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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 week case: Day 1″Should I stay or should I go…” (Term 8 Week 4 w/c Jun 9, 2014)

June 9, 2014 Leave a comment

Okay, first let’s set the scene.

For the purpose of this case you are working in a small intercity hospital. It is a Saturday, there are very few doctors in the hospital – most specialists are at home.

It’s been a slow day in anaesthetics. You are bored enough to be hanging out in the Emergency Department.

While you are there, a member of the public storms through the doors and states that there has just been a car accident literally on the corner street of the hospital. There  are two cars involved. The one car has T-boned (side impact) the other at high speed as it was turning.

You have no prior pre-hospital experience. Itt will take the emergency services at least 10 minutes to arrive on scene. It will take you 1 minute to run there.

 

Today’s questions:

What are you going to do? There are essentially two options: Either you go to scene or not.

So…

  • Will you go to the scene? Do you have to (legally/ethically/morally/safety)?
  • If so, what would you take? 
  • When you are there, what do you think can you do in the initial 5-10 minutes before the ambulance service arrives?
  • What can you do if you decide NOT to go to scene?

 

Looking forward to hearing your ideas.

More on the case tomorrow.

June week case with gas-and-air doc @mjslabbert – Quick introduction

June 9, 2014 Leave a comment

Hi everyone,

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…

Term 4 Week 10 (w/c 5/11/12)

November 5, 2012 Leave a comment

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.

Term 4 week 5 (w/c 01/10/2012)

October 1, 2012 Leave a comment

Thanks to everyone who contributed to last weeks discussion. We had a large number of views on our case discussion page and it was great to see that these were coming from right across the globe. It was particularly nice to see a joint discussion between quite different specialities (anaesthesia and general practice) and hopefully this is something we can do more often.

For this weeks case we will be looking at some of the difficult decisions that need to be made as part of prehospital anaesthesia. As always we will kick off with a fairly open ended question so that everyone can participate and hopefully learn something.

What factors make the administration of prehospital anaesthesia particularly hazardous?

Some good suggestions regarding the hazards of prehospital anaesthesia so far. We will develop the case further now…

You are called as part of a HEMS team to an accident on a building site. You are told that whilst working on the roof of a building a male has been struck by a moving steel beam. The site personnel tell you there is a lot of blood coming from his head

What other information do you need to enable you to form a plan?

Thanks for the contributions so far. It was interesting to see the divide between those that wanted more clinical information and those that wanted more information about the scene, specifically scene safety

As we have mentioned on twitter earlier today, you have spoken with the site manager. The worker was working on a roof approximately 2 stories high. The access is via a crane (cherry picker type). You have radio communications with his work mates who are still with him. He was knocked off his feet by the steel beam and has bled a lot from a head wound. They are able to tell you that he is breathing but he is not very responsive and he is clenching his teeth excessively.

Additional information

The site manager can confirm that the roof is load certified and he has offered use of fall arrest harnesses and the cherry picker. The HART team are on their way but at present you are the only medical response. The workers are able to confirm that the patient is in a safely accessible location on the roof (no weak floors, not close to the edge etc). You make a risk assessment and based on the information you have you deem it is safe enough to attend the patient on the roof. It takes 4 mins to reach him using the crane and the basket is big enough for 4 people (Can only fit spinal board / scoop plus escort)

On arrival:

Obvious head injury with large Scalp wound.

HR 130 min. BP 155/89. He is having a generalised seizure.

There are no other obvious injuries on your brief primary survey and you brief his co workers about your plan to move him on the board.

What would you do now? Feel free to add any comments to the twitter conversation

Please only Tweet one point and wait until someone else has tweeted.

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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Case Week 6 (w/c 07/11/11)

November 8, 2011 Leave a comment

This weeks case takes us into the Pre-hospital arena.

You are working as part of a doctor paramedic HEMS team. You are tasked to attend to an adult male who has fallen from a height. Ambulance control reports that a witness claims the height is at least 3 stories. You have no other information. You are 6 mins away.

Police and a road paramedic crew have also been dispatched. Due to the location it is likely that you will be first on scene.

Describe any preparative steps you will make en-route and what your immediate priorities will be upon landing?

On your arrival at scene you find an adult male. Whilst working on a roof he has fallen through a roof light, approximately 10 metres high.

The scene is safe, other than glass on the floor. It was witnessed by a colleague, who called the ambulance.  The patient is still face down when you arrive.

There is a large pool of blood around his head. One leg is obviously deformed and appears shortened.

He is pale, radial pulse is barely palpable. Cap refil time is 5 sec. There is no trace on SpO2. He is making groaning sounds only and doesn’t localise to pain (?flexes)

Describe your next few steps. For the benefit of others, explain any resuscitation efforts including end points?

The patient is carefully rolled into the supine position. The airway begins to obstruct and requires support.

The leg fracture is reduced and a pelvic binder is applied. IV/IO access is obtained and a fluid bolus using radial pulse as an end point is given.

As you begin to prepare for RSI, the patient has a generalised seizure.

How would you manage this? Discuss any drug choices including those used for RSI in this circumstance?

This case is an example of a fairly typical pre-hospital major trauma case. Whilst these cases can often seem very ‘protocolised’ (I would just follow ABC, ATLS etc) in reality they can be very difficult to deal with.

The majority of patients involved in major trauma are young males. Trauma is a serious multi system disease. The socioeconomic burden of trauma is said to be bigger than that of cancer and ischaemic heart disease combined.

One thing that the pre-hospital environment provides practioners, is a better appreciation for the mechanism of injury (kinematics). The clinical information suggested a very significant mechanism of injury (fall from over 6 – 10 foot is considered significant – this case was 10 meters.) It seems appropriate to think about patterns of injury whilst en-route (or waiting for the patient in resus) based on the information available. However, as was mentioned in the discussion, in these cases it is best to be prepared for anything. Information passed via the ambulance service is often third hand and can be very unreliable.

On scene we were presented with a multiply injured patient. He was obviously shocked and it was apparent he had a low GCS, suggesting Traumatic Brain Injury. The important thing to realise here is that this patient is ‘time critical’ and whilst resuscitation involves several processes, a short on scene time is key (Don’t stay and play).

The important resuscitative steps feature in many texts and many people mentioned the <C>ABC approach. There is increasing recognition that control of major haemorrhage should take a high priority as well as a general move toward circulation preservation. The kinematics of this injury open up the possibility of lower limb fractures, pelvic fractures (vertical shear) and abdominal injury, all of which are potential sources of haemorrhage.

As with many situations, there is not one correct answer about how to induce anaesthesia in this patient. The important thing is to recognise the potential pitfalls. Not only is this patient shocked but he has a potential brain injury. Avoidance of hypoxia and hypotension have been proven to be the key factors when dealing with head injured patients.

Anaesthesia for this case should only be practised within a well defined clinical governance system and it is likely that there will be defined protocols for inducing shocked patients and patients with head injury. Whilst the exact agents used can be debated, the most important factor is that the practioner is experienced and comfortable enough with the drug used to understand how to use it in this context.

That being said, Ketamine has gained wide acceptance in the pre-hospital community for a wide variety of reasons (Provides analgaesia, sedation and anaesthesia by varying the dose. Larger margin for error than some other drugs. Cardiovascularly stable. Can be given intramuscularly etc)

The final stumbling block was the patient having a seizure just prior to RSI. This is a very difficult situation as it is a manifestation of the clinical urgency yet may require some additional thought about induction of anaesthesia. Again there is no right answer here as the anticonvulsant properties of ketamine and etomidate are not as potent as say thiopental. They are however much more cardiostable and it is this dilemma that the clinician must face…

@gasclass

There are no trick questions on #gasclass. It is an educational tool only so please feel free to join the conversation. Remember to include the phrase #gasclass in your response. This is referred to as a ‘hashtag’ and you can easily follow the conversation by searching for ‘#gasclass’ in your twitter client.

#gasclass – Week 6 Transcript

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