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650 S P E C I A LT Y P R A C T I C E I N C R I T I C A L C A R E

Case study, Continued
Chris was ventilated in pressure control mode due to high peak embolised. Follow-up hematocrits were low but stable.
inspiratory pressures (PIPs). Sedation medication was increased to Follow-up CT showed no further increase in size of
facilitate ETT intolerance, and inotropes were required to maintain haematoma.
MAP goals. Continuous haemodynamic monitoring was required,
with target parameters within normal ranges. Serial ABGs, haemo- A surgical tracheostomy was performed due to prolonged ventila-
globin and coagulation profiles were also undertaken. tion wean, and allowed weaning of sedation. The Speech Pathol-
ogy department reviewed Chris and a Passy-Muir speaking valve
Teams involved in Chris’ care, and their reports, included: was used to assist him in communicating with his family.
l Cardiothoracic: flail chest, however no surgical intervention
required. Due to his size, a specialised chair that lay flat to allow transfer from
l Orthopaedics: # humerus, surgically fixed and placed in sling bed and is then moved into an upright position, allowed Chris to
with no internal rotation, and minimal external rotation for sit out of bed. Prior to surgical fixation of his spine CD was placed
dressings only. in a reverse Trendelenburg position to minimise axial loading on
l Plastics: degloving injuries, with a radial reverse forearm flap the C2 fracture when sitting to 30°.
performed. Prolonged bed rest, multiple skin folds and restricted movement
l Neurosurgery and orthotics: C2 # with Halothoracic brace contributed to a Grade 3 pressure area under Chris’ halothoracic
applied, posterior spinal fixation and reapplication of halo tho- brace and right shoulder. A treatment plan was developed that
racic brace for 3 weeks to provide further stabilisation. Inter- consisted of reducing the pressure by having the brace adjusted
mittently pre- and post-surgical fixation, Chris was noted to and regular dressings to debride the wound and provide an envi-
have absent movement in his lower limbs. Somato-Sensory ronment conducive to regranulation.
Evoked Potentials were undertaken which demonstrated bilat-
eral nerve conduction present. Chris’ girth precluded MRI A social worker met with Chris’ parents and his sister. Chris spent 4
investigation. weeks in ICU before being discharged to the ward and then to a
l Trauma Team: grade 3 liver laceration with positive FAST. As rehabilitation facility as he had significant muscle weakness due to
initial vital signs were stable, interventional radiology con- his myopathy from prolonged immobility. There was no ongoing
sulted for hepatic angiogram. A vessel of the hepatic artery was weakness as a result of spinal cord injury.

Research vignette

Ireland S, Endacott R, Cameron P, Fitzgerald M, Paul E. The incidence with a threefold independent risk of death: (OR (CI 95%)) 3.44
and significance of accidental hypothermia in major trauma – A (1.48–7.99), P = 0.04. Independent determinants for hypothermia
prospective observational study. Resuscitation 2011; 82(3): were prehospital intubation: (OR (CI 95%)) 5.18 (2.77–9.71),
300–306. P < 0.001, Injury Severity Score (ISS): 1.04 (1.01–1.06), P = 0.01,
Arrival Systolic Blood Pressure (ASBP) < 100 mmHg: 3.04 (1.24–
Abstract 7.44), P = 0.02, and wintertime: 1.84 (1.06–3.21), P = 0.03.
Background
Serious sequelae have been associated with injured patients who Of the 87 hypothermic patients who had repeat temperatures
are hypothermic (<35°C) including coagulopathy, acidosis, recorded in the Emergency Department, 77 (88.51%) patients had
decreased myocardial contractility and risk of mortality. a temperature greater than the recorded arrival temperature. There
was no change in recorded temperature for four (4.60%) patients,
Aim whereas six (6.90%) patients were colder at Emergency Depart-
Establish the incidence of accidental hypothermia in major trauma ment discharge.
patients and identify causative factors.
Conclusion
Method Seriously injured patients with accidental hypothermia have a
Prospective identification and subsequent review of 732 medical higher mortality independent of measured risk factors. For patients
records of major trauma patients presenting to an Adult Major with multiple injuries a coordinated effort by paramedics, nurses
Trauma Centre was undertaken between January and December and doctors is required to focus efforts toward early resolution of
2008. Multivariate analysis was performed using logistic regres- hypothermia aiming to achieve a temperature >35°C.
sion. Significant and clinically relevant variables from univariate
analysis were entered into multivariate models to evaluate deter- Critique
minants for hypothermia and for death. Goodness of fit was deter- All major trauma patients presenting for treatment of injury were
mined with the use of the Hosmer–Lemeshow statistic. enrolled into this prospective observational study. For this study,
the definition of major trauma is a surrogate of injury severity and
Main results risk of dying. However this criterion is not based on time critical
Overall mortality was 9.15%. The incidence of hypothermia was clinical criteria. Therefore this study design did have the propensity
13.25%. The mortality of patients with hypothermia was 29.9% of missing time-critical patients who had threat-to-life conditions