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Discussion

Scenario Help

You are working evenings on an orthopedic floor.

One of your patients, J.O., is a 25-year-old who was a new admission on day shift. He was involved in a motor vehicle accident (MVA) during a high-speed police chase. His admitting diagnosis is status post (S/P) open reduction and internal fixation (ORIF) of the right femur (which was performed under general anesthesia), multiple rib fractures, sternal bruises, and multiple abrasions.

Your initial assessment reveals stable VS of 116/78, 84, 16, 98.6° F. He has crackles in lung bases bilaterally. He has a NGT (nasogastric tube) connected to LWS (low wall suction). He has an IV of D5LR infusing in his left arm at 125 ml/hr. His abdomen is soft and non-tender.

At 1900, J.O. summons you to the room and he is cold and clammy, groaning, pale, agitated, and slightly confused. VS are 90/palp, 140, 28, 98.0° F. His pulse is weak and thready. His abdomen is painful and appears to be increased in size. J. O. begins to vomit copious amounts of greenish/yellow fluid. You summon the physician and he orders a stat H & H with a type and cross match for 6 units of packed cells.

1. What else can you do for J. O. before the physician arrives?

Start another IV line because you can't infuse blood in the same IV with the D5LR, Give him oxygen, Keep monitoring vitals, Put the Head of the bed up so he doesn't aspirate his vomit,

I'm assuming he has an active GI Bleed, is there anything else I'm missing to help this patient??

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    • Featured Replies

    Why a GI bleed? Nothing in your scenario really indicates that. With MVA, there are broken bones and broken organs especially with abdominal signs... think along those lines...

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    The things that stood out to me where the crackles in the base of his lungs

    and the greenish/yellow vomitus accompanied by the painful, distended abdomen.

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    Maybe not a GI bleed, but an intraabdominal one. What would be susceptible to blunt trauma, bleed like a stuck pig, and make you vomit up ... bile?

    And someone who is losing his BP does NOT get the head of his bed raised. Maybe the foot of his bed. Turn him on his side to help protect his airway...and stay very, very close. Do not leave this guy alone for a minute for he is drain-circling.

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    • Author

    thanks for the suggestions, I guess the only reason I thought internal bleed was because of the painful distended abdomen and the fact that the assignment is about blood transfusion which is not a good way to think..i should pretend as though I am there in the room with him...THANK YOU.

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    Don't treat #, always treat the patient!

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    He had an MVA so I agree and think it is an intraabdominal injury. I am thinking spleen or liver area. The liver is protected fairly well tucked under the rib cage but anything can still tear or get punctured from a loose rib.

    Most hospitals have an emergent care protocol that you can initiate right away.List your interventions in the order that you would actually do them and the ones that are most urgent. Position patient,protect the airway,maintain safety,call charge or other RNs for help,call rapid response,notify MD/LP. Check current IV site and make sure it is good,establish another large gauge access if able or call for IV nurse,get labs especially CBC, check O2 Sat,ABG,keep getting vitals and respond to any changes,keep assessing especially the abdomen and respiratory status,may need pressors and fluid bolus. Remember all of these things can occur fairly rapidly once you get things moving because your coworkers come in to help.

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    thanks for the suggestions, I guess the only reason I thought internal bleed was because of the painful distended abdomen and the fact that the assignment is about blood transfusion which is not a good way to think..i should pretend as though I am there in the room with him...THANK YOU.

    You said "GI bleed," which is "gastrointestinal." The vast majority of those are bleeding inside the esophagus / stomach, with some in colon. A liver laceration will bleed like hell, distend the abdomen, and make for nausea due to pressure on the liver capsule.

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    • Author

    thanks for your straight forward answer!

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    • Experts
    You are working evenings on an orthopedic floor.

    One of your patients, J.O., is a 25-year-old who was a new admission on day shift. He was involved in a motor vehicle accident (MVA) during a high-speed police chase. His admitting diagnosis is status post (S/P) open reduction and internal fixation (ORIF) of the right femur (which was performed under general anesthesia), multiple rib fractures, sternal bruises, and multiple abrasions.

    Your initial assessment reveals stable VS of 116/78, 84, 16, 98.6° F. He has crackles in lung bases bilaterally. He has a NGT (nasogastric tube) connected to LWS (low wall suction). He has an IV of D5LR infusing in his left arm at 125 ml/hr. His abdomen is soft and non-tender.

    At 1900, J.O. summons you to the room and he is cold and clammy, groaning, pale, agitated, and slightly confused. VS are 90/palp, 140, 28, 98.0° F. His pulse is weak and thready. His abdomen is painful and appears to be increased in size. J. O. begins to vomit copious amounts of greenish/yellow fluid. You summon the physician and he orders a stat H & H with a type and cross match for 6 units of packed cells.

    1. What else can you do for J. O. before the physician arrives?

    Start another IV line because you can’t infuse blood in the same IV with the D5LR, Give him oxygen, Keep monitoring vitals, Put the Head of the bed up so he doesn’t aspirate his vomit,

    I'm assuming he has an active GI Bleed, is there anything else I'm missing to help this patient??

    We all forgot the most important and simplest step of all.....make sure the NGT is functional and in position and patent with a functional wall suction system.

    This alone can distend the abdomen can cause pain and a vagal response which would make the patient diaphoretic and in pain. The confusion is concerning with a long bone fracture and multiple rib fractures I would also be concerned about a fatty emboli or a pneumothorax with the rib fractures and sternal injury and check their O2 sat and abg's as well as a portable CXR. You might be able to argue for an injury to one for the great vessels (ie:aorta) but a PCXR will show a widening mediastinum or the pneumo/hemo throax.

    Internal injuries are a concern when you have an impact high speed deceleration injury but those are usually cleared and stabilized long before a scheduled ORIF of the femur......these are usually acute injuries that are unstable and not suddenly appearing a couple of days later.

    Think about the car slamming to a halt and the body slamming into the steering wheel....where is the body struck and what organs are there.

    In this case I think it's a blocked NGT and the answer is simple.

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    Also, any one that has sternal involvement is at risk for cardiac tamponade and myocardial contusions. This scenario sound more like an acute abdomen, but it's a good thing to remember. If you suspect any cardiac involvement, a 2D echo, EKG is a great thing to get! A myocardial contusion can lead to fatal arrhythmias. The steering wheel can be just as deadly as the other car in the accident!

    And when you start that other IV, make sure it's a large bore. The bigger the better on trauma pts. You may need to dump huge amounts of blood.

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