every five years. This decreases your risk of lung infections.

4. Patient-Ventilator Dyssynchrony

Patient-Ventilator Dyssynchrony occurs when the patient’s demands are not met by the ventilator, resulting from problems with:

1. timing of inspiration
2. adequate inspiratory flow for demand
3. timing of the switch to expiration
4. duration of inspiration

VENTILATION STRATEGIES

Total Ventilator-controlled Mechanical Support:

• patients breathing pattern is totally controlled by ventilator (pressure generated by patient abolished by paralysis and sedation)
• risks: prolonged sedation and paralysis, respiratory muscle atrophy, over-distension, patient discomfort, prolonged weaning

Partial Patient-Controlled Mechanical Support:

• spontaneously breathing activity preserved
• weaning accelerated, preservation of respiratory muscle power
• risks: requires synchronization of patients ventilatory demand and ventilator settings

CAUSES

Patient factors

• ventilatory drive (inspiration)
• ventilatory requirements (how much flow and volume required)
• timing of the circuits generating the respiratory rhythm (I:E ratio)

Ventilator factors

• inspiratory trigger (flow, volume or pressure)
• delivery mechanism (flow, volume or pressure)
• cycling criteria (when ventilator stops assisting inspiration and allows passive exhalation)

TYPES OF VENTILATOR DYSSYNCHRONY

Ineffective triggering

• high PEEPi (must generate enough effort to overcome PEEPi)
• weakness
• incorrect ventilator settings
• ventilator dysfunction

Inappropriate triggering (patient inspires while the ventilator cycles to expiration)

• inspiratory time too short
• inspiratory flow rate too low
• set tidal volume low
• coughing and hiccups

Autotriggering (important to distinguish from ineffective triggering)

• hiccups
• coughing
• cardiac oscillations
• shivering
• seizures
• ‘rain out’ (condensation in ventilator circuit)
• trigger sensitivity set too low

Flow dyssynchrony (too fast or too slow)

• too slow: ‘pull down’ on pressure curve upstroke during inspiration
• too fast : e.g. discomfort from rise time too short

Exhalation dysynchrony (too early or too late)

ASSESSMENT

Examination

• work of breathing
• respiratory pattern
• audible sounds (e.g. cuff leak, stridor, wheeze)
• chest findings (e.g. hyperexpansion, dullness, crackles)

Monitor

• vital signs
• ETCO2
• SpO2

Ventilator

• waveforms
• alarms

Chest x-ray

MANAGEMENT

Resuscitation

• address life threats
• disconnect patient from ventilator and replace with BVM if required

Address patient factors

• treat patients respiratory pathology affecting resistance and/ or compliance (e.g. sputum, bronchospasm, chest wall eschar, pneumothorax)
• treat other patient factors (e.g. hunger, pain, weakness, sleep ,sedation, nutrition, physiotherapy)

Correct problems with the endotracheal tube

• kinking
• obstruction (e.g. secretions blocking)
• impingement on carina or between cords

Correct problems with the ventilator

• choose appropriate ventilator
• choose appropriate mode
• ensure sensitivity is not too low or high
• choose appropriate ventilator rate
• set appropriate flow rate
• check that patient isn’t auto-triggering (cardiogenic oscillations, high sensitivity, circuit leaks, water condensation in the circuit)
• sedate patient to reduce agitation
• taking over ventilation if fatigue is apparent

Address ineffective triggering

• address PEEPi: — apply increased externally applied PEEP — decrease tidal volume and respiratory rate — increase expiratory time — bronchodilators
• address weakness: — nutrition — reduce sedation — physiotherapy
• adjust trigger sensitivity threshold (may lead to inappropriate triggering)

Exhalation dyssynchrony

• treat underlying patient factors (e.g. COPD, asthma)
• adjust exhalation sensitivity or change to time-control cycling between inspiration and expiration or change to a volume-cycled mode