A 60-year-old patient is admitted to ICU after a high-speed motor vehicle accident. Their injuries include a spinal cord injury associated with cervical vertebral fractures, multiple rib fractures, abdominal injuries and pelvic fractures. They have had a laparotomy and external fixation of pelvic fractures. The cervical spine injury is managed with decompression and stabilisation. They remain intubated and ventilated.
Discuss the factors that would affect this patient’s ability to wean from mechanical ventilation during their ICU admission. (10 marks)
Syllabus topic/section:
2.1.13 Trauma Intensive Care - Severe and/or multiple trauma, spinal trauma: L1
2.1.5 Respiratory Intensive Care - Mechanical ventilatory support: L1
Discussion:
Many candidates did not discuss the spinal cord injury level in detail, and did not discuss implications of a complete or incomplete injury. Some candidates assumed lifelong ventilator dependence. Many candidates also discussed assessment and management issues that did not attract marks, whilst covering other relevant factors only superficially, eg “rib fractures affect weaning”. Many answers focussed on analgesia or extubation somewhat in isolation.
It is again recommended that candidates read the question carefully and are familiar with the glossary terms. This question asked candidates to discuss, and this requires a level of detail rather than simply a list. Consideration of the multi-trauma injuries was necessary to attain more marks.
Candidates who did better demonstrated a structured approach and the impact of each injury on weaning. The marking rubric is included to aid the candidate’s future study.
|
Below Standard |
At Standard |
Above Standard |
|
|
Discuss factors affecting patients' ability to wean |
Poor structure failing to consider trauma related and other causes weaning from mech vent Minimal understanding of the impact of the level and extent of cervical cord injury on respiratory mechanics Omission of explanation of other contributory factors 0 – 4.5 marks |
Reasonable structure mentioning trauma and trauma unrelated factors Demonstrates good understanding of impact of Cervical cord injury on respiratory mechanics Includes some of the other trauma and non- trauma related factors contributing to weaning failure 5 - 7 marks |
At standard plus Good structure with comprehensive prioritised list of Cervical cord related/ other trauma related injuries and comorbidities contributing to failure to wean. Detailed explanation of the impact by each of the mentioned factors on respiratory mechanics and its clinical implications 7.5-10 marks |
It is not clear how the inclusion of the rubric is expected to improve the candidate's preparation, considering that it contains statements such as "includes some of the other trauma and non-trauma related factors contributing to weaning failure". The candidates will intuitively grasp that they missed out on marks because they did not mention "some of the other factors".
This may masquerade as a trauma SAQ, but it is in fact a bog-standard mechanical ventilation question, that asks "what's likely to limit their progress". The stem is rich with detail, which means it should not be ignored that the patient:
There are two ways of approaching this: cycle through this list of facts to discuss how each affects weaning, or cycle through the list of the causes of weaning failure to discuss how each cause is represented in the list of injuries. Each has merit, but in the following answer the former was chosen, because it felt like trainees would benefit from consistently applying the same structure to such questions in the future (and the question details will change, whereas the causes of ventilation failure will remain the same). Thus:
| Airway safety |
|
| Respiratory load |
|
| Cardiac load |
|
| Neurological causes |
|
| Musculoskeletal causes |
|
| Metabolic disturbances |
|
Funk, Georg-Christian, et al. "Incidence and outcome of weaning from mechanical ventilation according to new categories." European Respiratory Journal 35.1 (2010): 88-94.
Boles, Jean-Michel, et al. "Weaning from mechanical ventilation." European Respiratory Journal 29.5 (2007): 1033-1056.
McConville, John F., and John P. Kress. "Weaning patients from the ventilator." New England Journal of Medicine 367.23 (2012): 2233-2239.
Hendershot, Kristopher A., and Kristine H. O’Phelan. "Respiratory complications and weaning considerations for patients with spinal cord injuries: A narrative review." Journal of personalized medicine 13.1 (2022): 97.
Piesesha, Virgiana. "Ventilator Weaning Difficulties in ICU: A Study on VAP Patients with Post-Tracheostomy, Thoracic Trauma, and Thoracic Spinal Cord Injury." Jurnal Kegawatdaruratan Medis Indonesia 4.1 (2025): 1-13.