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
Before I have a few hours sleep after my rather interesting nights shift in emergency theatre, I thought I’d post a few links.
Remember, you are never to old to learn or to young to stretch over your horizons or to stubborn to broaden your differential diagnosis. It’s a relatively rare condition, but definitely should alway be kept in mind in high speed motor vehicle accidents.
Here are a few links you could read through. Every day is a school day….
If some of the links aren’t working, try copy and past it into your browser of choice.
Conclusion and case summary bit later.
Hope you’ve enjoyed it so far.
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?
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.
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.
conclusion and ideas around management of his diagnosis and anaesthetic involvement further to follows.
Excellent comments on Twitter! Remember to use #gasclass so that everyone can follow the comments. Please continue to read on as the case develops. First a little summary and a few points to ponder.
So yesterday’s case started with a tricky situation: A two car accident occurred on corner streets of your hospital. EMS apparently 10-min away. The main consideration was: Should you go check it out or stay in hospital and prepare for patients arrival?
Here are a few points I was thinking of:
Summon help: Ensure that the local EMS activation number has definitely been dialled. It could be that this has not happened and someone just saw there is a hospital nearby and ran in, expecting or anticipating that the hospital will activate the prehospital providers. Also consider summoning more hospital resources early. Hopefully even a small hospital has some sort of escalation plan.
Remember, you have an established duty of care to these hospital patient and cannot leave them without sufficient medical care. It might be that you are the only clinician in the hospital and then you definitely can’t leave.
Don’t underestimate the pre-hospital environment. It is unsafe, unpredictable and not kind to novices. Personal protective equipment is essential. Hospital medics in scrubs and trainers are definitely not ideal.Also, take into account, the “jump bag” or transfer kit is not alway fit for purpose in the prehospital environment (what the heck are you going to do with an arterial line transducer on scene…?)
Having said all of that, there are some potentially essential life saving things that can be done in the first few minutes following an incident while EMS is still on route. We know this from the impact bystander CPR has on prehospital (non-traumatic) cardiac arrest cases.
Equally, in trauma cases, secondary brain injury from, for example hypoxia due to an occluded airway can have a dramatic impact on longterm neurological outcome of head injury patients. There are patients who die from potentially reversible causes before the ambulance crews arrive. Simple interventions could make the difference between leading a full live and being severely impaired or worse, death. Some of these simple interventions include: Opening an airway or putting direct pressure on a bleeding wound. You don’t need any equipment for this and could literally save someones life…
I’m not 100% sure there is a right answer to this. Like most things in medicine you have to way up the risks and benefits and try and make the best decision with the information, skills, team and equipment you have.
OKAY, DONT STOP READING NOW, the good stuff is still coming! Lets continue with the case:
So, luckily as you are trying to find the code to the combination lock on the (locked) door to the high-viz jackets and transfer bag, you can hear the sirens of an ambulance (with the prehospital professionals) turning the corner and arriving on scene. (Ambulance control had several calls on the incident and managed to mobilise an ambulance crew nearby.)
Within minutes the EMS crew brings three patients to the ER. Due to the proximity of the accident to the hospital, not too many interventions were done before the patients arrive with you. One patient is the driver of a large German car and he has only minor injuries and declines any medical care. The other two patients are husband and wife from the smaller car that had the side impact to the driver’s side.
The rest of the case will focus on the driver of the smaller car. Lets call him Adam 55.
Brief handover from ambulance crew to your trauma team (i.e you as anaesthetic airway support and whoever is there):
- 55y/o called Adam
- 10-min ago two car RTC
- Side impact on driver’s side. Was wearing a seatbelt. No clear history of loss of consciousness. Not mobilised on scene. Extricated via side door on an extrication board
- Injuries found: Neck pain; Tender ribs, good bilateral air entry. Open wound and possible fracture to right elbow. No suspected abdo, pelvis or other long bone injuries.
- Prehospital treatment received: Reassurance, spinal immobilisation with cervical collar, head blocks and on a hard board.
- GCS 15/15, moving all four limbs. Pupils equal and reactive. Vitals stable last 10-minutes.
The team do a thorough systematic evaluation (CAcBCDE) and confirm the above findings. eFAST negative. Portable pain chest X-ray and pelvis X-rays are normal. Observations within normal range. As an anaesthetist at this point you decide that your services are no longer required in the ER and this has been far to much excitement for a Saturday afternoon and you retreat to the coffee room – topping up on caffeine in anticipation of this patient potentially needing some sort of surgery for his elbow injury later.
In the mean time your Emergency Room colleague sends the patient to the X-ray Department at the back of the hospital for his elbow X-ray. No trauma CT done. To get a weekend CT in this hospital the CT radiographer needs to come in from home.
20-minutes later an out-of-breath hospital porter tracks you down in the coffee room and says: “Doc, the ER doc needs you to urgently go to the X-ray Department! That patient is now ‘not quite right’. That man is making no sense, doesn’t want to lie flat, looks like a ‘dear staring into headlamps’. The ER doc is dealing with the other lady patient and can’t go. Come!!”
You follow the porter to the rather remote X-ray department to find the radiographer physically trying to keep the patient on the bed. He is combative, and slurring his speech.
- What’s going on? What could have led to the change?
- Think of a differential diagnosis and how you would exclude or confirm it.
- What’s your course of action?
- What are the potential obstacles / challenges you might face to achieve this?
Remember, tweet your comments tagged to #gasclass and myself or the gasclass bloggers will try and retweet and reply to it. The aim is to generate discussion and learn from one another.
Look back at the blog regularly – it will get updated.
More to follow later…
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.
What are you going to do? There are essentially two options: Either you go to scene or not.
- 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.
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…