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Bethany Hamilton sustained blunt force Trauma to the left side of her body from a shark bite leaving her upper left extremity amputated at the scene.

Rapid transfusions of O- PRBC x2 were given until lab results are processed. 1L of NS was also given to try and elevate her blood pressure.

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Medical Lab:

What labs would we prioritize getting? What do the lab results show on B.H.?

Respiratory:

With everything happening in this scenario, do you think we should intubate? What do her ABG results show? And what medications would be given if we needed to intubate her?

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For respiratory based on current vital signs, patent airway, clear breath sounds and GCS it does not look like we need to intubate. After an ABG is drawn we can further evaluate her need for intubation. If her ABG presents a pH of <7.20 accompanied by a high CO2 intubation would be a good option then. For now she is satting well on 6 L/min via simple mask but it would be beneficial to bump it up to 7 L/min to improve SaO2 a bit more. If her shallow and tachypneic breathing does not improve we could then try non-invasive ventilation before intubating. If she needs to be intubated in the future we should consider giving her some sedatives/paralytics prior to intubation.

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These are results for the initial chemistry tests for Bethany Hamilton. The elevated lactate is likely due to lack of oxygen in the tissue due to blood loss and the increased CRP is likely due to the trauma. The patient has a decrease in GFRe and an increased BUN, creatinine, and BUN creatinine ratio which may indicate acute kidney injury also due to the lack of blood flow. Serum HCG ran on female patients who are likely to go to surgery or have a procedure done (at some facilities). Kidney function, CRP, and Lactate will likely improve with replacement of blood and fluids. CRP and Lact may not improve if patient later develops an infection due to the bite.

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B.H. Blood Bank and Hematology Initial Results

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B.H. Blood Bank and Hematology Initial Results

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The following results are from the Type and Screen and an automated CBC:

Type and Screen Results:

Blood type- O-

Antibody Screen-negative

CBC Results:

RBC- 2.95 -   L

HGB-7.1 -       L

HCT- 27.3-     L

MCV-69.7-    L

MCH-22.6-   L

MCHC- 30.8-   L

RDW-18.4-    H

PLT-387

WBC- 5.5

Neutrophils-54.7%

Lymphocytes-34.1%

Monocytes-7.5%

Eosinophils-3.0%

Basophils-0.7%

With the results from the type and screen, there should be no transfusion reactions but continue to monitor as protocol indicates to be sure
The CBC results are to be expected after a traumatic injury with blood loss. The RBC, hemoglobin, hematocrit, MCV, MCH, and MCHC are all low due to the loss. The RDW is high because of the different size of sells present after transfusion. Platelets are on the higher end of normal because of the trauma, it would be a good to continue to monitor this count and possibly get coagulation tests done to monitor clotting. The WBC is on the low end of normal. Likely caused by a steep decrease initially with the blood loss, but an increase following due to the inflammation and physical stress of the trauma. It would be good to continue monitoring the WBC count to see if it increases as an inflection sets in or not.

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We will continue to provide O2 via face mask at 7 L/min and monitor for breathing or sat changes that may lead to the need for intubation.

There will be an intubation kit in the room if needed.

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We would continue to give the patient blood products to increase her blood counts while monitoring for any reactions. CBC tests will continue to be drawn periodically to check for improvements.

Coagulation tests will be ordered and drawn to monitor clotting and coagulation factors.

Patient will be monitored for any signs or symptoms of infection due to the low WBCs.

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O2 and blood products as well as fluids will be continued to improve kidney function and lactate levels. Signs and symptoms of infection will be closely watched.

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Where is the tourniquet placed? In the assessment drawing there is no remaining limb to tourniquet. Was the entire humorus pulled out by the shark, was shoulder bitten off as well?

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PTT - 109

PT/INR - 75.4/6.43

Fibrinogen - 123

DDimer - 3341

The above values represent a typical coagulopathy picture of a patient who has suffered traumatic injury.

Increased PT/PTT values can indicate the depletion of clotting factors in the plasma and are expected to return to normal once hemostasis is achieved.

Fibrinogen is expected to decrease in trauma patients but should slowly begin to return to normal levels as seen here. However, fibrinogen is an indicator of bleeding in trauma patients and should be monitored closely along with PLT count to assess risk for bleeding, especially if patient will undergo multiple corrective surgeries.

DDimer is expected to be elevated after trauma due to inflammation and fibrinolysis. This is also expected to deplete back to normal levels.

Be advised that these levels may fluctuate if the patient is undergoing multiple surgeries in a short span of time.

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As the RN receiving report of this patient (Case study 3) there are some further complications that are concerning. A concerning risk factor is for surgical site infection, there is many sources for B.H. that could cause an infection. She had a major break in skin and an upper limb amputation, she was exposed to infiltrates from the ocean and the shark bite. Additionally, blood transfusions also increase risk of infection. In SAITO(et al., 2022) the site that 1.8% of patients suffered from a surgical site infection. This risk of infection can be mediated by debridement, wound care, and surgical measures to prevent infection. - Elisabeth D. RN

SAITO, T., UEHARA, T., NAKAHARA, R., SHIMAMURA, Y., NAKAO, A., & OZAKI, T. (2022). Risk factors for infection following operative treatment of traumatic upper extremity amputation injury. The Journal of Hand Surgery (Asian-Pacific Volume), 27(04), 691–697. https://doi.org/10.1142/s2424835522500709

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Looking at a continuation of care/risk for infection for this patient my top priorities are lab values, airway management, and ABC. Looking at the lab value marker for infections, WBC are WNL and others are also WNL. I would also continue to monitor the WBC for signs of infection. The lactic level is also slightly elevated. This can be elevated due to infection, but also to a variety of other reasons.

for Airway, CO2 levels are wnl and is a sign of adequate oxygenation.

Elisabeth D. RN

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Looking at further complications and patient progress I would be concerned about their airway, breathing, and circulation status. I concur with you assessment of respiratory function. I love to have the information from the ABG and chest xray for any chest or lung damage. I would continue to monitor her airway management and work of breathing.

Elisabeth D. RN

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RBC- 4.3   -    L
HGB- 11.2  -    L
HCT-32.2   -   L
MCV-81.6
MCH-29.9
MCHC-32.7
RDW-13.7.  -     H
PLT-321
WBC- 13.5.   -   H
Neutrophils- 74.1%
Lymphocytes-20.2%
Monocytes-5.4%
Eosinophils-0.2%
Basophils-0.1%

The RBC, HCT, and HGB are all still low but near normal which is good. The RDW is still slightly high but nearing normal as well. The WBC is elevated which correlates to the suspicion of infection. With the highest percentage of WBC’s being neutrophils, it is likely that a bacterial infection is present.

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RBC- 4.3   -    L

HGB- 11.2  -    L

HCT-32.2   -   L

MCV-81.6

MCH-29.9

MCHC-32.7

RDW-13.7.  -     H

PLT-321

WBC- 13.5.   -   H

Neutrophils- 74.1%

Lymphocytes-20.2%

Monocytes-5.4%

Eosinophils-0.2%

Basophils-0.1%

The RBC, HCT, and HGB are all still low but near normal which is good. The RDW is still slightly high but nearing normal as well. The WBC is elevated which correlates to the suspicion of infection. With the highest percentage of WBC’s being neutrophils, it is likely that a bacterial infection is present.

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Mikaila Turcotte

(Case Study 3)

My group decided to focus on the potential complication of surgical site infection after B.H. amputation of upper left extremity. There is a large potential for infection based on the nature of the initial amputation which took place in the ocean from a bite from a shark. This exposes the site to multiple different microorganisms present in the water. prior to the surgical closure of the site. Seidelman et al. (2023) states that when somebody undergoes surgery, there is between a 0.5% to 3.0% risk of infection. This risk that occurs with every surgical procedure, combined with the potential wound site contamination that occurred from where the initial amputation took place. Certain things that can affect whether a person will develop an infection would be if the persons immune system, degree of bacterial wound contamination, presence of foreign material, and if prophylactic antibiotics were used (Seidelman et al., 2023). Post op monitoring for signs of infection are important which include redness, swelling, extreme pain, purulent drainage, warmth to the site, and fever.

Seidelman, J., Mantyh, C. R., & Anderson, D. J. (2023). Surgical site infection prevention. JAMA, 329(3), 244. https://doi.org/10.1001/jama.2022.24075

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To manage and monitor for the potential complication of surgical site infection, labs need to be closely monitored. A large spike in white blood cell count could be an indicator of an infection as well. CRP is another lab that would be beneficial to monitor, as infection can increase the level of CRP in the body. Blood cultures could be taken if sepsis is suspected or if fever is high in this patient. Wound cultures could also be taken to see what type of infection is taking place. Lab, is there anything else that you believe that I am leaving off that would be beneficial to monitor?

Mikaila Turcotte

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As far as management of potential complications, the patients airways seems to be maintained. She is still sating good on a simple mask but i agree she would benefit from bumping her O2 up to 7L to maintain good oxygen saturation. I believe that we would need an ABG to properly be able to assess whether she is properly oxygenating as her breathing is shallow and tachypneic. Close monitoring of patients airway and breathing would be necessary going forward.

Mikaila Turcotte

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If I was the nurse receiving report on this patient (case study 3) a big complication I would be worried about infection. Having a big open wound creates a large concern for infection. Especially after a limb amputation. She was also exposed to seawater and bacteria from the shark that bit her arm off, which could aid in her risk for infection. To prevent complications further down the road of potential sepsis due to the infection, close monitoring as well as cultures and antibiotics should be added to the care plan (Morgan, 2022).

Morgan, A. S. (2022). Risk factors for infection in the trauma patient. Journal of the National Medical Association, 84(12), 1019–1023. https://pubmed.ncbi.nlm.nih.gov/1296993/#:~:text=The%20traumatized%20patient%20has%20a

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The tourniquet was places as far as EMS could place above where the shoulder would have been. The limb including the humerus was not found at the scene, so yes, her whole arm was bitten off clean by the shark. EMS was watching for extensive bleeding, and the patient was transferred to the hospital for further intervention to help stop the bleeding and to help stabilize her enough to get into surgery.

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Additional test: Procalcitonin value: 0.24 (Range <0.05 normal, 0.05 – <0.5 systemic infection unlikely; possible local infection, 0.5 – <2 possible systemic

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CRP and Lactate are still elevated but they are coming down. BUN is also going down with the blood and fluids. A procalcitonin was added and the value is slightly elevated. This can be from the start of an infection.

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PTT - 28

PT/INR - 12.0/1.1

Fibrinogen - 225

DDimer - <200

The patient's values represent hemostasis returning to normal. All values are within normal range. The time course of changes in DDimer values with trauma patients typically show an extreme increase in levels followed by a rapid decrease back down to normal levels. Patients who then develop a second rise in DDimer levels are at risk for pathological thrombosis. It is advised to monitor until patient is deemed stable.