Want to keep learning?

This content is taken from the The University of Edinburgh & Royal College of Physicians of Edinburgh's online course, COVID-19 Critical Care: Understanding and Application. Join the course to learn more.

Skip to 0 minutes and 0 seconds OK, team, shall we go see the next patient?

Skip to 0 minutes and 9 seconds OK, Rachael I think you saw this patient. Yes, I did. Do you want to present them? I can do that. So this is Jason Elliott. He’s 29 years old. So he came in for a with polytrauma. and so he has an unstable pelvic ring fracture left sided flial segment, right side pneumothorax right sided pulmonary contusions and right lower leg crush injury with compartment syndrome an AKI and rhabdomyolysis. He was an unrestrained passenger in a car two days ago. Ejected from the car.

Skip to 0 minutes and 43 seconds Intubated in A&E Grade 2 intubation had a chest drain inserted on his right side and there’s one litre of blood drained from that pneumothorax. And a right calf compartment syndrome. CT, which his head and neck was clear, without injury. And on the left side, there’s pulmonary contusions, and his rib fractures, a small residual pneumothorax and drain put in in A&E. So active problems. ongoing worsening oxygenation, raised airway pressure, his Hb has dropped since theatre ongoing pain issues and we haven’t managed to place a naso gastric.

Skip to 1 minute and 28 seconds And so on assessment respiratory-wise he is ventilated on SIMV, tube 22cm at his lips, and is on 60% oxygen, which is giving him sats of about 95, reducied air entry on his right side and sa right sided intercostal drain which is swinging and draining. surgical emohysema of the chest wall.

Skip to 1 minute and 47 seconds On the ventilator he is on SIMV 16 breaths by 480ml, PEEP of 8 and his peak airway pressure is up there at 22 he’s not making any spontaneous respiratory effort.

Skip to 2 minutes and 1 second Cardiovascularly he’s in sinus rhythm at around 78 beats. And blood pressure’s 98 over 47, mean of 64. Single strength norad going at 5mls per hour, CVP is eleven, a bit cool to the peripheries in both his hands and feet.

Skip to 2 minutes and 34 seconds Pupils are equal and reactive to light, size 4. His [NPIs were 4.4 on the right and 4.3 on the left. We could also determine that he gets analgesia boluses when he is turned. His neck’s been cleared, and his hard collar removed.

Skip to 2 minutes and 57 seconds Ongoing issues with not absorbing his NG feeding since theatre, high aspirates.since theatre He’s got a wound dressing on his abdomen which has got some shine through. his Otherwise his abdomen is soft scanty bowel sounds heard on auscultation, BMs are stable and he hasn’t moved his bowels since he came in.

Skip to 3 minutes and 9 seconds Renally so his 24 hour fluid balance is negative 500ml his urine output is poor 24 hour and his urea is 21.4, sodium 148 And potassium was 5.7 So it was 7.9 at its highest. Microwise he’s normothermic, not on any antibiotics, his white count is 10, and there are no antibiotics to review.

Skip to 3 minutes and 38 seconds And in terms of invasive devices he has a right IJ central line, a right IJ dialysis, a right radial arterial line and two cannulas in the ACF, one in each ACF, clean. They are all day 2 and clean. he And in terms of medication, the review is to look at his analgesia which has been recently changed.

Skip to 4 minutes and 1 second and we could add in regular paracetamol. And he had Flotrons and TEDs on and I’ve prescribed dalteparin. I’ve also prescribed ranitidine So overall impression so polytrauma post op pelvic fixation, pain on moving from his ribs mainly, worsening oxygenation, not sure if that’s related to pain or from the contusions and rib fractures, and an AKI from his rhabdomyolysis.

Skip to 4 minutes and 30 seconds So provisional plan is just to keep his repeat his blood gas and chase his bloods outstanding from this morning and review his chest x ray on the round and increase his alfentanil up and change his paracetamol to regular from prn Add in prokinetics, ongoing haemofiltration whether or not he’s a candidate for– OK. All right, let’s have a wee look thank you. And, David, any other issues from your side, the bedside nurse? No it’s just the chest and feeds.

Skip to 5 minutes and 6 seconds And is this Jason’s family member here? Yeah. My name’s Dr. Jones] I’m just going to do ward round now, so I’m just going to have a look at all the other bits and pieces and we’ll make a plan for the day. After we do that, I’ll then come back and give you an update as well, OK? So in terms of the ward round plan, yeah, I agree. We should get a chest X-ray. And we should ensure we’re doing lung protective ventilation. I think it’d be a good idea just to check his ideal body weight and make sure that’s the correct type of volume for him. I am happy with the cardiovascular plan, and also the plan for sedation.

Skip to 5 minutes and 53 seconds I see that he’s not been absorbing his feed. So we should maybe think about some prokinetics as well. In terms of the renal balance, I suppose it’s going to be important to keep a negative balance in terms of his potential of having ARDS. So we’ll continue with that negative balance target. And again, where he is now, so he’s not on antibiotics. If there’s any sign of further infection, such as a further rise in his white cell count, we might want to do a septic screen. Happy with all the lines at the moment. And I agree with the rest of your plan in terms of medication and [thrombo prophylaxis. OK, everyone. Shall we just go through the checklist?

Skip to 6 minutes and 44 seconds So let’s have a quick look at the drug chart again.

Skip to 6 minutes and 57 seconds So you can see the medication he’s on. And we discussed those on the ward round. He’s on ranitidine, 50 milligrammes IV, for ulcer prophylaxis. I think we can leave that on at the moment He’s also on TEDs as well.

Skip to 7 minutes and 13 seconds I see he’s not got any allergies.

Skip to 7 minutes and 18 seconds Infusions, he’s on noradrenaline, alfentanil and propofol. We probably need all those at the moment. Last in terms of his drug chart, we’re happy with this station at the moment. And we should maybe think about doing a sedation hold later on. We are managing 45 degrees head up, And we’re managing for standard eye care and mouth care protocols. In terms of feeding, as we said, we added some prokinetics. But from the dietitian’s point of view, I think you just need to be mindful of these requirements. So if he continues to not absorb feed the next couple of days, we’ll have to think about alternatives for him.

Skip to 8 minutes and 4 seconds We’re happy with the fluid balance at the moment, we’ve talked about ulcer prophylaxis. I see from the latest gas that his glycemic control is acceptable. In terms of his bowel care, OK. We’ll keep an eye on that. But he’s quite early on in his critical care stay state. In terms of thrombo prophylaxis, again, you mentioned that in your presentation. In terms of his tubes and lines, all his invasive lines, his arterial and central line and dialysis line are quite new. I see the ICD is still swinging, and there’s no plans to remove that at the moment. We’ll see what its position’s like at the latest X-ray. And OK.

Skip to 8 minutes and 47 seconds And in terms of other things, does anyone have any other things that they don’t think we’ve covered? OK, guys. Like I say, we’ll come and update you at the end of the ward round. But that’s all I’ve planned for the moment. OK. Shall we move on then]?

Ward Round: Presenting a Patient

Presenting a patient during the ward round as well as multidisciplinary team discussion regarding patient’s management plan.

Share this video:

This video is from the free online course:

COVID-19 Critical Care: Understanding and Application

The University of Edinburgh