Home > Uncategorized > Term 7 Week 9 (WC 1/12/2013)

Term 7 Week 9 (WC 1/12/2013)

December 1, 2013

Hello and welcome to December. This week’s Gasclass is under the guest editorship of Traumagasdoc and one of his registrars, Laura.

The case that will underpin the learning this week is a real one that came in recently. The patient has given written consent and is thrilled that her case is being used for education. She is doing well, and will be shown the discussion that results from this. Trauma care is truly multidisciplinary and we welcome other specialties to contribute.

You are the anaesthetist on call in a Major Trauma Centre. A trauma call goes off and you attend resus. On arrival you are told that HEMS (the pre-hospital emergency service) are bringing in a 23 year old female pedal cyclist vs lorry. She is GCS 15 (fully conscious) but has had a prolonged extrication from underneath the lorry and is bleeding extensively. You have ten minutes before the patient arrives.

What injuries are you expecting?
How are you going to use these ten minutes?
What will you prepare and who will you call?

Please add the hashtag #gasclass to all twitter contributions including replies. More detail will be added later. Don’t be shy, please join in.

The ten minutes before arrival
Thank you to everyone who contributed so far. The ten minutes or so preparation time is so important and needs to be used well. I’m going to add a few tips here from my own experience. They’re not definitive and other ways are available, but they’ve stood me in good stead over the years.

The pre-alert is so important because it gives you an idea of the possible injuries. Cyclist vs lorry makes you think of lower limb, abdominal and chest injuries. The fact that she is fully conscious makes a head injury less likely, but nothing is ever impossible and we must obviously be ready for anything. Injuries I would be expecting are degloving injuries, pelvic and other long bone fractures and abdominal bleeding. The prolonged extrication means that (certainly in our climate) your patient is likely to be hypothermic.

I often think of trauma as having a patient whose operation started 30ish minutes ago, no one is willing to tell you what operation it is and we have to play catch up and sleuth to find out exactly what was done.

Things to do in your first ten minutes:

Make sure you know your trauma team. Introduce yourself to the trauma team leader and find out their name. I have a personal aversion to being known as Anaesthesia (except possibly on Saturdays). Names are really important for good team function. This is going to be a challenging case, and there’s certainly too much to do for one anaesthetist. Get your boss in. You need three people at the top end minimum: either 2 great ODPs and one anaesthetist, or 2 anaesthetists and one great Odp. Ideal is 4 people…one flying the plane, one on blood, one on procedures, one looking ten minutes ahead and getting stuff ready. Assign these roles before the patient arrives. The most senior anaesthetist should be in overall control.

For a case like this where you know there’s going to be bleeding get your rapid infuser primed and ready. Ensure there’s a pelvic binder in place and a warming blanket which is on and blowing warm air. Check all your kit, make sure you have GA drugs and emergency drugs to hand, your airway equipment and suction. Get your ODP to run through arterial line transducer set.

Activate your hospital’s major haemorrhage protocol. Please make sure you tell transfusion it’s a young woman. Rh negative blood is a rare precious resource and O-pos is often given to men and postmenapausal women. Giving a young woman Rh positive blood may impair fertility later on in life.

So, we have our team ready and briefed, rapid infuser prepared and blood/FFP on its way. Let’s get going.

The patient arrives in resus with HEMS, and is transferred on to the A&E trolley on a scoop. You receive the following hand over in addition to information already provided:

From top to toe, the patient has sustained injuries including an open pelvic fracture, perineal/PV bleeding, tyre marks to right thigh, open left tib/fib fracture, and her abdomen appears distended. She has remained GCS 15 throughout transfer but became haemodynamically unstable during transfer.

Management to date includes C-spine immobilisation, high-flow oxygen, 2x 16g IV access, 2 units of O negative blood (second unit currently running), pelvic binder, box splint left leg, 10mg IV morphine, 1g tranexamic acid.

Latest observations include HR 92, BP 90/40, RR 26, sats 98%, temp 35.3oC. She is normally fit and well with no known drug allergies.

What are your main concerns?

How would you initially manage this case?

What investigations would guide your resuscitation and ongoing care?

Please add the hashtag #gasclass to all twitter contributions including replies. More detail to be added later.

Thank you for all your contributions.

Haemorrhage and the potential for coagulopathy are obviously a prime concern, along with the severe injuries which are clearly the result of a high-energy impact. There will need to be input from multiple surgical specialties – ortho, general, gynae.

Initial management will need to include A with C spine control, B with adequate ventilation, C & D. Circulation is what needs immediate attention. At least 2 peripheral IV access (at least 16G), warmed blood and blood products. Consider rapid infuser line and have a Level One infuser available and primed. Close communication with haematology and blood bank. Tranexamic acid, arterial line and keep the patient warm. Don’t forget analgesia and antibiotics for open fractures, tetanus status and AMPLE history.

Investigations should include FBC, clotting, U&E, full cross-match, glucose and venous or arterial blood gas. Helpful point-of-care tests also include the use of TEG. FAST scan and the usual primary survey imaging– C-spine, chest & pelvis x-rays. Further imaging (i.e. CT) is required, but only if the patient is stable! Don’t forget the importance of clinical parameters – RR, HR, BP, cap refill to guide resuscitation.

Our patient has now received 4 units of red blood cells, 3 pools of FFP and a pool of platelets and her HR is 75 and BP 105/60. She remains GCS 15 and is saturating 100% on 15l/min oxygen. Venous blood gas shows pH 7.53, Lactate 1.8, BE -3.5 and Hb 9.8. With haemodynamic stability achieved, the patient is transferred to CT.

CT shows the following injuries:

-pelvic free fluid

-uterine irregularity

-rectal irregularity

-complex pelvic fracture including bilateral sacral foramina, right iliac wing, bilateral superior and inferior pubic rami and bilateral acetabulum. There is displacement of the right SI joint and diastesis of the pubic symphysis.

-haematoma anterior to the bladder but no active extravasation of contrast

-haemoperitoneum

-L5 spinous process fracture

-normal spleen, liver, head and C-spine.

How should the patient be managed next?

What injuries require most urgent attention?

All comments and input welcome! Please add the hashtag #gasclass to all twitter contributions including replies.

The patient remains stable in CT and the decision is made to return to resus to complete a secondary survey.

The gynaecologists have been called to attend. Initial TEG data back – R 4.6, K 2.1, Alpha angle 61.3, MA 59.8.

The pelvic and perineal injuries are assessed by the orthopaedic, gynaecology and general surgeons. The pelvic fracture is open, there are significant perineal & vaginal soft tissue injuries and a urethral catheter cannot be passed. PR is normal.

The decision is made to go to theatre in a joint surgical procedure for pelvic ex-fix, debridement of wounds, EUA of perineum and pelvic organs and insertion of suprapubic catheter.

How will you anaesthetise this patient?

What considerations need to be made with transferring and positioning this patient?

How will you manage intra-op and post-op pain?

All comments and input welcome! Please add the hashtag #gasclass to all twitter contributions including replies.

And so to theatre…

The patient is transferred to theatre with full monitoring. She is transferred on to the operating table by log-rolling as the C-spine is not clinically cleared. The pelvic binder is removed in preparation for surgery.

An arterial line was sited in resus and she is anaesthetised with a rapid sequence induction with in-line C-spine immobilisation. She is a grade I intubation. Anaesthesia is maintained with desflurane and remifentanil. A decision to not site an epidural is made in view of the haemorrhage and difficult positioning of a patient with an unstable pelvic fracture. Analgesia is provided by paracetamol, morphine and infiltration of local anaesthetic, with a morphine PCA post-op. Intra-operatively 3l crystalloid and 2 further units of blood are infused.

An MDT approach to positioning of this patient is key. Gynaecologists require lithotomy position, which is difficult with a pelvic fracture. The pelvic ex-fix is fitted first to stabilise the pelvis, to then allow gynaecologists to make their assessment, definitively control the perineal bleeding and to site a suprapubic catheter. Urethroscopy demonstrates that the urethra has been transacted.

The patient remains haemodynamically stable, arterial blood gases and TEG values are normal and she is extubated at the end of the case. She is managed on an HDU post-operatively.

The patient returns to theatre on several occasions for definitive fixation of the pelvis at which point an epidural is sited; for left leg VAC dressing and then later debridement and skin grafting of the leg wound. A urethral catheter is also sited and remains in-situ for two weeks, concurrently with the supra-pubic catheter. The patient has to have non-weight bearing rest for the pelvis for six weeks, is having ongoing urodynamic investigations but is doing incredibly well.

 We would like to say a huge thank you to this fantastically strong young woman who has generously allowed us to share the lessons we learnt from managing her injuries.

Any further comments and feedback welcome. Don’t forget to include #gasclass!

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