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.
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.
Good morning everyone and welcome to a new case discussion on Gasclass.
Last weeks discussion saw consistent visitor numbers and means we are continuing with one of the strongest terms we have had. We were also exceptionally pleased to pass the 1000 follower mark, so thank you all!
As always we are going to begin our case discussion with a fairly general and open ended question. We do this to encourage new and more junior members to participate. As the week progresses we will increase the complexity so that hopefully there are learning points for all of us. So lets start off with the following question…
What are the important considerations to the anaesthetist of vascular surgery?
Thanks for the contributions so far. It’s good to see people thinking about risk factors in this patient group. Vascular surgery can consist of a range of proceedures several of which come with their own unique challenge(s) for the anaesthetist. Before we get on to the specific details of this weeks case, lets consider the following
What are the anaesthetic challenges when dealing with surgery to the carotid artery (endarterectomy for example)
Some good input everyone. It feels like we are making some progress in exploring this type of surgery. Carotid endarterectomy is a relatively common proceedure in vascular units. Using some of the principals we have mentioned lets see if we can deal with the following?
Additional case information
The next patient on your vascular list has been listed for excision of a carotid body tumor
Reviewing the patient you find a young female who presented with a painless swelling in her neck several weeks ago.
She is otherwise fit and well, takes no medicines and has had a previous GA some years ago for a gynae proceedure without problem.
A CT suggested carotid body tumor and this was confirmed with MR angiogram
Using the discussion above to inform your thoughts. How are you going to anaesthetise her? Lets see if we can form a sensible plan for this rare case between us…
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.
Welcome to this weeks Gasclass.
For the final week of this term we remain in theatre. You have been assigned to the Tuesday vascular list, where a 75 year old man has been listed for an elective Endovascular Aortic Aneurysm Repair (EVAR).
Today’s task is to list concerns and considertations relevant to anaesthesia for EVAR.
You go and see the patient. He is a 70 year old man with an asymptomatic 7cm Abdominal Aortic Aneurysm. This has been identified whilst having an ultrasound examination of his renal tract.
The patient has had 3x MI the last being 4 years ago when he underwent PCI with insertion of 3 coronary stents. At that time his echocardiogram revealed severe LV dysfunction. He continues to smoke 40 cigarettes a day. He is hypertensive treated with Ramipril and Bisoprolol. ECG reveals Q waves in lead 3.
What other information would you like before you embark on anaesthesia?
Thank you for your comments.
He has an exercise tolerance of approximately 2 miles on the flat at 1 mile on walking up a hill. A dobuamine stress test in 2009 revealed no ST changes. His FEV1 is 1.2 and FVC 2.3 FEV1/FVC 52%.
The procedure will be performed in an adapted room in the middle of the radiology department.
What are the anaesthetic options? What is your anaesthetic plan?
Following discussion with the patient you decide to undertake the procedure using a combined spinal & epidural technique. The procedure appears to be progressing well when after 2 hours the patient suddenly develops shortness of breath, becomes restless, tachycardic and hypotensive. There is no evidence of rupture. The surgeons do however have concerns regarding blood flow into the legs and may need to perform a crossover graft.
What are your thoughts now? How will you now manage the patient?
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.
This week #gasclass moves back into theatre.
You have been allocated to a vascular list. On the list is a patient who requires fistula formation.
As you walk to the ward what thoughts regarding the patients condition and potential comorbidities cross your mind?
You have thought about various comorbidities surrounding the patient. You meet the surgeon whilst walking to the ward. The surgeon tells you that the patient has had dialysis dependent renal failure for many years and has had multiple previous fistlulae that have failed. The patient was dialysed yesterday evening in preparation for theatre.
What are your thoughts now? What would be your anaesthetic plan?
There is a split between LA, Regional and GA. The surgeon continued to tell you that she intends to create a left brachio-basillic fistula. The vessels look very small on doppler and that the procedure is likely to be difficult and take a long time.
Would this change your plan? Any other concerns now?
So leaning towards giving a GA for this procedure you get to see the patient. He has had previous GA’s and does not want a regional block under any circumstances.
He has longstanding ESRF of unknown aetiology, he is hypertensive controlled with medication but no ACE-I. 2 years ago he had a stroke but has no residual deficit. Post dialysis bloods reveal Na 140 K 3.9 Ur 13.5 Cr 210. Reading his notes you notice a 24hr ECG which shows multiple runs of VT. The man admits to having had dizzy spells. Asking about the treatment for this he casually mentions “it’s ok doc I’ve got a shock thingy fitted”
What are you going to do now? Will this alter your anaesthetic plan?
There are no trick questions in #gasclass. It is an educational tool only. Everyones 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 specialities and you can send us a direct message if you would prefer to remain anonymous.