Case Week 3 (w/c 17/10/11)
This week the case will start off with some Pre hospital information for front of house staff. We would like contributions from those who might receive patients in the first instance. No single tweet will raise all the relevant points so we would like as many as possible to join in. This case is suitable for all receiving specialities as well as general practice.
An 8 year old boy is being brought into Emergency Department. He has been cycling in the woods with friends and has run into a tree at speed. The Paramedics report that he is a bit breathless, although his saturations are 100% on Oxygen. He is complaining of some pain in his chest.
What are your initial thoughts and actions?
Thank you for comments so far.
Our 8 year old boy has now had analgesia in the form of paracetamol and morphine IV to total 0.2 mg/kg.
He is more sleepy now and not crying. His breathing is still a little laboured and expansion not equal both sides. ABG have been performed. pH 7.4, pCO2 6.9, pO2 18.6 on 15l reservoir mask.
The CXR has been performed on portable (poor quality) and a CT chest and abdomen is requested as well as plain films of Right femur. These results will follow. What is the ideal (alveolar) gas equation. What is the minimum FiO2?
The CT chest and abdomen only confirm the Right pneumothorax. There is no tension. The EM doctors have now decided that a chest drain is required. You are the anaesthetist on call. The EM consultant phones you and says that she has an 8 year old boy who needs to go to sleep for insertion of chest drain. She is quite clear that he will not be able to cooperate with this procedure without anaesthesia.
What are you thinking as you walk down the corridor?
It’s been a very long corridor and you have had plenty of time to think of plan A and plan B.
When you arrive in resusc your end of bed assessment is a frightened 8 year old boy, just over 30 kg ( experienced estimate). The pneumothorax is known about and EM would like to insert chest drain with help of anaesthesia. He also has a soft tissue injury to his thigh which is dirty and soiled from the tree. This needs a washout as well. Orthopaedics are now involved as well and would like to take him to theatre.
Blood tests are unremarkable. Observations stable and unchanged over last 30 minutes.
Mum has turned up. History is previously fit and well. Fasted for three hours prior to accident. You note a wobbly upper right B tooth where he has banged his face.
Is your plan going to change?
Time to wrap up the case.
The approach to all trauma cases should take an ABCDE approach. The core findings in this case showed a child in a relatively stable condition needing closer respiratory assessment and pain relief.
Blood gas analysis showed a significant Alveolar arterial oxygen gradient AaDO2 which is always worrying. One should never be reassured by saturations in the presence of high concentrations of inspired oxygen.
CXR and other investigations revealed a pneumothorax which clearly needs treatment.
Anaesthesia for this is not needed in a cooperative patient. However at 8 years old this may be a fairly disturbing experience. General anaesthesia brings a risk of aspiration so prompts endotracheal intubation and positive pressure ventilation. This could make the pneumothorax much worse and prompts a different decision. Experience prompts good preparation for whatever the eventuality is going to be.
Emergency Doctors feel comfortable with Ketamine as a dissociative anaesthetic analgesic and it may well be just the trick for this problem. The child will continue to breath spontaneously and hopefully tolerate the procedure. Many Doctors are convinced they can manage this well. However the last piece of information that more is required pushes most anaesthetists to reconsider that a GA seems sensible to carry out all treatments for an 8 year old at the same time.
Some however still liked the idea of Ketamine for this too.
There are no correct answers to this dilemma. However there may well be wrong answers and the decision depends on experience. No plan is ever going to survive without a backup and this case exemplifies that knowing what will happen next is the most important thing to think about.
If you have any other comments please let us know.
Transcript for Week 3 #gasclass – Transcript Week 3