Home > Anaesthesia, Emergency Medicine, Orthopaedics, Prehospital Care > Term 4 Week 10 (w/c 5/11/12)

Term 4 Week 10 (w/c 5/11/12)

Thanks for a fantastic term so far. The Gasclass Team have learnt loads so it must have been good. We have taken our total of views on the Gasclass Blog over 11000 and if only someone in China could see it we could cover the globe. this is truly a worldwide anaesthesia class.

This week we are starting off in the field….literally.

You are watching the local Under 17 Rugby team playing their nearest rivals. There are some wonderfully timed tackles going in but the referee has called the game to a halt. Following the last big pitch pile up one of the boys is motionless face down in the mud. The referee calls for some assistance, especially if there is a doctor or anyone else who can help.

For the purposes of North America please substitute American Football or Ice Hockey as you wish. For the rest of the world, you know what we mean.

As you run onto the pitch what are you thinking?

He is now turned over by you and four helpers, whilst maintaining in line immobilisation. He seems a little dazed but obviously in pain. A brief review shows an obvious deformity of his right lower leg. It is an easy decision that he needs removed from the pitch and the spine board is brought down from the club shed. After removal a helpful local doctor who was watching the Under 14s next pitch says he has a medical bag…….

What in your perfect world would you want him/ her to magic out of this bag?
Just tweet one suggestion!

Lots of great suggestions on the Twitter feed. First and foremost is the suggestion that a phone is the place to start. As long as he has an Ac and a B assessment it is now fairly obvious that he needs to go to medical care. There are many who believe that Ketamine is an excellent choice of analgesic in this situation, but equal proponents of Morphine and Entonox. Clearly the role of potent analgesia must follow a neurological observation.

Assuming his neuro observation is satisfactory and he is compliant:

Which pitch side analgesic do you prefer?
Tweet one word Morphine / Ketamine / Entonox / Other (what exactly?)
We really want some newbies to tweet their preferred choice including non anaesthetists.

The boy has now arrived in the emergency department and it is noticed that he has a white foot.

What is your plan now?

Generally its clear now he needs some kind of treatment and after a temporising manipulation it is decided to move urgently to theatre. The induction proceeds fairly as planned but it seems to be deteriorating some while in.

Any thoughts?

 

 

Ask The Expert….

 

This week we have asked a new expert Phil who is a Pre Hospital Consultant.

 

The optimum analgesic agent to give in the pre-hospital environment is open to debate and will depend on the patient as much as the injury. My preference for a closed tibial fracture would be start with entonox and progress to an IV opioid if required. I would normally reserve ketamine for tibial fractures that required urgent manipulation to salvage the foot or the skin integrity. It should be remembered that immobilising and splinting alone can provide excellent analgesia.

Once this patient arrived in hospital, he was rapidly transferred to theatre for fixation which was entirely appropriate. Some way into the operation he developed a tachycardia and hypoxaemia. The possible causes for this are many and varied so it is important to have a structure in mind, and gather further information to assist in the diagnosis. Fat embolism syndrome is one possible cause and is a known complication of intra-medullary nailing of long bones. It is however important to exclude other potentially life threateneing conditions such as a pneumothorax (we may have missed his rib fractures!), bleeding or PE.

 

Thanks to everyone this week for contributing. Our favourite Tweet was that the Magic Doctor Bag should have an ultrasound machine in it. Ideal!

There are no trick questions in #gasclass. It is an educational tool only. Everyone’s opinion is as valid as the next person. Follow the conversation by using (or searching for) the hashtag #gasclass on twitter. We welcome input from all specialties and you can send us a direct message if you would prefer to remain anonymous.

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