Although none of the editors of InsideSurgery.com are participating in her care, we have noted that Charla Nash, who was viciously attacked by an adult male chimpanzee February 26, 2009, is reportedly improving and is now following commands.
She is currently hospitalized in the intensive care unit at Cleveland Clinic in Ohio, where she was transferred from Stamford Hospital in Stamford, Connecticut after she was initially treated about the attack.
Her brother, Michael Nash, is reporting on NBC News that his sister is still being heavily sedated but that she is moving and following simple commands. Dr. Kevin Miller, her treating trauma surgeon at Stamford Hospital reported that her two main clinical issues at this time are traumatic brain injury and infection.
Doctors treating her are detailing injuries that include neuro trauma, traumatic amputation of both her hands and loss of her lips, nose, and eyelids.
Although care for each patient in the ICU is customized, there are general treatment strategies that are used by all trauma and critical care physicians in treating severely injured patients such as Nash. A typical treatment plan would be as discussed below:
Patients such as Nash who have such devastating injuries usually suffer hemorrhagic shock from blood loss and are often seen in the trauma bay with a low blood pressure. The first order of business is to stop the ongoing bleeding. In the field, paramedics would place direct pressure by manually holding bandages on the nose, lips (which are very vascular) and eyelid areas to control bleeding.
In addition, pressure or, with experienced paramedics in the setting of life-threatening hemorrhage, tourniquets are placed on the stumps where the hands were avulsed or torn off.
The prehospital team would also immediately place intravenous lines (IV’s) so that blood and fluids can be administered. The goal is to place at least two large bore (16 Fr.) in the antecubital areas (at the elbow crease).
Likely in a situation such as Nash’s with extensive facial trauma and blood loss and with the report that she was not arousable when they arrived at the scene, the prehospital team would attempt to place an airway. In patients with extensive facial trauma it is possible that placing an endotracheal tube would be difficult and consideration would be given for an emergent or urgent cricothyroidotomy.
A styrofoam collar would be placed around her neck to stabilize her cervical spine in case of fracture or dislocation.
On the transfer to the trauma bay, the patient would receive packed red blood cells. Upon arrival in the trauma bay, a series of diagnostic and therapeutic events take place.
The classic teaching for trauma surgeons upon arrival of a patient in the trauma bay is evaluating a patient using the protocol is known as the ABC’s – an acronym for airway, breathing, and circulation.
A patent airway is needed for the patient to be ventilated and oxygenated. In a situation like Nash’s with such devastating injuries, if the airway had not been placed in the field, it would be done immediately either by intubation or cricothyroidotomy.
The assessment of breathing is an assessment of the function of the lungs. This is done by auscultating the lung fields with a stetoscope evaluating whether the breath sounds are heard on inspiration. Loss of lung sounds in one or both lungs are a sign of pneumothorax, hemothorax, tension pneumothorax, and malposition of the endotracheal tube in one of the main stem bronchi.
Circulation is assessed by the heart rate of the patient and the systolic and diastolic blood pressure. The heart rate is usually evaluated by placing monitor leads on the patients chest that send electrical signals similar to a continuous electrocardiogram. The blood pressure is taken initially manually by sphygomanometer (blood pressure cuff), with many trauma programs requiring the first three blood pressure recordings to be manual recordings.
Because of her injuries Nash was undoubtedly taken to the operating room shortly after arriving at the hospital trauma bay.
After the initial stabilizing surgical procedures are completed, patients such as Nash are taken to a surgical intensive care unit. The initial goal in the first 24 to 48 hours is to stabilize the patient in the face of any ongoing blood loss and the likely massive systemic inflammatory response (SIRS) patients that are severely injured undergo.
She would be continued on a ventilator and given pain medication and sedation. A typical regimen would be an around-the-clock infusion of the narcotic fentanyl (i.e., a fentanyl drip) and an around-the-clock infusion of midazolam (Versed).