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? 

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College Answer

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?

Discussion

What would you do?...

  • Airway
    • ensure good quality regular tracheal aspiration of secretions
  • Breathing
    • ensure the patient is ona humidified circuit, preferably with a humidifier rather than HME
    • increase PEEP to recruit available alveoli
    • titrate FiO2 to normoxia
    • consider bronchoscopy to clear any obstructions
    • send sputum specimens for gram stain and microbiology
    • commence rotation therapy (alternate left and right recovery position)
  • Supportive management
    • ensure nasgastric tube is in appropriate position; consider advancing it to a post-jejunal location
    • ensure good quality regular oral hygiene
    • consider selective digestive tract decontamination
    • consider upright posture, whatever the spinal injury permits
  • Specific management
    • broad spectrum antibiotics
    • regular chest physiotherapy to assist clearance of secretions