Prolonged ICU stay

comlication
Dr. Clarence Ojo
History
Patient is 29 yr old male who presented as
major trauma after being struck by vehicle.
As per EMS he was appropriately
answering questions initially but soon
became somnolent and experienced
seizure. He was intubated in ED for airway
protection due to decreased mental status.
(GCS 9)
Physical
BP 151/93 HR 104 RR 30
Patient had abrasions to left forehead, with
palpable bony deformity on the left
temporal area. He also had left otorrhea.
Patient also had a lower right leg deformity
with palpable bilateral DPs.

Radiologic findings
CXR: neg
Pelvis xray: normal
Xray right tib/fib: Comminuted fx of right
tibia
CTHead: Small extra axial left occipital
hematoma with minimal subarachnoid
blood on left frontal lobe. Non-displaced
left temporal bone fracture.

Labs
CBC: 9.2> 13.8/45.2< 207
BMP 149 104 19 123
4.4 21 1.2

ABG: 7.32/50.7/181.3/25.7/-.9

Initial workup
Ortho: brought patient for external fixation
of right tibia and fasciotomy.
Neurosurgery: Repeat CT shows
increased opacification of the
mesencephalic patient was taken for
ventriculostomy and ICP placement.
Post ventriculostomy
In PACU ICP monitor increased from 20-
24 to 60 sustained for more than 5
mintutes and patient was immediately
bagged and received mannitol ICP was
quickly normalized hypothermic protocal
was also started.
POD 5
Patient developed RLL infiltrate and had
white count to 16 and fever was seen by
ID and started on Vanco, Cefepime and
Flagyl. He has also been hypotensive
necessitating Levophed drip
Hgb had dropped to 6.5 and pateitn was
transfused 2 units
Conitnue SICU course
Patient continued to have white count and
fever.
Patients Cr started elevating on POD 11
and necessitated placing Shiley catheter
for dialysis due to AKI
Patient grew Acinetobacter from cultures
and was started on Unasyn/ trobramycin
Second bleed
Patient has head MRI which showed
Large subacute left frontal hemmorhage in
the left frontal lobe. Neurosurgery did not
recommend any interventions unless
follow up CT showed a change.
Feeding tube insertion
Patient necessitated insertion of feeding
tube on 6/5/14 since patient since old tube
became dislodged.
Several attempts were made at blind
insertion by SICU residents and consult
resident was notified that there was no
visible feeding tube on CXR
10PM CXR

NGT replacement
NGT was replaced by consult resident
blindly with no areas of resistance noted

Post CT insertion
Post chest tube insertion it was noted that
the feeding tube placed by consult
resident had actually perforated the right
lung and was immediately taken out.
Patient was not fed through the NGT at
any time.
5AM CXR

Post chest tube
Patients chest tube was discontinued after
air leak resolved and the right lung had
fully expanded. Post removal CXR does
not show any pneumo
Pneumothorax identified
Radiology called SICU resident to inform
of 30% right pneumothorax identified on
10PM CXR
28 French chest tube was emergently
placed on right side