Posted in Med Surg

 

It’s your first shift of four-in-a-row and little do you know that you are in for a tough stretch! Your shift starts out calmly enough, but at 0200 you take report on a 23-yr old post-surgical trauma patient who came in through the ED due to a pedestrian vs auto incident. The patient was crossing the road on a dark, rainy night when she was struck by a vehicle at approximately 30 mph. Her injuries are:

  • pelvic fracture
  • severe brain injury with skull fracture left parietal region and 8 cm scalp laceration
  • right lung contusion
  • right ribs 3-6 fracture
  • right clavicle fracture
  • closed right femur fracture
  • open right tib/fib fracture
  • closed right ulnar/radial fracture
  • face laceration left cheek
  • scattered abrasions

The patient was intubated by EMS and brought by helicopter to your level 1 trauma center. A foley catheter is placed. She’s had  CT of her head, neck, chest and pelvis. Her initial assessment reveals the following:

  • GCS 6 (No eye opening, no speech, withdraws to painful stimuli)
  • Gross hematuria noted in urine drainage bag
  • Profuse bleeding from head and open right tib/fib fracture

The patient is taken to emergency surgery for a decompressive craniotomy with bone flap, EVD placement and exploratory laparotomy with bladder repair. She is then brought to you in the surgical ICU. What do you expect to see and do for this patient? Let’s use LATTE!  If you don’t know what LATTE is, check it out here!

L = LOOK: After a decompressive craniotomy with a flap, your patient will have a large gauze dressing on her head. In this case she also has an EVD (extraventricular drain). She will be on a ventilator because her GCS is still 6. And, due to the exploratory laparotomy, she’ll also have an abdominal dressing and possibly a drain. If C-spine is involved, she’ll be wearing a collar, but our gal’s C-spine was cleared…yay!

A = ASSESS: The main assessments you will be doing on this patient are neurological and hemodynamics. What is she doing neurologically? What is her GCS? Are her pupils equal? Are there signs of shock? Is she bleeding anywhere? And, because she’s vented, you’ll be keeping an eye on her respiratory status as well…is she compliant with the vent? How do her lungs sound? What’s her O2 saturation? Is she breathing spontaneously? What kind of tidal volumes are we getting?

T = TESTS: You’ll do an ABG at some point to make sure she’s being ventilated adequately. You’ll also want to keep a close eye on CBC and coags as you monitor for bleeding and infection. Other labs include a chem panel to keep those electrolytes optimized! Expect to be taking this patient to CT a few times to keep an eye on the bleeding into her brain and any hydrocephalus that may be present. She’ll get a chest X-Ray daily since she’s on a vent and has rib/clavicle fractures. She may also get cystogram studies to keep an eye on how her bladder is doing. Remember she had hematuria…so they’ll want to keep a close eye on that.

T = TREATMENTS: How will this patient be treated? If you read my book, Nursing School Thrive Guide, you’ll recall that I talk quite a bit about prioritizing continuously. The treatments you provide at 0300 could be vastly different from the treatments you’re providing at 0600, based on the patient’s condition. For a fresh post-op patient who’s had a decompressive craniotomy many of your treatments/interventions are going to be focused on keeping the ICP within normal limits. You’ll also be administering pain and sedation meds as well as antibiotics. Depending on blood loss, you may be giving packed red blood cells. Note that we haven’t fixed her open fracture yet…that has to wait until morning when the ortho doc can get to her. So for now we’re just adding additional dressings to the site and keeping an eye on bleeding.

E = EDUCATION: At this point, you’re not providing education to the patient with a GCS of 6. However, you will be educating the family. In this acute phase, you don’t want to overwhelm them with information…it’s going to go in one ear and out the other. The highlights to hit on include: ICP management, pain control and sedation.

It is now 0430 and your monitor alarm starts going off for elevated ICP. It’s 23. Whatcha gonna do? (For a refresher on ICP management, check out this post here!)

First things first…assess your patient, not the monitor. You enter the room and do a quick assessment…this is what you find: head crooked off to one side, knees gatched, temp elevated, tachypnea and dyssynchrony with the ventilator, no drainage since you last drained the EVD an hour ago. Hmmm….what’s wrong with this picture?

Step 1: Straighten the patient’s neck to allow CSF to drain more freely.
Step 2: Un-gatch the knees to reduce intrathoracic pressure
Step 3: Looks like she might be fighting the vent…increase sedation and pain medication
Step 4: Check EVD…make sure there are no kinks in the tubing. In most facilities, policy states that you can BRIEFLY drop the level of the drainage bag to ensure patency…you do this and note drainage in the bag…so there are no kinks or clots. Hmmm…
Step 5: Initiate cooling measures…IV Tylenol works great as do ice packs. Be careful of shivering, though! Shivering increases ICP.
Step 6: Give it a few minutes and re-assess.

It is now 0445. You’ve gone up on your propofol and fentanyl, and the patient is now breathing trauma nursingin synchrony with the ventilator. The ICP is now 18-19…hovering near the top end of your parameters. You’re going to keep a close eye on this patient.

Thankfully the rest of your shift goes smoothly. You report off to Super Nurse, RN and head home for a day of blissful sleep. When you come back in that evening, this is what you hear in report:

  • Pt went to surgery at 1000 that morning for ORIF of the right tib/fib fracture, right ulnar/radial fracture and right femur fracture.
  • Hgb dropped from 8.5 to 7.2…you are now doing serial Hgb and Hct every six hours. Your next draw is due at 2200.
  • Temp spiked to 39.1, cultures drawn, antibiotics continued.
  • ICPs still hovering around 18-20. Neurosurgeon changed the height of the EVD from 10mm Hg to 5mm Hg…EVD drainage has been steady at 10ml/hr throughout shift.
  • GCS remains at 6.
  • Pt still on ventilator.
  • Plan is for pt to have pelvic fracture fixed the next day.

Upon your initial assessment you note the following:

  • BP lower than it was last night…hovering around 95 systolic.
  • O2 sats a bit lower than the night before. They were 98% then, they’re 93-95% now.
  • Temp is better…that’s good!
  • Lung sounds are mildly coarse.
  • ICP 19-20. EVD drainage is good and she’s adequately sedated.

An hour later, you’re at the nurse’s station doing an ungodly amount of charting, when your monitor alarm goes off. ICP is 22. You do all your checks…positioning, temp, EVD patency…all looks good. But her ICPs are still high. As you are doing your assessment, the ICP creeps up to 23-24. Time to notify the neurosurgeon on call.

SBAR Communication

“This is Nurse Sam, calling about your patient Ramirez in Trauma ICU bed 10. She had a decompressive craniotomy yesterday. Her ICPs are holding steady in the 23-24 range. She’s afebrile, well-sedated, compliant with vent. GCS remains at 6 and EVD drainage is averaging about 10ml/hr. What do you think about trying mannitol?”

So, your neurosurgeon thinks this is a fantastic idea and orders Mannitol q 4 hr prn ICP > 20; Check serum sodium prior to each dose; Hold for serum sodium > 146. You give your first dose and watch the monitor as the ICP drops down bit by bit to a more acceptable 14. Go you!

A few hours hours later, at 2230, you notice your patient’s O2 sats have dropped dramatically…they’re now 74%. What the heck? You hustle into the room and amp up the ventilator to give 100% FiO2. As you place your stethoscope into your ears, you quickly assess the ET tube to ensure it hasn’t become dislodged. You listen to her lungs and hear no lung sounds on the right…the same site as her rib fractures and lung contusion. You call for help and immediately take her off the vent and manually breathe for her using the BVM. When your nurse friends show up, you ask one to call RT, one to call the doc and another to put in an order for a stat Chest X-RAY. What is going on?

As you are bagging the patient, waiting for the RT to show up and take over, you notice tracheal deviation off to the left and BP has dropped to 83/54. You relay this to the nurse who is on the phone with the MD, stressing that she needs to get up there STAT! Your patient has a pneumothorax and seconds count. The respiratory therapist arrives to take over the airway and you ask one of your friends to obtain a large-bore needle.  You ask another to grab a chest tube kit…it’s time to get serious folks.

The MD arrives, agrees with your assessment of tension pneumothorax and, using the large-bore needle, performs an emergent pleural decompression. You watch in amazement as the patient’s O2 saturation levels quickly start to climb back to 93%. You prep the pleuravac and monitor the patient while the MD inserts a chest tube on the right side. Good catch!

While you have the doc there, you notify her that the 2200 H&H showed a hemoglobin of 6.9. She orders 2 units packed red cells. You give the blood and, happily, the patient’s O2 saturation and blood pressure both improve. And, with a couple of Mannitol doses your patient’s ICP hangs around 14 for the rest of the night. Nice job…you go home and sleep a beautiful sleep.

When you come on that night, the off-going nurse reports the following:

  • Your patient had her pelvic fractures repaired that day, returning from surgery at 1120 with hemovac drain at surgical site.
  • The tachycardia that has been present since admission has slowed to normal sinus rhythm, likely due to decreased pain now that all her fractures are repaired.
  • Urine output averaging 75ml/hr.
  • The biggest news is that her GCS has improved dramatically…she’s now a 9 (opens eyes to speech (3 points), no verbal response due to ETT (1 point) and localizes to pain (5 points). This is a massive improvement! Guess she likes that EVD and all that lovely Mannitol.
  • The plan is to let her rest overnight, and lighten up her sedation early in the morning with the neurosurgeon rounds.

Your initial assessment reveals the following:

  • VS stable
  • ICP 11 (yay!) with 5ml CSF from last hour…looks like drainage is slowing down.
  • BP 129/67; HR 85
  • Surgical dressing across abdomen and at right hip. Both are clean, dry, intact. Belly is soft, flat; pt grimaces and moves hands toward abdomen as you palpate…likely very tender.
  • All other dressings from prior surgeries also clean, dry, intact.
  • Lung sounds equal bilaterally; chest tube is patent; O2 saturation 98% on 30% FiO2.
  • GCS remains at 9…she is slowly but steadily improving. Whew!

At 2300, you notice that your patient’s  blood pressure is trending down and heart rate is trending up. You aren’t alarmed yet…though you are keeping a careful eye on things. Currently, her O2 saturation is 94%, BP is 109/63, HR is 104, urine output 45/hr. Nothing scary yet, but you don’t like how the trend is going. An hour later, at 0000 you notice O2 sat is now 92 %, BP is 98/62, HR is 115 and urine output for the past hour is 25. You definitely don’t like how this is going. At all. You perform your midnight assessment and notice that your hemovac is full…it was empty two hours ago…what’s going on? You drain the hemovac and pull back the patient’s gown. You immediately see that her belly isn’t quite as flat…and when you touch it it feels much more firm. You immediately go call the ortho surgeon…you’re getting pretty good at waking docs up in the middle of the night, so this SBAR should be a no-brainer!

“This is Nurse Sam, calling about your patient Ramirez in Trauma ICU bed 10. You performed an ORIF on her pelvis today and I’m concerned she may be bleeding into the abdomen. BP has dropped 30 points since 1900, most of the past hour. HR is up from 85 to 115, O2 sats are down to 91 from 98, and urine output is decreasing. Her belly is a bit rounded and more firm than on my initial assessment. I’d like to get a stat Abdominal scan, a stat CBC and coags, and ask you to come see this patient.”

The ortho surgeon agrees with your order requests and states she is going to call the general surgeon who is on site at the hospital right now. If the patient is bleeding, she’s going to need to go to surgery asap. You anticipate this happening, so you get ready:

  • You assign a friend to draw a rainbow (this means you’re going to draw the three main studies…a chemistry panel, a CBC and a coagulation panel…these are in different colored tubes so we call it a “rainbow”).
  • Another nurse calls blood bank to ensure the patient has units on hold and also calls CT to tell them they’ve got a stat patient coming in.
  • You call RT so they can come put the patient on the portable ventilator.
  • You get the patient packed up and ready to transport to CT. They quickly run the scan and a few minutes after you return to the room the general surgeon shows up. She assesses the patient, agrees with your findings, and logs into the computer to view the scan which has miraculously been processed amazingly fast! She notes blood in the abdominal space and says what you’ve been anticipating for the past hour…”We’re going to surgery.”
  • You wheel the patient down to surgery, report off to the circulating RN and anesthesiologist and decide this is a perfect time for your lunch break.  Nice work,  you!

The patient comes back from the OR 90 minutes later. The surgeon tells you she’d had a large hematoma in one of her pelvic vessels that ultimately burst, causing the drop in pressure and distended abdomen. The patient received four units packed red blood cells in the OR and you’re back to doing q 6-hr H & Hs. BP has improved to 115/67, HR Is 94 and O2 saturation is 98%. That was a close one! Thankfully, the rest of your night goes off without a hitch. When the neurosurgeon rounds at 0600, you’ve had sedation off for about 20 minutes. The patient is moving much more and opening eyes spontaneously. She is not, however, following commands…but her total GCS is now 10. The neurosurgeon likes what he sees and states that if she continues to improve she could likely be weaned from the ventilator soon.

Your relief arrives right on time, you report off and tell her you’re back again that night for your fourth shift in a row. You feel like this patient has really put you through the wringer and hope your last night of the week is easier than the last three! Off you go to sleep.

When you arrive that night, you receive the following information in report:

  • GCS is now 11…patient is following commands and trying to write notes! Sedation is minimal.
  • Pt has been on CPAP for the past three hours and doing great with RR 14-22 and O2 saturation levels > 95%. She’s pulling good tidal volumes and on a measly 30% FiO2. Awesome!
  • ICP has been 4-8 all day with minimal drainage from EVD.
  • The PM doc is planning to be by around 2000 to assess pt. You are to have an ABG done at that time to assess for readiness to extubate. You cross your fingers!
  • All other VS stable, all dressings CDI and hemovac draining an appropriate amount of serosanguinous fluid.

When the doc comes by at 2000,  you’ve got sedation completely off and your ABG done. After a review of that morning’s CXR and a glance at your patient’s fantastic ABG results, the MD decides to write an order to extubate. Finally some real progress!

You contact your respiratory therapist, grab a towel and a 12 ml syringe. You suction the patient’s mouth and oropharynx thoroughly, making sure you get all the secretions cleared from above the ET cuff. The RT loosens the ET holder from the patient’s face while you get the nasal cannula ready to go with 2L O2. The RT then deflates the cough, tells the patient to cough and pulls the tube. You place the nasal cannula on the patient and instruct her not to talk for a little while. You encourage her to take slow, deep breaths through her nose and cough periodically to keep her lungs clear. Her O2 saturation is 99% and when you ask her how she’s doing she gives you a thumbs up to indicate she is doing fine. You did it!

Now that you’ve got an awake pt who could potentially  move around a lot in bed, you need to be extra careful you don’t over drain through the EVD. You explain to the patient (and the patient’s family) that she is not to abruptly change position or move the head of the bed. She nods to indicate understanding and then mouths the words, “What happened?” You give her a brief synopsis…something along the lines of,

“You were in an accident four days ago and badly injured. You’ve had several surgeries for a head injury and broken bones. You currently have a drain in your head to keep the swelling in your brain under control. You also have a chest tube in place to keep your lungs expanding normally. You also have a catheter in your bladder draining urine. Currently everything looks good. Your vital signs are stable and your neuro status is improving. The short term plan is to keep your pain controlled and monitor your neuro status throughout the night. To do that I’ll have to wake you every couple of hours. Do you understand? Now, I know this is a lot to take in and I want you to try not to worry…that’s my job. I’ll be right out there all night and I’m watching over you continuously. You are hooked up to monitors that may occasionally make noise…a lot of times those noises are false alarms and nothing to be concerned about so try not to let it upset you. As long as I’m not alarmed, you don’t need to be alarmed. OK? Now, what is your pain level on a 0-10 scale?”

Throughout the rest of the night, you’re on dilaudid duty and neuro-assessment duty. The patient is scoring a 14 by the time morning rolls around and you report off to the oncoming nurse feeling like you’ve done an awesome job these past four nights. You rock!

I hope you enjoyed this scenario-based look at caring for a post-surgical trauma patient. Luckily I haven’t had a patient with this many complications, but the point is you are always on the lookout for what COULD go wrong. Being ready when the shizzle hits the fan can mean the difference between life and death…but you’re an awesome nurse and you got this!

Note I couldn’t cover every contingency, assessment, treatment, med and diagnostic test in this one case study…this is just an example and I sincerely hope it helped paint a picture for you! Got a story to share about how you caught a problem before it got too big? Got questions about post-op care? Let’s talk about it in our Facebook Group, Thriving Nursing Students.

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