Term 8 Week 2 (w/c 26/5/14)
Good morning and welcome to a new week of Gasclass!
You are on call for anesthesia and your pager goes off: “Level 1 Trauma MVC multip inj. ETA 20mins”. When you call down to the ED to find out more about the patient, they can only tell you that he’s the driver of a high speed single car rollover, and there are multiple severe injuries, not intubated. They are being airlifted by helicopter from the scene directly to your hospital.
What potential injuries are you concerned about? Is there anything, if any, that you would like to do or prepare in the next 20 mins?
Given the additional information that you’ve received from HEMS, you have asked for a fiberoptic bronchoscope to be brought down and a tracheostomy tray opened and ready. 4 units of trauma O pos blood is in the room. You have informed the OR and they have set aside a room and one of your anesthesia colleagues is preparing the OR.
As the HEMS arrives they swing the pt into the trauma bay and quickly give handover:
“This is a 50yo man, belted driver in a T-bone with a large truck and subsequently rolled over. Extrication was approx. 30mins. He has an expanding subcu emphysema in the neck and hoarseness, but has maintained spontaneous breathing during transfer. There was an episode of decreased air entry on the left and hypotension enroute so we did a needle decompression that seemed to have helped… He was complaining of severe chest and back pain, and has decreased sensation in his lower limbs. His pelvis was bound on spec because there was severe intrusion of the driver side. He was GCS 13 on scene and had no recollection of the collision.”
Vitals currently are: HR 144 BP 95/32 SpO2 93% on 100% assisted BMV with self-inflating bag.
What are your concerns at this point?
Bilateral chest tubes are inserted under local. A moderate amount of blood is drained from the left side. You proceed to secure the airway with collar off and MILS.
Post-intubation vitals HR 155 BP 75/30 SpO2 90% on 1.0 FiO2.
FAST is positive for fluid in pelvis. Subcostal view is nondiagnostic. The CXR shows a possibly enlarged mediastinum, multiple rib fractures and subcu air. There appears to be pneumopericardium. The TTL wants to do a log roll and change the pelvic binder before proceeding to CT scan.
Brief exam of the lower extremities reveals an enlarged, tense and bruised left thigh.
What are your next steps?
You accompany the patient with the trauma team to the CT scanner. The prelim report shows multiple rib fractures on the left side and underlying lung contusion, massive subcu air in the upper mediastinum, chest wall and neck. Descending aortic dissection starting at the left subclavian, and may involve part of the subclavian. There is a pelvic ring fracture and a left femur fracture.
What are the options for management of this patient?
After some discussion, it is decided to begin with IR embolization of pelvic bleeders and TEVAR for repair of the aortic injury. Orthopedics wants to piggyback with pelvic ex-fix and femur ORIF. During this time the patient continues to hypotensive.
What are your concerns with this plan and what is your anesthetic plan? What would you do if you suspect the hypotension may be due to neurogenic shock?
Thank you everyone for another fantastic discussion! Storify summary is here. This week we had a very tough trauma scenario that had a lot of conflicting priorities and diagnostic dilemmas. It’s not entirely unrealistic, and I think everyone did a great job!
Next week we will return to pediatric anesthesia with a short series of scenarios.
Remember there are no right or wrong answers. Please tag your replies on twitter with #gasclass!