Anonymous
timer Asked: May 7th, 2020

Question Description

JohnBudd, a 7Z-year-old, arrived in the emergency department unconscious, with stab wourids to the upper-right abdomen and lower-right chest that were sustained in his home while fighting off a burglar. The paramedics secured two large-bore intravenous (IV) catheters in his right and left antecubital spaces and infused lactated Ringer,s solution wide open in both sites. An endotracheal tube was inserted, and ventilation w-ith a resuscitation bag at 1000/o oxygen was begun. Medical antishock trousers (MAST) were in place. pressure dressings to both wounds were secured. A S-cm (Z-inch) stab wound to his right lower chest and a 7.5-cm (3-inch) stab wound to his upper-right abdomen were inspected. Chest tubes were inserted into the upper-right and lower-right midaxillary regions. Immediatety, 500 ml of red drainage returned via the lower chest tube. His heart rate (HR) was 125 bpm, and the monitor showed sinus tachycardia without ectopy. His blood pressure (BP) was TOIS0 mm Hg. Inserting a Fo1ey catheter resuited in drainage of 400 ml clear, dark yellow urine. After infusion of more than 2000 mi of lactated Ringer's solution, Mr. Budd was sent to surger)4, still in a hypotensive state. Preoperative body weight was 74 kg (1651b). Surgical lntervention During surgery/ a right thoracotomy and dght abdominal laparotomy were performed.


hello please just answers the case study

Unformatted Attachment Preview

SepsislSeptic M, LWrc Rodgers; &MC; ,k*S,N, CCRN, C.'NR.nf, ACNV.BC Emergency Department JohnBudd, a 7Z-year-old, arrived in the emergency department unconscious, with stab wourids to the upper-right abdomen and lower-right chest that were sustained in his home while fighting off a burglar. The paramedics secured two large-bore intravenous (IV) catheters in his right and left antecubital spaces and infused lactated Ringer,s solution wide open in both sites. An endotracheal tube was inserted, and ventilation w-ith a resuscitation bag at 1000/o oxygen was begun. Medical antishock trousers (MAST) were in place. pressure dressings to both wounds were secured. A S-cm (Z-inch) stab wound to his right lower chest and a 7.5-cm (3-inch) stab wound to his upper-right abdomen were inspected. Chest tubes were inserted into the upper-right and lower-right midaxillary regions. Immediatety, 500 ml of red drainage returned via the lower chest tube. His heart rate (HR) was 125 bpm, and the monitor showed sinus tachycardia without ectopy. His blood pressure (BP) was TOIS0 mm Hg. Inserting a Fo1ey catheter resuited in drainage of 400 ml clear, dark yellow urine. After infusion of more than 2000 mi of lactated Ringer's solution, Mr. Budd was sent to surger)4, still in a hypotensive state. Preoperative body weight was 74 kg (1651b). Surgical lntervention During surgery/ a right thoracotomy and dght abdominal laparotomy were performed. The right chest wound was explored, and a lacerated intercostal artery was ligated. Exploration of his upper-right abdominal wound revealed more extensive damag". the livei and the duodenum were lacerated. Extensive hemorrhage and leaking of intestinal contents were apparent after opening the peritoneum. Mr. Budd's injuries were repaired, the peritoneal cavity was irrigated with antibiotic solution, and incisional sump drains were plaied in the duodenum. During the 4-hour surgery, Mr. Budd received 6 U of biood and an additional 3 L of lactated Ringer's solution. A pulmonary artery catheter (PAC) and right radiai arterial line were inserted. lntensive Care Unit: Immediately after Surgery When Mr. Budd arrived in the surgical intensive care unit (ICU), he was receiving ventilatory support. Ventilator settings were as follows: 370 377 ChaPter 26 Sepsis/SePtic Shock Assist Rate mode Fio, Vr 600/o 72 800 ml were the immediately after surgery parameters hemodynamic Vital signs and 92l52mm Hg BP 114 bPm 12 breaths/min HR Respirations TemPerature 36.2' 2018 PAP c (97.2 F) mm Hg 6mmHg 4mmHg PCWP CVP 5 L/min co 2.9 Llminlmz 1040 dYnes/sec/cm- cl SVR cetl (WBC) count normal. Except for a white blood Arterial blood gas values were ^i."Li rr ro g7at, Mr' Budd's other laboratory values of 13.6 x 103/mm3 and a hemoglobin were within normal limits' ICU: PostoPerative DaY 1 t#: ;Hffi ;;J;drows,vandreceivedventilato?*Ytp,:,':l?'.11',1?SirTHi;" ?iil.?,#:fr iffi::il;l;':qTr*#S:*":.",il:Ti*"?"*:TJ,T:; f;'?x,1S.Tf :ril"jfiil::ff'Jfi:1,.i']xi;.'$d;!i*!*::"ry:*3Tlt"g,:T,*""*Tff l*# ;il#ffi fi *T"ilil,['*,T""1iie"iyq:4**"}iffi ,::,11i#*3i;Il?Ti"'::l;'#"i; 51trilT[H'#,iil11;fii,#'il1':i.ffi ;fi nrm ii"'f# +HI5jl""l]o','^','*:J*:"*ff :fr oo -rir,,. His abdomen was slightrv :ffi'll'l""l??"ff 'h*.-1::ffi;'.,:"*r"*",'n,rl' no bowel sounds' u.rJ aitt""aed, and he had Postoperative DaY 2 he his second postoperative day' At this time Mr. Budd's condition remained stable until to commanai' Hls respirations were 28 became difficult to arouse but did respond output dropped to 20 ml/hr' His skin became breaths/min, shallow, and labored' His urine included the following: warm, dry, and flushed' Other clinical data 80/50 mm Hg BP 132 bpm HR 36.2' C (97.2 T) Temperature 7417 mm Hg PAP PCWP CVP co CI SVR WBCs Glucose 4mmHg 2mm Hg 8 L/min 4.7 Llminlmz 560 dynes/sec/cm s Z2,OOOlmm3 270 mgldl indicated gram-negative bacilli' Culture and sensitivity repolts from wound drainage naloxone we11 as"IV hvdrocortisone and Appropriate IV antibiotics were iA*f,iri.t.d, ;; done' was nutritional needs (Narcan). A pharmaciconsuitation to formulate and calculate phase i; prepareto' the suspected hvperdvnamic and total parenteral tl"Hl#fi;;;,;;' was inicreased to 150 ml/hr' and of septic shock, infusion of lactated Ringer;s ,ol.,tion of ZOOmglZSO ml of 5olo dopamine at 5 pg/kg/min was started *itf. u concentration dextrose in water (DSW)' Inc All rights reserved O 2004, 2001,1996 Elsevier' - 372 UNIT VII MULTISYSTEM ALTERATIONS ICU: Postoperative DaY 6 dramatically. His skin B_v-- the sixth postoperative day, Mr. Budd's condition had deteriorated r,r;as cool, ,rrotttea, and moist. His sclerae were yellow tinged. He no longer responded to stimuli. A norepinephrine (Levophed) drip infused at 6 Fg/min with a concentration of lmglZlO ml of D5W, along with a dopamine drip at 2 ptgikg/min was begun. His monitor showed sinus tachycardia with short runs of ventricular tachycardia. ST-segment elevation, T-wave inversion, and the development of Q waves over most of the anterior V leads on his electrocardiogram (ECG). A 75 mg bolus of lidocaine was given followed by a continuous intusion atimglmin with a concentration of 2 gl5OO ml of D5W. His breath sounds revealed crackles throughout his chest. Urinary output was only 3 to 5 ml/hr and was grossly bloody. His abdomen was enlarged and flrm. His abdominal suture lines had dehisced, and the peritoneum could be seen. The duodenal sump and NGT drainage started to turn red. AII irterial and venous puncture sites began oozing blood. Further clinical data included the following: 70152 mm Hg 140 bpm BP HR Respirations Temperature PAP PCWP CVP 14 breaths/min 35.8' C (96.4'F) 44126 mm Hg 24 mm Hg 8mmHg Z Llmin co 1.1 Liminlm2 2000 dynes/sec/cm cr SVR s Other abnormal laboratory results included the following: 7.74 49 mm Hg 46 mm Hg pH Pco2 Po, Sao, B5% HCO3- 72 mmoUL Lactic Acid 3.0 mEq/L Na* 152 mmol/L 5.9 mmol/L 3.4 mg/dl K* Creatinine Amylase Lipase ALT (SGOT) AST (SGPT) 290UlL FDP 39 3.9 TJ IL u/L 100 BZIJIL Platelets 75,000/mm3 PT 22 PTT 98.5 Fibrinogen 130 mg/dl sec 640UlL CK TroPonin sec I >50 Final Developments Despite attempts to reduce afterload with sodium nitroprusside (Nipride) and increase contraciility with dobutamine (Dobutrex), Mr. Budd's hemodynamic status failed even further. When his cardiac rhythm deteriorated into ventricular fibrillation, resuscitation efforts were unsuccessful. An autopsy revealed several small abscessed areas in the lung, acute hepatic failure, multiple hemorrhagic ateas, and an acute myocardial infarction (MI). O 2004, 2001, 1996 Elsevier, lnc. All rights reserved. t73 26 Chapter SePsis/SePtic Shock SEPSIS/SEPTIC SHOCK and the rerationship in hospirarized patienrs sepsis and bacteremia the masnitude of between these two diagnoses' "fT:::: those that of septic shock? Identify development and infection for what are the risk factors z. aPPlied to Mr' Budd' 3. Discuss the rationale septic shock' for use of a PAC in monitoring 4.Whatorganismsmostcommonlycausesepticshock?lnwhichsitesisinfectionmostoften seen? 5.Whatpathophysiologicprocessesoccurwithsepticshock?Whataretheeffectsofthese volume' and pump? processes on the ilffifi""'ililii'"t' 6.Discussclinical,laboratory'andtherapychangesthatoccurredonMr'Budd'ssecond postoPerative daY' lnc' All rights reserved' O 2004, 2001,1996 Elsevier' 374 UNIT VII MULTISYSTEM ALTERATIONS 7' what is the rationale for each of the following therapeutic modalities ordered for Mr. Budd on the second postoperative day? lV rate increased to .l50 ml/hr Dopamine 5 pglkg/min Steroids Naloxone lV infusion Total parenteral nutrition 8' 9' Discuss the clinical changes that occurred during Mr. Budd's sixth postoperative day. what is the rationale for each of the following therapeutic modalities ordered on the sixth postoperative day? How many milliliters pur liou, should be infused for each drug listed? Norepinephrine 6 pglmin Dopamine 2 p"glkg/min Lidocaine 2 mglkg/min 10. What are the reasons for the changes in the following hemodynamic parameters noted on the sixth postoperative day? 5VR CO/CI PCWP : ll' Interpret Mr. Budd's blood gas levels on the sixth postoperative day. 12' why are the renal, liver, and pancreatic laboratory values reported on the sixth postoperative day abnormal? i l i @2004,2001,1996 Elsevier, lnc. AII rights reserved, >-. ;**&w&,:ra. i1 Chapter 26 I Sepsis/Septic Shock 375 13. what complications do the hematorogic raboratory varues suggest? 14. What would account for the ECC changes described? Mr. Budd's liver was lacer:ated during the stabbing. What effect, if any, did this have on his eventual outcome? I :a ,' .i:: '/,. 'r' 16' t. :; Describe the differences in the parameters below between hyperdynamic or warm septic shock and hypodynamic or cold septic shock. i: Hyperdynamic ':t, , Hypodynamic LOC BP HR Respirations , Pulse Pressure Skin ? ,,, t; , SVR ,,, , co/cr I Urine Output ,: 17. How do elderly patients manifest symptoms of sepsis? 18' What antimicrobial and antiendotoxin therapies should be instituted in 19. What does the future hold for therapy in septic shock? @ 2Oo4,2$8tr,lg€tr-. ...
Student has agreed that all tutoring, explanations, and answers provided by the tutor will be used to help in the learning process and in accordance with Studypool's honor code & terms of service.

This question has not been answered.

Create a free account to get help with this and any other question!

Similar Questions
Related Tags

Brown University





1271 Tutors

California Institute of Technology




2131 Tutors

Carnegie Mellon University




982 Tutors

Columbia University





1256 Tutors

Dartmouth University





2113 Tutors

Emory University





2279 Tutors

Harvard University





599 Tutors

Massachusetts Institute of Technology



2319 Tutors

New York University





1645 Tutors

Notre Dam University





1911 Tutors

Oklahoma University





2122 Tutors

Pennsylvania State University





932 Tutors

Princeton University





1211 Tutors

Stanford University





983 Tutors

University of California





1282 Tutors

Oxford University





123 Tutors

Yale University





2325 Tutors