Patient Scenarios: Trauma

• A 62 yo F with PMHx significant for VTE (on warfarin) is admitted to the trauma ICU after sustaining a severe TBI from a fall. She is intubated and sedated with fentanyl and midazolam infusions. She has a bolt for intracranial pressure (ICP) monitoring and is on mannitol therapy at 1 g/kg every 6 hours. Objective data: HR 80 bpm, BP 128/78 mmHg, ICP 18 mmHg, RR 22, serum osmolality 330.

What is the best course of action regarding this patient’s hyperosmolar therapy?

• A 22 yo M with unknown PMHx is brought to the emergency department sustaining multiple gunshot wounds. He presents to the resuscitation bay with altered mental status and a BP of 82/48 mmHg, concerning the team for hemorrhagic shock. Massive transfusion protocol is activated.

After receiving 4 units of PRBC’s, which would be the most appropriate intervention?

• A multi-vehicle collision has occurred, and your level one trauma center receives an 18 yo M with PMHx notable for asthma sustaining multiple lower extremity open fractures with significant blood loss in the field. Upon arrival to the trauma bay, a massive transfusion protocol is initiated. In addition to blood products for resuscitation, what additional therapy should be initiated for this patient?

• 40 yo M PMHx HTN, HFrEF presents to the emergency department after sustaining a motor vehicle collision (car vs. tree). Positive head strike with airbag deployment. The patient is alert and oriented, however without motor or sensation below the level of the clavicles and absent rectal tone, concerning for a spinal cord injury. His objective data is as follows: BP 92/67 mmHg, HR 73 BPM, Temp 36 C, RR 16. Which is the most appropriate intervention?

• A 58 yo M without significant PMHx is BIBEMS to the emergency department after suffering a motorcycle collision vs. car. Physical exam is notable for a Gustilo Type IIIb open fracture in the left lower extremity. The patient states he has no known drug allergies. Which is the most appropriate antibiotic regimen for infection prophylaxis?