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Summary and conclusion of June Case (Term 8)

June 15, 2014 Leave a comment

Hi Team!

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.

Summary:

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.

Final words:

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!!

docMJ 

Anaesthetics and Intensive Care doctor Oxford UK

Ambulance Pre Hospital Emergency Physician and Helicopter Doctor

 

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June case (week 8): RTC altered neurology: Summary so far and what’s to come…

June 12, 2014 Leave a comment

Hi All,

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.

Screen Shot 2014-06-12 at 16.48.52

 

 

 

 

 

 

 

 

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?

Keep participating.

June case: (week 8 day3): okay, back to Resus then!!

June 12, 2014 Leave a comment

Hi All!

Thank you for everyone’s participation. Remember tag tour tweets with #gasclass so everyone can see it.

So, where were we? Oh yes, ultimate nightmare: The polytrauma patient from the car crash has suddenly deteriorated in the radiology Department, afterhours on a Saturday afternoon in a small intercity hospital. You, as anaesthetic doctor are called by the porter to go and help out. When you arrive the patient is incredibly restless, doesn’t want to lie flat.

Most people on twitter suggested the plan of action should be to rush the patient immediately back to resus.

So, that’s what you do. Radiology in this hospital is quite remote and there is barely an oxygen cylinder about to speak off, so you and the porter rush the patient back to the Emergency Department.  All the way down the corridor you keep on thinking : “What dit I miss, WHAT DID I MISS? What is going on!!??¥$%#

In resus you reunite with your ER colleague and go through another primary survey:

A: Patent, talking but not coherent. C-spine still in collar. Bruising and slight swelling over neck from seatbelt

B: Sats 99% on highflow O2. Bilateral air entry. No pneumothorax on U/S. Small bit of fluid right chest and visible seatbelt sign

C: BP: 160/88mmHg. pulse 108. No blood in abdomen on re FAST. Pelvis still appears intact on examination

D: GCS: E4V3M5  pupils unequal with one pinpoint. Patient not moving his left side. Patient remains restless and uncooperative.

E: Glucose level normal. Minimal bleeding from open elbow fracture right.

Questions:

What’s going on?

What is your course of action?

okay, everyone would probably want to do a CT head right? What if I tell you the plain head CT appears normal…well, to you and your ER colleague at least.

 

happy tweeting.

conclusion and ideas around management of his diagnosis and anaesthetic involvement further to follows.

 

Term 7 Week 1 (w/c 07/10/13)

October 7, 2013 Leave a comment

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?

A00368F02       1230552-1267029-1354tn

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?

@gasclass

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.

Term 6 Week 1 (w/c 29/04/13)

April 28, 2013 Leave a comment

#gasclass is back for term 6

We have had a great holiday and the team has been conferring for some new cases and appointing a new member for the team.

This week we are starting off in theatre reception and your list has a trans-sphenoidal hypophysectomy.

In classic #gasclass questioning style tell us on Twitter what you are thinking as you walk towards the admission unit.

What anaesthetic issues are you thinking about?

We will release more details as we go along.

As you walk onto the ward thinking all sorts of clever thoughts the nursing staff say you need to know the 72 year old Hypophysectomy patient’s blood pressure was 195/115 on admission. It’s very helpful of them to let you know.

What are you thinking as you head towards the note trolley?

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

Term 5 Week 9 (w/c 18/03/13)

March 18, 2013 Leave a comment

A 20 year old man is admitted to Emergency Medicine, intubated and ventilated at scene after a road traffic accident. His GCS was 9 on arrival of medical team at scene and fell to 7 prompting the decision to intubate.

What are the key features that need to be looked for?

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.

@Gasclass

Categories: Emergency Medicine, Neuro

Term 5 Week 7 (w/c 04/03/13)

March 3, 2013 Leave a comment

Apologies for the missing #gasclass last week.

This week we go back to the Intensive Care Unit. Case details will follow later in the week but we will start with the following question:

What are the indications for Tracheostomy?

Sorry for the delayed update today.

You are working on ICU and are asked to assess 54 year old man on the neurology ward. He was admitted 24 hours ago with ascending weakness intially affecting his feet and legs but now affecting his arms. He had an episode of diarrhoea a few days ago.

When would you admit this man to critical care?

You make the decision to admit the patient to the Intensive Care Unit. Over the course of the evening his weakness progresses and he develops bulbar symptoms. You decide to intubate and ventilate. He is treated with intravenous immunoglobulin.

When would you consider performing a tracheostomy?

Thank you for yesterdays contributions.

You are called to attend urgently because the patient has become agitated, hypertensive and acutely hypoxic. A tracheostomy was inserted 12 hours ago with no complications.

What would you do as you arrive? What are your initial thoughts?

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.

@Gasclass