Thank your great comments and participation in this case. As we mentioned at the start of the case, the idea is not to lecture, but to share ideas and reflect on the generic issues that a case like this might reveal.
I thought I’d finish with a little summary and conclusion of the tricky decision making steps with regards to a case like this. These comments are my own and based on a bit of experience and background reading. As always, summoning help early and asking the experts and keeping up with relevant evidence base is super important. I am not trying to tell you how to do it, my aim is to get you to think about how you would manage a patient like this if you ever needed to.
If you have any further points please tweet us and remember the hashtag #gasclass so everyone can follow you comments.
Day 1: “Should I stay or should I go”
Day 1 posed the challenges faced by a hospital team when there is an incident near the hospital and whether to proceed to scene or stay in hospital preparing to receive the patient.
This created a wonderful discussion on twitter! Seems the general feeling was that if you have no prehospital experience but can be of great value to the patient in hospital then it is probably better to stay in hospital and prepare. Do not underestimate the prehospital environment. Keeping in mind that early basic bystander interventions without any equipment can be life saving at scene. Depending where you work and the availability of both in and out of hospital resources, you need to weigh up (as always) the risks and benefits (not just for the patient involved in the accident, but also considering the duty of care you have to the patients in your department).
I am not aware that you have a legal ability to attend – this might differ from country to country.
Ethically, I would want to ( but again, not leave my hospital patients unattended)
FYI, in this case none of the hospital staff attended the scene because the EMS arrived rapidly.
Day 2: “Unexpected turn of events”
Day 2 posed the challenges faced when a patient, who arrived really stable in ER suddenly deteriorates. In this case the patient deteriorated in the Radiology Department, which poses additional difficulties as a remote site with likely very little resources. A lonely place to be with a critically injured deteriorating patient.
For me there are several important points:
Even BEFORE the patient leaves the ER to go to radiology, an initial thorough clinical (ideally multi-disciplinary) assessment is paramount. Make sure that you haven’t missed anything and the patient IS indeed stable enough to leave the Emergency Department if that’s the plan.
Careful attention to the mechanism of injury is always essential and integral to the patient’s story. Build a picture of “worse case scenario” and actively look for clues and exclude these.
When a patient suddenly deteriorate, this will be stressful! Be aware of how this will impact on human factors, such as your own confidence, teamwork, situational awareness.
Go back to the basics! ABCD! Stabilise and resuscitate. The pilots have a saying in a emergency in flight. They: Aviate, navigate and communicate (in that order). Yes, the diagnosis is important and reversible causes needs to be addressed, but keep to the system. It can be tremendously stressful when all your mind is doing is asking :”what is going on, what did I miss…?” You might not have missed anything. Some pathology takes time to present itself clinically. Keep it simple, start at airway and work your way through the ABCD
Get the patient back to a place of safety: When stuck in the Radiology Department with a deteriorating critical patient, or on the ward, or in outpatients etc. do not hesitate to get the patient back to resus. Sometimes the scoop and run technique is best. As anaesthetic registrars doing ICU we are often called to see unwell patients on the ward. I have often prioritised a rapid transfer to critical care above prolonged interventions in a less than ideal environment.
Day 3: “Okay, back to resus then”
Day 3 took us back to resus and essentially a “re-trauma call”.
It is important to start again. As said above, stick to your system. Don’t assume anything. Try and pick up on the clues. “what has actually changed?”
Do not be afraid to remove the collar while maintaining c-spine immobilisation manually to assess the neck thoroughly. This might not have been done initially and you could miss clues.
If you are planning to perform emergency anaesthesia on this patient it is important to document all found neurological findings before RSI.
Be aware that although there were no signs of a pneumothorax in the primary assessment, this can also evolve with time and especially if there are rib fractures or in this case “a small but of fluid in the right chest underlying a seatbelt injury” (likely some blood), you need to remain vigilant when converting to positive pressure ventilation.
Alway do a glucose level in any patient who deteriorates!
The decision to RSI:
Several people on twitter suggested at this point on returning to the ER the patient should undergo a emergency anaesthesia with Rapid Sequence Induction.
I think at this point the patient is really difficult to manage, agitated / irritable, has dropped his GCS. The temptation would be to “give him something to calm him down” i.e. sedation and reach for the midazolam. This is a possible course of action, however might render the patient slightly less conscious and potentially compromise his airway and leave you in the limbo situation. It is clear he requires more imaging, likely a transfer to a neuro centre and at this point it is unclear whether he will require surgical intervention. Based on predicted clinical cause, I would probably give the patient an anaesthetic at this point.
Again, intubating combative patients with a possible or assumed head injury (or something intracranial going on) is a challenge in itself. More even so if you are a junior anaesthetist.
Trauma patients in cervical collars who are not starved, agitated, hyper or hypotensive with possible head and chest injuries are not easy anaesthetic customers! It is tricky to assess their airways, pre-oxigination might be suboptimal, you want to maintain cerebral perfusion by not dropping the blood pressure on induction, but at the same time don’t want to increase ICP. Do not embark on emergency anaesthesia without adequate assistance and a robust plan. This is not the time to reach for drugs or equipment you have never used!! Keep it safe and simple.
Spend time preparing kit while maintaining the airway by simple manoeuvres.
Consider using a checklist (I do in any emergency anaesthetic outside of my anaesthetic room).
Optimise your first laryngoscopy. DO NOT leave the collar done up. You cannot intubate someone with a c-collar done up. Open the front of the collar and have someone maintain inline stabilisation. I very seldom put the collar back on after RSI bit maintain neural alignment with blocks, sandbags or towel strapped next to the patient’s head.
If concerned about intracraneal pathology, don’t make it works i.e. prevent secondary brain injury: Prevent hypoxia, hypotension, venous congestion, hypercapnoea, coughing that can dramatically rise ICP…
Use drugs and equipment you are familiar with: If that is propofol and suxamethonium then be it. Let it not be the first time you use ketamine because that is what all the cool kids on twitter seem to use…
And ask for help (early). It might not arrive in time, but it might.
Day 4 “Could it be a traumatic carotid dissection?”
Day 4 threw in a diagnosis: Traumatic carotid dissection. Not something you see every day.
Rightly, everyone stated that all the common reversible causes (tension pneumothorax, bleeding , hypoxia etc.) should first be identified, treated and eliminated as the cause for the polytrauma patient’s clinical deterioration. But remember that you might need to broaden your diagnostic mind and consider something like carotid dissections.
Yes, it is not that common, but several of you twitter-ratie stumbled on it, and I’ve definitely seen it a few times. Although it is rare, it is a definite consideration in this case and should form part of your differential diagnosis. Also, it can take hour and DAYS to develop so it might be the deteriorating trauma patient on the ward that you are called to several days later….
Patients can present with headache, neck pain, facial pain, transient episodes of blindness (amaurosis fugal) partial Horner’s with miosis and ptosis, hemiparesis, necks swelling, pulsitile tints, deteriorating GCS. As many as 20% of patients present with an ischemic stroke without any warning signs.
The additional challenge that this diagnosis offer is that the treatment is anti-coagulation with heparin and then warfarin…and who of us really feel comfortable with anti coagulating an acute polytrauma patient? I know I don’t. Hence managing and excluding bleeding is essential. Weighing up the risks and the benefits is paramount! And involving specialists is definitely required (even if it is for telephonic advice).
Arranging early critical care transfer for this patient might be the best course of action after you’ve addressed what you can. It is unlikely that a CT angio would be available in small resource limited institutions and starting the process early might save time to definitive treatment. Angioplasty and stent placement might be required if a patient has persistent symptoms and contraindications for anticoagulation. Surgery has a limited role but consultation with vascular surgeons, neurosurgeons, interventional radiology and neurology will be helpful.
Your intubated ventilated polytrauma patient gets transferred to a tertiary neuro centre with you as the anaesthetist escorting him by road, you get home at 11pm after what turned out to be a long, long Saturday shift! The patient ends up making a full recovery.
Well, that’s it folks. Hope you guys enjoyed the case and found it useful. As in everything in medicine, everything is a balance between risks and benefits and it’s is seldom easy decisions we face in critical care.
Remember, everyday is a school day!
Till next time!!
Anaesthetics and Intensive Care doctor Oxford UK
Ambulance Pre Hospital Emergency Physician and Helicopter Doctor
Over the next two days our case of the motor vehicle crash victim who developed altered neurology some time after arriving in the ER will conclude. We have already touched on some tricky decisions and situations you might find yourself in:
Day one focused on decision making with regards to attending prehsopital scenes as “in-hospital” medical providers when the proximity to the hospital makes the decision challenging.
Day two focussed on the deteriorating trauma patient in a remote hospital location such as the Radiology Department, but might as well have been on the ward.
Day three focussed on the importance of returning to a place of safety and resources (resus) and the concept of reassessing ABCD, resuscitate and support then diagnose and thorough clinical assessment and broadening your diagnosis. I think important non-technical aspects come into play here such as self-doubt, confusion with regards to diagnosis, fear for your patient’s clinical deterioration, lack of resources in small institutions, the concept of going from a state of boredom to a state of stress.
Day four will focus on solving the mystery, considering the actual pathology found in this case and risks vs benefits of treatment.
Day five: Tomorrow will conclude with safe inter-facility transfer to definitive care / retrieval and discussions / ideas around “best anaesthetic”
….and who said the anaesthetists role is restricted to the OR?
The lovely blogger-hosts of gasclass have kindly invited me to facilitate this weeks gasclass case. I’ve chosen a case that has some elements of several of my interests and will hopefully open some interesting discussions. Although I have dealt with similar pathology in the past, no identifiable information will be used and most of the details have been changed.
As always over the week the case will develop and more info will be shared (well, only if you participate). This is a hybrid forum where responses can be posted on twitter, so follow the @gasclass account and search using #gasclass tag to see other people’s replies.
As always, there are no right or wrong answers. It is meant to promote discussion and awareness of basic and advanced topics in anesthesia and critical care and might stretch you outside the safe walls of the OR and ICU. Please include #gasclass in your tweets when you reply!
Case will be introduced in the next blog post, so please click on it…
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!
Good evening everyone,
Welcome to another week of #Gasclass. Last week we restarted the term with a complex case of acute spinal cord trauma. Here is a Storify summary of last week’s case.
This week, we will proceed back to the ICU.
You are on call for ICU when you get paged to the ED. You hear that there is an elderly patient whom the internal medicine senior wants to intubate imminently. Her vitals are BP 220/130, HR 155, SaO2 97%, RR 40, T 39.4 C. She was just cardioverted for atrial flutter with rapid ventricular response, and now seems to be in a SVT. She received midazolam 2mg for the cardioversion, as well as an amiodarone bolus and now is much less responsive, hence their decision to intubate.
What are your immediate concerns to consider while you are heading down to the ED?
You ask the medicine resident to move the patient into the resus bay for better monitoring and accessibility of equipment.
When you arrive in the ER, you get the story of an elderly woman from a nursing home, who presented to ED 3 days ago with lower back pain and fever. She was discharged home after some CT scans with the dx “lower abdo pain NYD”, not prescribed any antibiotics. She was found febrile and less responsive in the nursing home, and an ambulance was called.
The emerg staff is at the head of the bed, preparing to intubate her while SaO2 is 99% on 2-3L NP. She has difficult IV access because of morbid obesity, and is currently receiving a dose of pip-tazo and a labetalol infusion for her hypertension. The medicine resident says all this happened quickly after the SVT and cardioversion, and was waiting for a CT chest to rule out PE.
What are your thoughts at this point? How will you approach and manage this situation?
After some discussion with the medicine and emerg staff, you decide that it’s safe to delay intubation for a few minutes in order to review the chart and attempt to contact the substitute decision maker. The patient is noticed to have pink frothy foam from the mouth. BP remains high at 220/120. A quick review of the chart reviews that multiple comorbidities and a long medication list, as well as a pre-existing code status that includes intubation, CPR, and ICU admission. The SDM could not be reached.
The emerg staff supervises the internal medicine resident for intubation (because they wanted to do it) and takes over after a failed first attempt. The patient was sedated with propofol alone. Her pressure never went lower than 150 systolic.
After intubation, you take over the care of the patient. You decide to insert a central line for potassium replacement (K 2.9 mmol/L) and insert an arterial line because she is on a labetalol infusion. As soon as the arterial line is inserted, you see a BP of 50/30 with NIBP on the contralateral arm being 150/60.
Has your differential changed? Why would the blood pressure be so disparate between the NIBP and arterial line?
You start a norepinephrine infusion and start boluses of norepi and vasopressin, as well as fluid boluses. Her BP is 90/50 HR 150s while on high doses of norepi and vasopressin. The labetalol infusion was stopped. CCU was consulted and is at the bedside doing an echo. The windows are poor, but grossly no effusion and both RV and LV appear empty. The medicine resident and CCU resident are suggesting starting IV heparin, and the CCU resident would also like to add on a CT angio to rule out dissection.
How would you manage and investigate now?
You decide that the patient is too sick for transport to CT scan right now, and transfer the patient to ICU for stabilization.
A closer review of the patient’s medications and past medical history reveal chronic pain issues for which she is on fentanyl patch, hydromorphone, as well as an SNRI. She remains on high dose norepi and vasopressin, and now liver enzymes and creatinine are increasing, as well as the INR. She remains febrile, now at 42C. A few minutes after a bronch to rule out pneumonia (no pus was seen, BALs were sent anyway) was done with sedation with fentanyl and midazolam, the patient starts having increasingly frequent and severe twitching.
What are your concerns now, and what is your management plan?
The twitching don’t appear to be organized seizure activity, but more like myoclonic jerking. Given the picture of hyperthermia, hyper-reflexia, clonus and hemodynamic instability you are concerned about serotonin syndrome.
You decide to cool the patient immediately and administer midazolam. Initial CK is 3300.
What are your plans for cooling? What if the temperature remains elevated despite starting a cooling blanket?
Thanks everyone for the interesting discussion this week! Here is a Storify summary.
Please tag your responses on Twitter with the #gasclass hashtag. There are no right or wrong answers, and everyone is encouraged to participate.
Good morning everyone.
Welcome to a new term of Gasclass. We have been away over the summer but the team is reassembled and stronger than ever so that hopefully over the next few weeks we can tap into our (and your) collective knowledge to have some really useful discussions.
For those who are new to Gasclass, we hold our actual case discussion using twitter. There are lots of advantages to this including the fact that it is optimised for mobile devices. You can follow the conversation by searching for #gasclass (don’t forget to include this hashtag in your answers so that others can see it)
We will usually begin with some fairly open ended questions about a core topic. This is to allow a wide range of people to join and also to begin building the cognitive framework on which we can expand with more advanced topics as the week goes on. We will endeavour to produce a summary at the end of each week so that people can revisit the conversation whenever they please.
We have some ideas in the pipeline for future developments but we also like to receive feedback and suggestions for improvement. Feel free to send us a direct message if you have anything to say (or if you would like us to post a comment on your behalf.)
As with a real classroom the more people that contribute the more productive the weeks discussion is likely to be so get involved!
Case information for this week
You are the anaesthetist responsible for the trauma list. The next patient on your list is a young adult male who was involved in a road traffic collision 36 hours ago. He is currently in the intensive care.
In general terms, describe the key components to preparing and moving a patient from the intensive care to the operating theatre including any key bits of information you will seek and resources you will require?
You now have some more information about the intended surgery. The patient has a flexion distraction injury of the upper thoracic spine identified on his trauma CT (illustrated below). He is currently intubated and ventilated but assessment prior to RSI suggested there was lower limb paralysis. The surgical team feel early surgery is indicted to allow decompression, stabilisation and earlier mobilisation?
What are the headline issues and anaesthetic goals in the management of these kinds of patient? Assume the injury is at the T4 level…
You discuss the surgery with the team. They are planning on a posterior approach to decompression and stabilisation. The team have reason to believe it is an incomplete lesion and they would like to be able to monitor spinal cord function intraoperatively…
What methods of spinal cord monitoring are you aware of? Will this alter your planned technique?
There are no trick questions in #Gasclass. Everyone’s contribution is welcome. Please do not forget to add the ‘hashtag’ #gasclass to every Tweet so that it is included in the conversation. To help give new contributors an opportunity to join in we would advise that you should only add one idea per tweet and not contribute until another Tweeter has joined in.
Wecome to this weeks #gasclass.
You are helping in the pre-assessment clinic. Your next patient is a a 68 year old man who is listed for an open cystectomy and formation of ilieal conduit.
To start this week – What are the potential surgical / procedure issues relevant to an anaesthetist?
Thank you for all your comments so far. We all agree that it will be a long case and has the potential for major blood loss.
The patient attends the clinic. As he walks into the room you hear an audible wheeze.
He is a retired chemist and ex 40 pack year smoker. He is 85kg and Height is 1.76m.
PMH include hypertension and type 2 DM.
What are your thoughts? What else would you like to know & what investigations will you order?
Thank you for comments yesterday. Further questioning reveals a gradual onset of SOB over the last 6 months. His exercise tolerance has not been reduced, although he comments that it now takes him longer to walk the same distance to the shops. He sleeps on 2 pillows. BP 176/88 P85 reg CXR is unremarkable. ECG shows NSR with mild LVH
Hb 110g/l WBC 5.3 PLTS 150 Na 130 K 3.6 Ur 7.8 Cr 120 HBA1C 8.9
What else would you like to know? What is your anaesthetic plan?
We had a few thoughts and ideas yesterday.
His PFTs reveal an obstructive pattern with an FEV1 of 1.2L His echo revealed moderate LVH and mild LV systolic dysfunction.
You discuss with him the options for anaesthesia and he agrees to have an epidural followed by GA with invasive monitoring.
A week later the man arrives in your anaesthetic room. You insert the epidural and induce anaesthesia. During the procedure there is suddenly major blood loss ~2L and he develops ST segment elevation and hypotension.
What are your thoughts now and what are you going to do?
Please remember to add the hashtag #gasclass to all correspondence on Twitter. Please also take turns to put your thoughts. Try to keep to one issue and then wait until another Tweeter has contributed before giving more thoughts.
Everyone’s views are welcome. We really would like to welcome more contributions this term so new people are very welcome whatever your background or grade.
The Gasclass Team
The Storify summary for this weeks case can be found here