The patient was a 24-year-old black male who was brought to the emergency room via an ambulance on June 21 at 03:50 pm. The report indicated that it was a pedestrian versus vehicle accident. The state of the patient reported included acute lung injury, pulmonary contusion, deep road rash extending over right side of axillary region to the abdomen, deep avulsion to the right hip area and exposed muscles. Trauma alert team and the respiratory therapist were called to the bedside. The patient developed respiratory failure and immediately was intubated by the respiratory therapist with an endotracheal tube size 7.5 mm. The end-tidal CO2 detector indicated good color change. The endotracheal tube was taped at 23 cm at lips, cuff pressure was 25 cmH2o and present bilateral breath sound was auscultated by the therapist and then the therapist started ventilating the patient with ambu bag easily. A small amount of frothy, red-tinged secretion via endotracheal tube had suctioned.
The patient is single and lives with his parents. The patient’s social history was positive for tobacco abuse for 5 years. The parents considered him a heavy smoker with average consumption of half a pack at least per day. The parents denied their son alcohol abuse. There is no family history for coronary artery diseases or respiratory diseases. The patient was not on any medications and has no known drug allergy, hospitalization history, or previous surgeries.
The patient’s appearance on arrival to the emergency room revealed uneven chest expansion, dyspnea, shallow and rapid breathing, decreased breath sounds, tachycardia, and cyanosis. The patient was on severe pain and significantly restless. The patient vital signs upon arrival to the emergency room were as follows: respiratory rate was 32 bpm, heart rate was 96 bpm, body temperature was 98.7 °F, blood pressure was 111/51 mmHg and O2 saturation on nasal cannula was 87%.
The physical examination on the patient revealed a young adult black male with bruising and abrasion of the chest wall, shortness of breath, acute respiratory distress, chest tenderness, crepitus and diminished sound right lower lobe. Cardiovascular assessment revealed irregular rate and rhythm without murmurs, or gallops. Abrasions on the right chest side, axillary side, right hip and open wound left ankle.
Chest radiograph was taken, and it showed a 5th right rib fracture, multifocal patchy airspace opacities on the right lung with an air-fluid level in the mid-portion of the right lung and no pneumothorax. Findings represent pulmonary contusions. Computed Tomography Scan showed no injury to the head and the spines, large right chest soft tissues defect and hematoma, right pulmonary contusion with fracture of 5th right rib and no chest pneumothorax. CT scan of the abdomen showed slight inferior spleen laceration, right hip dislocation, left pelvic wall hematoma, and left ankle fracture. The final impression and the diagnosis of the patient was acute lung injury, unilateral pulmonary contusion with deep road rash of the right flank and right hip and left ankle fracture due to pedestrian versus vehicle accident.
Arterial blood gas was drawn while the patient was being ventilated with ambu-bag on 100% oxygen, and it showed the following results: pH of 7.21, PaCO2 of 74 mmHg, PaO2 of 47 mmHg, HCO3-of 21.1 mEq/L, and SaO2 was 97 %. These results were interpreted as uncompensated respiratory acidosis with moderate hypoxemia. Blood samples were drawn for laboratory investigations, and it revealed the following: Na+ 142 mmol/L (normal), K+ 3.4 mmol/L (normal), Cl - 104 mmol/L (normal), Glucose: 176 mg/dL (high), BUN: 21 mg/dL (high) and Creatinine 1.35 mg/dL (normal). The complete blood count: WBC: 14.1 K/uL (high), RBC: 3.85 M/uL (low), hemoglobin: 8.2 gm/dl (low), hematocrit (HCT): 34.9% (low) and platelets count: 246 K/uL (normal). ECG showed a normal sinus tachycardia.
While the patient was in the emergency room, he had pleural chest tube placed on the right side of the chest by ER physician. The patient’s wounds were stitched followed by wound dressing. The orthopedic surgeon scheduled a wound debridement for the patient later. Intravenous fluid 1000 ml normal saline was started and Hydromorphone (Dilaudid®), an opioid pain medication, 1mg I.V given once. Additionally, Diphtheria and tetanus toxoids (no brands available) as vaccines 0.5 ml were given once.
The trauma team assessment plan for the patient was to initiate invasive mechanical ventilation to overcome the respiratory failure and maintain the patient’s injuries. This was then to be followed by orthopedic consult, burn consult, wound care and O.R for debridement.
The patient was admitted to surgical intensive care unit at 06:10 pm and an arterial line was inserted through the left brachial artery. The patient received a blood transfusion of 3 units of packed red blood cells (PRBC) and 3 units of fresh frozen plasma (FFP) to correct his blood loss and low Hb. Piperacillin (zosyn®) a penicillin antibiotic, 3.375 mg was given as I.V. once a day, cefazolin sodium (Ancef®) as antibiotic 1g I.V was given once per day for 7 days. Docusate (Colace®) a stool softener, 100mg I.V BID, and Fentanyl (Sublimaze®) a narcotic (opioid) pain medicine, 1250 mcg/275 ml I.V drip were given at 1.0 mcg /kg/hr and titrate up to 3.0 mcg/kg/hr as needed per the pain scale. The respiratory therapist connected the patient to the Servo I ventilator with the following setting; mode: SIMV (VC) + PS, FiO₂ 100%, VT 550 ml, set RR 16 bpm, PEEP +10 mmHg and PS 12 mmHg. VAP Bundle was applied to prevent ventilator-associated pneumonia. Arterial blood gas was taken half an hour later, and it showed pH 7.24, PaCO₂76.9 mmHg, HCO³ˉ 14.3mEq/L, PaO₂79 mmHg, BE -5mEq/L, SaO₂ 100% (compound respiratory and metabolic acidosis with mild hypoxemia). The therapists started recording the vent follow sheet and monitoring the vent waveforms to detect any abnormalities. There was no spontaneous respiratory effort that was triggered by the patient. The measured peak inspiratory pressure (PIP) for the patient was 36 cmH2O, which was considered above the normal limit, so the therapist checked the ventilator tubes, and it was okay. He then later suctioned the patient’s ET tube, he got moderate thin white, and blood tinged secretions. At 11:00 pm on the first night, the respiratory therapist repeated the ABG and he got a pH of 7.27, PaCO₂ 71.3 mmHg, HCO³ˉ 16.6mEq/L, PaO₂119 mmHg, BE -6mEq/L, SaO₂ 99% (compound respiratory and metabolic acidosis with over corrected hypoxemia). The right pleural chest tube drained 210 cc off blood.
At SICU, the patient was still on the same ventilator setting. The respiratory therapist noted that the PIP was 39 cmH2O. He then taped the ET tube and suction in the patient but no significant change occurred. ABG was drawn through the arterial line, and the result was a pH of 7.29, PaCO₂69.4 mmHg, HCO³ˉ 20.6mEq/L, PaO₂280 mmHg, BE -4mEq/L, SaO₂ 99% (compound respiratory and metabolic acidosis with over corrected hypoxemia). The pulmonologist suggested changing the ventilator mode to PRVC with the following settings; FiO₂80% VT 500 ml, set RR 22 bpm, PEEP +15 mmHg, and PIP 34cmH2O. The patient was moved to the operating room for wound debridement, full thickness excision to the right flank and open reduction and internal fixation for the left ankle. The patient received propofol (Diprivan®) as a hypnotic and sedative 1g I.V on drip infusion. Vecuronium Bromide (Norcuron®) a nondepolarizing neuromuscular blocking agent was given10 mg I.V and Fentanyl (Sublimaze®) a narcotic pain medicine 100 mg I.V. was also given. During the surgery, the patient received the second blood transfusion of 2 units of packed red blood cells (PRBC) and 2 units of fresh frozen plasma (FFP). The patient was moved back to SICU after the surgery and connected to the mechanical ventilator on the PRVC using the same previous setting. The respiratory therapist drew an ABG, and it revealed the following: pH 7.33, PaCO₂ 57.4 mmHg, HCO³ˉ 23.6mEq/L, PaO₂ 280 mmHg, BE -3mEq/L, SaO₂ 97% (partially compensated respiratory acidosis with over corrected hypoxemia). Then the FiO₂ was reduced from 100% to 80% and the set RR reduced to 20 bpm.
Third Day
The patient remained on the previous ventilator settings. The right pleural chest tube drained 90 cc of blood. Another blood sample was drawn for chemistry, and CBC and it revealed the following: Na+ 143mmol/L (normal), K+ 3.5 mmol/L (normal), Cl - 104 mmol/L (normal), Glucose: 135 mg/dL (high), BUN 18 mg/dL (normal), Creatinine 1.02mg/dL (normal), WBC: 12.3 K/uL (high), RBC: 4.03 M/uL (low), hemoglobin: 10.4 gm/dl (low), hematocrit (HCT): 37.4% (low), and platelets count: 246 K/uL (normal). The patient pain scale was 7 of 10, and it was recommended that fentanyl narcotic to be continued.
The patient developed coarse crackle and expiratory wheezing bilateral breath sound when he was auscultated and copious, thick yellow and blood-tinged secretions, which required the respiratory therapist to do frequent ET tube suctioning. ABG was drawn, and it showed the following: pH 7.34, PaCO₂ 55.1 mmHg, HCO³ˉ 23.9mEq/L, PaO₂ 234 mmHg, BE -4mEq/L, SaO₂ 99% (partially compensated respiratory acidosis with over corrected hypoxemia). The pulmonologist ordered ipratropium bromide and albuterol (Combivent®) as bronchodilator MDI 4 puff QID, and she recommended decreasing the FiO₂ from 80% to 60%, drop the set RR 18 bpm and the PEEP to be decreased to +10cmH2O.
Fourth Day
The patient was prepared for bronchoscopy procedure at SICU; he received Midazolam (Versed®) a benzodiazepine sedative 4mg I.V once. The respiratory therapist attending the patient’s bedside increased the FiO₂ from 60% to 100%. The bronchoscopy was done safely. (BAL) bronchoalveolar lavage was performed to reduce bacterial contamination and pneumonia possibility. It was very effective in suctioning and to clear a lot of the copious secretion with no complications. The findings were N/A of abnormalities or any thing significant. Half an hour after bronchoscopy procedure was done, the respiratory therapist noted that PIP dropped to 29 cmH2O. He then drew an ABG, and it revealed pH 7.35, PaCO₂ 51.2 mmHg, HCO³ˉ 22.7mEq/L, PaO₂ 297 mmHg, BE -4mEq/L, SaO₂ 99% (compensated respiratory acidosis with over corrected hypoxemia). Then the FiO₂ was reduced from 60% to 40% and the set VT was reduced from 500 ml 480 ml.
Fifth Day
The patient was shifted to the CT scan to achieve better prognosis of the patient’s pulmonary contusion level. The CT scan images revealed a reduction in pulmonary contusion and the hematoma compared to the first day images. On a purpose to facilitate the patient weaning from mechanical ventilation, the patient underwent a tracheostomy procedure and 7.0 mm tracheostomy tube was placed easily. Bacitracin (Neosporin®) 3.5mg as antibiotic ointment was applied to all abrasions for antimicrobial protection and wound dressing was also applied.
Sixth Day
The pulmonologist recommended the patient to be placed on SIMV (VC) +PS mode with the following setting: FiO₂ 60%, VT 500 ml, set RR 16 bpm, PEEP +10 mmHg and PS 12 mmHg. ABG was taken half an hour later and showed pH 7.36, PaCO₂47.3 mmHg, HCO³ˉ 22.4mEq/L, PaO₂167 mmHg, BE -3mEq/L, SaO₂ 100% (compensated respiratory acidosis with overcorrected hypoxemia). The patient right pleural chest tube drained very little amount of blood less than 20 cc. The auscultation of the breath sound revealed slight bilateral wheezing but a reduction on the amount of the bronchial secretions. The PIP was maintained at 23 cmH2O. The patient spontaneous RR was 8bpm and spontaneous VT was measured to 340 ml. The patient received another blood transfusion of 2 units of packed red blood cells (PRBC) and 2 units of fresh frozen plasma (FFP). Blood samples were drawn for chemistry and CBC, and it revealed the following: Na+ 143mmol/L (normal), K+ 3.5 mmol/L (normal), Cl - 104 mmol/L (normal), Glucose: 135 mg/dL (high), BUN 18 mg/dL (normal), Creatinine 1.02mg/dL (normal), WBC: 10.9K/uL (high), RBC: 4.03 M/uL (low), hemoglobin: 13.6 gm/dl (normal), hematocrit (HCT): 46.7% (normal), and platelets count: 246 K/uL (normal). The patient pain scale was 2 of 10. The patient was weaned of the narcotic pain medications as needed per the pain scale.
Seventh Day
The patient started responding to stimulation and opening eyes. Tracheostomy tube care and the patient oral care were done. The respiratory therapist checked the ventilator flow sheet and the waveforms and detected patient respiratory effort triggering no leak or obstruction. The measured values were: PIP 24 cmH2O, spontaneous RR 12 bpm, VE 7.2 L/m and spontaneous VT 418 ml. The following ventilator setting was used; mode: SIMV (VC) +PS FiO₂40%, VT 480 ml, set RR 16 bpm, PEEP +5 cmH2O and PS 10 cmH2O. ABG was taken half an hour later to satisfy the latest setting, and it showed pH 7.35, PaCO₂ 43.2 mmHg, HCO³ˉ 26.1mEq/L, PaO₂ 116 mmHg, BE -3mEq/L, SaO₂ 100% (normal ABG with slight overcorrected hypoxemia).
Eighth and Ninth Day
There were no significant events. There was no significant ABG result, or radical changes on ventilator mode or setting. The patient showed effort in triggering spontaneous breathing and convenient spontaneous VT. Breath sound was clear bilateral, and there were mild white thin secretions. Breathing treatment was done using (Combivent®). The patient Hb level was raised to 14.2 gm/dl (normal), and WBC reduced to 9.1K/uL (normal).
Tenth Day
The respiratory therapist had drawn an ABG for the patient, and it showed: pH 7.34, PaCO₂ 46.2 mmHg, HCO³ˉ 23.7mEq/L, PaO₂ 102 mmHg, BE -2mEq/L, SaO₂ 100% (partially compensated respiratory acidosis). The pulmonologist ordered to place the patient on the mode CPAP/PS with the following setting: PS 12cmH2O, FiO₂ 50%, and the PEEP +5 cmH2O. The patient measured values were as follows: spontaneous respiratory rate was 24 bpm, spontaneous VT was 490 ml and VE 9.4 L/m. Two hours later the PS had been reduced to 8 cmH2O and FiO₂ to 40%. ABG was repeated one hour later, and it revealed: pH 7.46, PaCO₂ 44.2 mmHg, HCO³ˉ 20.3mEq/L, PaO₂ 131 mmHg, BE -4mEq/L, SaO₂ 100% (partially compensated metabolic acidosis).
On 2nd July, the patient was weaned of the mechanical ventilation and placed on trach collar connected to a large volume nebulizer on 40 % oxygen. The patient’s vital signs were SpO2 99 %, HR 87 beat/m, RR 21 breath/m, BP 137/83 mmHg, and T max 99.1 F0. The patient was responsive and conscious. The patient breath sound was clear bilateral with mild tracheal secretion. ABG was done later, and it showed the following: pH 7.41, PaCO₂ 39.1 mmHg, HCO³ˉ 20.3mEq/L, PaO₂ 109 mmHg, BE -4mEq/L, SaO₂ 100% (fully compensated metabolic acidosis). The patient remained in the SICU and the treating team decided to discharge him to the floor. The patient continued to receive care as this case report ended.
Overview
The patient, a 24-year-old black male, was brought to the emergency room via an ambulance on June 21st following a pedestrian versus vehicle accident with a report of acute lung injury, pulmonary contusion, and poly-trauma. The patient developed respiratory failure and had to be intubated. CT scan, radiography, and laboratory investigations were done, and it confirmed the diagnosis of acute lung injury with unilateral pulmonary contusion. The patient was admitted to SICU and was placed on mechanical ventilation on SIMV (VC) +PS. The patient received antibiotics, pain medication, breathing medicine and blood transfusion to correct the hypervolemia and low level Hb. The patient was taken to surgery for wound debridement and left ankle fixation. Bronchoscopy was done, and BAL performed. ABG was taken periodically and it helped in applying the best ventilator mode and setting. The ventilator mode was changed to PRVC to control the high increase of the PIP. The patient underwent tracheostomy procedure to facilitate weaning of ventilator. The pulmonologist recommended returning the patient on SIMV (VC) +PS. The patient was able to take spontaneous breathing and convenient spontaneous VT. The patient was then placed on CPAP/PS mode, and he did well, and managed to keep SpO2 above 92 %. The patient was weaned of mechanical ventilation and placed on trach collar with large volume nebulizer on 40 % oxygen. The patient was to be discharged from the SICU to the floor sooner.
Work Cited
Guldager H, Nielsen S, Carl P, Soerensen M. A comparison of volume control and pressure-regulated volume control ventilation in acute respiratory failure. Critical Care (London, England) [serial online].1997; 1(2): 75-77.
The above citation is for the article I have chosen as a relevant article as it relates to the case report I have written. My case report is discussing a pedestrian versus vehicle accident. The patient had an acute lung injury and pulmonary contusion that led to respiratory failure, which required endotracheal intubation and initiation of mechanical ventilation. The patient peak inspiratory pressure was unusually high, which would have caused serious pulmonary complications apart from what the patient already had. The pulmonologist recommended changing the patient from the SIMV (VC) to the PRVC mode, which played a role in controlling the patient high PIP.
The article authors are discussing the advantages of PRVC mode over the VC mode. They mention that high PIP may cause a barotrauma or hyperinflation that could make the patient liable to the pneumothorax, inflammation, or pulmonary interstitial edema, which reflects the ARDS or ALI. The article authors stated that, in the situation of ARDS, it is preferred to avoid high-pressure ventilation. The article study focuses on how PRVC improves the mechanics of respiration and the peak inspiratory pressure. Further, it improves the partial pressure of arterial oxygen slightly, mean arterial pressure and it reduces the period spent by the patient in the ICU.
The conclusion of the article stated that in case of acute respiratory failure, placing the patient on the mechanical ventilation on the mode of PRVC plays a significant role over the VC mode in reducing the peak inspiratory pressure.
