GSW Case Study - Clinical Course

HPI: The patient was admitted to a tertiary care center on September 22, 1996. He was a 23 year old African American male who was suffering from multiple gun shot wounds. One shot penetrated the left lower leg causing a comminuted area of around 4 cm distal to the proximal tip of the fibula with bullet fragments noted. The decision to amputate the left lower leg below the knee was made. Another bullet entered the right chest causing extensive damage and internal bleeding. A chest tube was placed with an immediate return of 400 cc of blood. A right middle and upper lobectomy were also performed. The patient hemorrhaged losing a significant amount of blood and was transfused with over 9 units of type O blood.(view a powerpoint presentation on the nurse anesthetist's account of the surgery) Due to the extensive fluid administration, pulmonary edema soon appeared.

(View powerpoint presentation on gunshot wounds by Scott Richey, BSRT, RRT)

9/22 - After surgery the patient was admitted to the Surgical Intensive Care Unit with an oral size 7.5 endotracheal tube (ETT) already in place at a depth of 23 cm at the teeth. The patient was sedated and paralyzed when placed on a 7200 ventilator with these initial settings: Pressure Control (PC) of 36 cm H2O, Rate of 10, Positive End Expiratory Pressure (PEEP) of 5 cm H2O, FiO2 of 1.00, and I:E of 1.5:1. Throughout the day, changes were made to the settings to accommodate the patient. The PC level decreased from 36 to 32 to 28 cm H2O, and the PEEP level increased from 5 to 10 to 15 cm H2O. The patient's arterial oxygen saturations (SaO2) ranged from 87-90%. Rhonchi were heard upon auscultation, and large amounts of bloody secretions were suctioned from the ETT. A bronchodilator treatment of 0.5 cc albuterol/3 cc normal saline every 4 hours was initiated. The patient's arterial blood gas (ABG) was as follows: pH 7.24, PaCO2 41, and PaO2 60.

9/23 - Volume Control Mode on the ventilator was attempted with a rate of 28 breaths/min, tidal volume (TV) of 560 ml, PEEP of 5 cm H2O, and an FiO2 of 1.00. This approach produced high peak inspiratory pressures (PIPs) ranging from 38-46 cm H2O. Therefore, PC Mode was reinstituted. The settings were as follows: PC of 28 cm H2O, Rate of 20, PEEP of 15 cm H2O, FiO2 of 1.00, and an I:E of 1:1. Returned TVs ranged from 660-740 ml.

Crackles were heard upon auscultation, and large amounts of pink frothy secretions were suctioned. SaO2s ranged from 78-90%. Nebulizer treatments of 50% ethanol were begun to treat the pulmonary edema.

9/24 - The patient remained sedated and paralyzed. Pressure Control Inverse Ratio Ventilation (PCIRV) was initiated. The settings were as follows: PC of 28 cm H2O, Rate of 18, PEEP of 12 cm H2O, FiO2 of 1.00, and an I:E of 1.5:1 to 1.8:1. Returned TVs ranged from 680-740 ml, and an auto-PEEP of 5 cm H2O was noted. Large amounts of pink frothy secretions continued to be suctioned. The nebulizer treatment of 0.5 cc albuterol/3 cc normal saline was changed to 2 puffs of albuterol every four hours via a metered dose inhaler (MDI) and aerochamber placed 3 lengths of tubing proximal to the patient wye.

9/25 - The ventilator settings remained the same except for the increase in the I:E to 2:1 and the decrease in FiO2 to 0.80. SaO2s ranged from 91-93%, and returned TVs averaged 700 ml. Rhonchi were heard upon auscultation, and moderate amounts of pink frothy secretions were suctioned.

9/26 - The rate was decreased to 16, the FiO2 was decreased to 0.60, and the PEEP was decreased to 12 cmH2O. SaO2s ranged from 94-95%, and TVs ranged from 720-740 ml. Small amounts of cloudy secretions were suctioned.

9/27 - The patient remained sedated and paralyzed. The ventilator settings remained the same except for a decrease in the FiO2 to 0.50. The patient's ABG was as follows: pH 7.44, PaCO2 38, and PaO2 72.

9/28 - The PC level was decreased to 26 cmH2O, the PEEP was decreased to 10 cmH2O, and the FiO2 was decreased to 0.40.

9/29 - The patient remained sedated and paralyzed. The PEEP was decreased to 7 cmH2O. The ABG was as follows: pH 7.43, PaCO2 37, and PaO2 83. The patient was diagnosed with Red Man's Syndrome due to an allergic reaction to Vancomycin.

9/30 - The I:E was decreased from 2:1 to 1.8:1 to 1.6:1. PC level was decreased to 26 cmH2O with returned TVs around 790-820 ml. Rhonchi were still heard upon auscultation, and small amounts of cloudy secretions were suctioned.

10/1 - The I:E was decreased to 1.4:1. SaO2s ranged from 94-96%. The ABG values remained about the same except for the increase in the PaO2 to 91.

10/4 - The patient remained sedated and paralyzed. Due to disseminated intravascular coagulation (DIC), a clot formed in the right posterior tibial artery of the leg. Pulse beyond the clot was only detectable with
ultrasound. Therefore, the right leg was amputated below the middle of the foreleg on this day.

10/5 - Sedation and paralysis was discontinued.

10/6 - The patient was awake and cooperating well with the ventilator. IRV was discontinued leaving the patient on pressure control at a peak pressure of 30 cm H2O. FiO2 was set at 0.35 with SaO2s ranging from 92-95%.

10/11 - A tracheotomy was performed with no complications.

10/22 - A tracheostomy shield trial on 0.35 oxygen was accomplished for 11 hours. During the trial, SaO2s ranged from 94-98%, and the respiratory rate ranged from 20-28. The patient was then returned to PC Mode with a PC level of 30 cm H2O to prevent fatigue.

10/23 - Synchronized Intermittent Mandatory Ventilation (SIMV) of 12 bpm was initiated along with the PC level of 30 cm H2O. No spontaneous breaths were seen while the patient was on SIMV. A trach shield trial on 0.35 oxygen was performed for 3 hours with SaO2s remaining at 98%. A swallow study was performed with the tracheostomy tube cuff deflated. The study proved to be successful. The patient was then decannulated and placed on a 0.40 face mask powered by a large volume jet nebulizer. The patient's respiratory rate remained around 24 bpm. Slight rhonchi were heard upon auscultation, and moderate amounts of large cloudy secretions were collected. Aerosol treatments of 0.5 cc albuterol/3 cc normal saline every 4 hours, and postural drainage and vibration (PD&V) every 4 hours was initiated.

10/26 - The aerosol treatment was decreased to every 6 hours, and the PD&V was discontinued. The FiO2 was decreased to 0.21 on the nebulizer, so the patient was just receiving humidified air. SaO2s remained around 96%. Rhonchi were heard upon auscultation, and large amounts of thick cloudy secretions were suctioned. The patient was also able to cough up some secretions on his own.

10/31 - The patient was discharged to a rehabilitation center.