[geekgolightly]

floor trauma/ortho nurse here with pt came in six days ago bilat pelvic fx and now has developed ileus and also really cruddy lungs. hes tachy 100's, on 3L, has NG tube draining foul sulphur smelling dark brown fluid. stopped peeing on his own yesterday but was able to straight cath 600 dark amber urine. bp running 90's over 60's. trauma doc ordered 2L LR open and then increase D5LR to 200 and insert foley, which i did. thing is, im new to this trauma world and dont know if running fluids on wet lungs is a good idea or not. shouldnt he have started a drip to keep pressure up or is there some other reason he wanted to run that fluid in? i cant seem to find any answers when i google. any ideas? this guy is a big big trauma doc and i'm brand spanking new to trauma.

[Dr. Kathy]

Originally Posted by geekgolightly

floor trauma/ortho nurse here with pt came in six days ago bilat pelvic fx and now has developed ileus and also really cruddy lungs. hes tachy 100's, on 3L, has NG tube draining foul sulphur smelling dark brown fluid. stopped peeing on his own yesterday but was able to straight cath 600 dark amber urine. bp running 90's over 60's. trauma doc ordered 2L LR open and then increase D5LR to 200 and insert foley, which i did. thing is, im new to this trauma world and dont know if running fluids on wet lungs is a good idea or not. shouldnt he have started a drip to keep pressure up or is there some other reason he wanted to run that fluid in? i cant seem to find any answers when i google. any ideas? this guy is a big big trauma doc and i'm brand spanking new to trauma.

This patient sounds like they are septic or on the road to MODS. In these patients, aggressive volume infusion to optimize perfusion and cellular uptake of 02 is essential. You said the lungs are "cruddy." Is that ARDS, pneumonia or fluid volume overload? One way to monitor these folks is to watch their serum lactates, and base deficits as well as their urine output. Lactates will normalize, as will base deficits as perfusion is restored. This patient would also be a good candidate for the monitoring of intrabdominal hypertension. Most cutting edge folks now use vasopressors ONLY after volume therapy fails. Although it is not about trauma, per se, google "Early Goal Directed Sepsis Therapy" or "EGDT" and you will find some of the rationales for these actions.

Good luck--this can be a great patient to learn from.

Dr. Kathy, RN, PhD, CCNS

[augigi]

You can fix wet lungs, you can't fix dead. If I had someone tachy, with BP 90/60, not peeing and getting gut ischemia, I'd be giving volume too! Agree that they sound septic. If so, fluids probably won't fix the problem, but i wouldn't want to be starting potent vasoconstrictors without adequate perfusion/intravascular volume first.

[Dinith88]

Originally Posted by Dr. Kathy

Is that ARDS, pneumonia or fluid volume overload? CCNS

THis sentence says it all.

Just know that sometimes lungs can be 'wet' and it wont be cardiogenic (due to weak heart/overload). ARDS is common in septic patients AND can be seen in trauma (without sepsis)...These patients will have wet, crackley, pulmonary edema lungs even if the patient is clinically dehydrated. ('noncardiogenic pulmonary edema').

The picture you presented is that of a septic/mods patient...and like the other posters have said, they can become severely hypotensive...and pressors are useless unless their fluid volume is optimized (pressing on empty hoses isnt effective...and can even be detrimental by closing off capillary beds).

The only thing i disagree with the above poster about is that this is 'cutting edge'. It's not. It is (should be) standard practice.

[dorimar]

Very impressive response by all. I have nothing else to add except my agreement.

[tethys]

some addition:

??? CPK of the patient is very high? it's common and sometimes it may be up to >6000 in trauma cases. then the DRs will flush the kidneys with fluids and will keep the urine output more than usual. to avoid renal failure caused by rhadomyolysis.

[tridil2000]

Originally Posted by Dinith88

THis sentence says it all.

Just know that sometimes lungs can be 'wet' and it wont be cardiogenic (due to weak heart/overload). ARDS is common in septic patients AND can be seen in trauma (without sepsis)...These patients will have wet, crackley, pulmonary edema lungs even if the patient is clinically dehydrated. ('noncardiogenic pulmonary edema').

The picture you presented is that of a septic/mods patient...and like the other posters have said, they can become severely hypotensive...and pressors are useless unless their fluid volume is optimized (pressing on empty hoses isnt effective...and can even be detrimental by closing off capillary beds).

The only thing i disagree with the above poster about is that this is 'cutting edge'. It's not. It is (should be) standard practice.

absolutely! it amazes me how many people think vasopressors are the first treatment for decreased bp/co!

love the concept of "you're just squeezing an empty hose!"

tough case! sepsis and ards = bad!

what happened?

[geekgolightly]

This patient was on an ortho-trauma floor. I had four other patients including a fresh post-op.

No other labs were ordered at that time and this patient did get really really bad within 24 hours. I wish that I had questioned what he was thinking while he was writing the orders. I felt decidedly uncomfortable with this patient being on my floor where I have no way to properly monitor him. I told the oncoming nurse that evening that I had a really bad feeling about him. I heard just last weekend that he finally made it out of ICU.

I appreciate your responses.

[sunshineCCRN]

Originally Posted by geekgolightly

This patient was on an ortho-trauma floor. I had four other patients including a fresh post-op.

No other labs were ordered at that time and this patient did get really really bad within 24 hours. I wish that I had questioned what he was thinking while he was writing the orders. I felt decidedly uncomfortable with this patient being on my floor where I have no way to properly monitor him. I told the oncoming nurse that evening that I had a really bad feeling about him. I heard just last weekend that he finally made it out of ICU.

I appreciate your responses.

You did a good job with him. Good thing you recognized a problem and acted--now you have a valuable experience that will probably come in handy sooner than you think!

[geekgolightly]

Originally Posted by sunshineCCRN

You did a good job with him. Good thing you recognized a problem and acted--now you have a valuable experience that will probably come in handy sooner than you think!

<3 thank you.

Someday, I will comfortable enough to begin ICU; part of that comfort is going to come from reading this forum.