A 50 year old man is brought into the Emergency Department after acute flexion injury to the neck while surfing. He is unable to move both arms or legs and has a sensory level at C4·5. He ls a heavy smoker with a history of chronic bronchitis.
(c) Two days later he develops fever, dirty sputum and basal CXR changes.
What will you do?
A bread and butter ICU problem. ?nosocomial infection, but it has occurred early and may indicate aspiration pneumonia or exacerbation of his bronchitis leading to pneumonia. Is this infection? Other causes, a pulmonary infarct and sepsis elsewhere, should be considered.
The nosocomial pneumonia should be handled by tracheal aspirate, culture, antibiotics and physiotherapy. There is no strong evidence to support the routine use of covered brush, BAL techniques at this stage but bronchoscopy may aid sputum clearance if physiotherapy is ineffective. The likely pathogens and hence choice of antibiotics should be listed. H.flu should be included considering his history.
The next problem is to consider how to prevent further episodes of infection:
- vigorous physiotherapy with assisted coughing
- early tracheostomy and surgical stabilisation should be considered
- can the patient be mobilised into a Philadelphia collar (if he has a stable spine and . complete lesion this may be possible)?
- can he be sat up?
is there a place for an Evac tube or Pitt tube to aspirate secretions from above the cuff?
What would you do?...