A 52-year-old worker of normal body habitus was injured in a fall from approximately 15 ft (5 m) of height. He sustained fractures to the vertebral bodies of C3 and C4, as well as a C5 transverse process fracture. He was retrieved by an ambulance team and admitted to the hospital in a hemodynamically stable condition. His breathing on admission was noted to be normal, albeit with decreased air entry to the right side. An infiltrate on chest x-ray was consistent with aspiration. Neurologically, the patient was awake and alert. He had evidence of a Brown-Sequard syndrome with an almost complete paralysis of his left limbs and a sensory deficit on his right.
The patient's neck had been placed in a rigid cervical collar at the scene and he was given oxygen via a face mask. Tracheal intubation was performed uneventfully by elective bronchoscopic intubation in the operating room (OR) for dorsal fixation of his C-spine. Completion of internal fixation by ventral stabilization was planned at a later date and in the interim the patient was placed in a halo frame for external fixation (Figure 29-1). He was then transferred to the intensive care unit (ICU) intubated and ventilated, as his oxygen requirements had increased to 60%. An aspiration pneumonia was suspected and he was sedated and ventilated according to a lung protective ventilation strategy.
Patient with Halo frame for stabilization of cervical spine fractures (produced with permission).
Past medical history included hypertension, GERD, and a question of significant alcohol consumption.
By day 3 of his ICU admission, the pulmonary situation had improved marginally. He still required a FiO2 of 0.45 and was breathing spontaneously with a pressure support of 12 cm H2O and positive end-expiratory pressure (PEEP) of 10 cm H2O. Attempts to wean the pressure support had failed at that point, resulting in tachypnea and oxygen desaturation. Thick purulent sputum was being suctioned from his endotracheal tube (ETT) twice per shift, and he was receiving empiric antibiotics to treat his presumed pneumonia.
Agitation had become a major issue, thought to be delirium tremens secondary to alcohol withdrawal. A cranial CT had ruled out posttraumatic intracerebral hemorrhage as the underlying cause. The patient was difficult to manage, often requiring more than one nurse at the bedside, and he had tried to remove lines and ETT with his functioning hand. For this reason he required passive restraints and sedation.
On day 4, the bedside nurse called urgently to report that the patient in his agitation had bitten off the pilot line to the ETT cuff. The cuff was leaking and the patient was being inadequately oxygenated, with a drop of SpO2 to 87%.
29.2.1. Medical Considerations