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In message <[log in to unmask]>, Carlos Arturo Perez Avila <[log in to unmask]> writes >Yesturday I received a stable trauma (one that has no physiological >abnormality i.e. normal Triage Trauma Score). I wander if the list can let >me know waht they would have done with him. In a couple of days I will let >you know what we did with him. >Oxygen sats 85% with no oxygen 90% with oxygen on and off as he removed the >re-breathing bag. Gases COS tetention low Oxygen saturation. >No wheeze and good air entry. Abdomen distended bowel sound >apparently abscent very tender. >Fracture of the right first rib and 5 more on that side, no flail segment >On the left fracture of the 4th 5th 6th and 7th.Lung parenchyma staring to >show signs of lunng contusion bilaterally. >Patient referred to surgeons and orthopaedics for in patient management. >Was given Morphine 5 mgs IV with good control of the pain and no >significant reduction in RR or O2 sats. > >What would you have done with this patient? Anyone fancy calculating his TRISS / predicted survival with these injuries at his age? If it is as dire as I suspect, would there be case for minimally invasive supportive / symptomatic therapy but nil else (boos from the gallery, hate mail from the Royal Society for the Prevention of Neglect of the over 90s). Once the dust settles, what's his usual quality of life? Discuss with family EARLY. Neck: Assuming he's got a full set of marbles and no neurology, couldn't justify sedating him (probably requiring IPPV) just to allow "proper" neck control and investigation, so pragmatic approach needed, although mechanism and age raise serious worries re. his spine. A+B: Not sure from your post whether this poor chap's "O2 sats" imply arterial gases or pulse oximetry only. Assuming his PaO2, pH and PaCO2 were stable and acceptable (for a 90+ year old with COPD), then watchful waiting and analgesia sound good. Reliance on Pulse Oximetry, especially with supplementary FiO2 worries me. Its all too easy to be lulled into a false sense of security: patient comfortably snoozing with Pulse Ox>90% could be judicious analgesia and an adequate respiratory reserve, but it could be the combined effects of morphine, lung contusion and still painful chest causing CO2 retention, with a misleadingly reassuring pulse ox reflecting supplementary FiO2 rather than adequate ventialtion. With those injuries, he needs ITU or VERY close obs (of sats, gases, RR and CVS) on HDU if left spont ventilating. If more than morphine needed, would there be any mileage in pleural / rib blocks or a thoracic epidural (brave anaesthetist to attempt up to 1st rib!)? If gases still going off despite above, no option but to IPPV (with bilateral drains, electively probably). What odds against ever getting a nonogenarian COPD with those injuries off the vent?. What's going on in his belly? Assuming he's stable enough, would anyone fancy scanning him (USS or CT)?.... aortic dissection retro-pertitoneal bleed mesenteric tear possibly diaphragmatic rupture intra-capsular liver / spleen haematoma.... ...would all be missed by DPL. I know DPL is complementary to USS, but what about an USS 1st (portable, non-invasive)? It may be that your chap's belly was too tender / distended to tolerate the attentions of a radiologists jelly-covered probe (ooh-er, Missus).