Term 2 Week 10 (w/c 19/03/12)
This is the final week of term. It has been an excellent ten weeks and we have covered a lot of different discussion points. We are returning the Emergency Medicine Department this week for a final session.
It is midnight in the EMD. There are two cases ‘on route’ who have been phoned in by ambulance services. There has been a fatal accident and two further teenagers have been trapped in the vehicle with burns. They are now extricated.
Both patients, one female and one male are on their way. What drugs are you going to get out of the cupboard and fridge?
Both patients have now arrived in the ED. The team in attendance consists of you and the Emergency Medicine team. Additional anaesthetic / critical care help is on it’s way but will not be available for upto 15 mins
Provisional clinical details of the 2 patients is provided below
Patient 1: Unrestrained driver. Apparently thrown from vehicle. Adult male.
Confused at scene, now increasingly combative. Smells of alcohol.
SpO2 96%. No obvious chest injury.
Radial pulse barely palpable. Cool peripheries. Pelvis splint applied prehospital.
Patient 2: Restrained passenger. Adult female.
Trapped in partially burning vehicle for up to 10 mins prior to being dragged out by passer by.
Obvious burn to right side of torso. Talking, slightly hoarse voice. Intermittently drowsy.
How will you manage your team and prioritise treatment in the next few minutes. State any clinical features that may help in your decisions. There are no right or wrong answers here.
After securing the airway in patient 2, the ED staff feel able to continue her care. Bloods are sent from both patients and critical care help arrives allowing you to solely concentrate on looking after patient 1.
There is no obvious airway or chest injury. He is obviously shocked. Pelvic splint is applied and he has had 2 x 250ml fluid boluses to which he is a ‘partial responder’. There are no external signs of head injury but he is agitated.
You perform your preferred choice of RSI. He remains hypotensive. Cross matched blood is 40 mins away. The surgeon is keen to take him for CT prior to any trip to theatre.
What is your strategy for this patients subsequent management including any trip to the operating theatre?
You take the patient for emergency laparotomy. The surgeon has agreed that damage control is the priority and the plan is to take him to critical care immediately post op for on going resuscitation.
Intraoperatively however, things start to go wrong. The anaesthetic chart is illustrated below
What are the possible causes for the above? How would you manage it?
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