Back in resus with our polytauma patient that has deteriorated. You are a bit baffled by it all. A sudden unexpected dramatic change in his condition has lead you to believe what you are seeing is a patient that is having a stroke right there in front of you.
A stroke? Really? Scenarios of “what came first, was it the chicken or the egg” runs trough your mind: Can it be that the patient had a transient ischaemic attack and then crashed? Is it coincidental? Are these two separate pathologies? Or a drug effect , or a bleed?
Regardless of the cause for this, in true anaesthetist style you decide it is more important to support than diagnose and decide to give that patient an anaesthetic, secure the airway, control ventilation and then have a team hunt for the diagnosis to explain how a quite boring Saturday afternoon has unraveled into this enigma!
- How would you anaesthetise this person? What drugs would you use?
The question remain: What is going on? The answer doesn’t seem that clear to your slightly overwhelmed and tired brain at the moment. There is no external signs of a head injury in this patient and the plain c-spine films didn’t show any cervical spine fractures. Never ever have you seen this before, so surely it must be rare or not even a thing. Then one of the nurses asks a question that sort of just hangs in the air: “Surely a whiplash injury can’t give you this neurology? Or a blow to the neck maybe?
Slowly you baffled mind refocuses on the neck area. “Can it?” You wander. “Can a rapid deceleration and rotation of the neck put enough stress on the vessels in the neck to cause this? And add to this a seatbelt..”
With your patient now anaesthetised, the team decide further imaging is required.
You decide it might be some sort of vascular neck injury affecting cerebral perfusion.
- What imaging will confirm your suspicions?
- How do traumatic carotid dissections classically present?
- What is the treatment for traumatic carotid dissections?
- What are important consideration in polytrauma patients with traumatic carotid dissections?
Put your thinking caps on. Google or bing or consult your textbooks. Try and share helpful links if you find any and remember to use the hashtag #gasclass in your tweets so that everyone can follow it.
Case conclusion tomorrow ( or in my case, later today, since the sun is just rising on my theatre night shift).
Be part of the conversation.
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…
Welcome to a new week of Gasclass! This week we’ll talk about a short series of pediatric anesthesia cases.
Case 1: You are on-call and paged by ENT because they want to book a 2 yo child for extraction of foreign body.
How will you manage this situation?
As mentioned on twitter, there are two options for induction: inhalational or IV.
You induce the child with an inhalational induction because they do not have an IV. After placing an IV asleep, you continue to deepen the anesthetic under spontaneous ventilation and test the depth with laryngoscopy. While going in with the laryngoscope and about to spray the cords, you notice a piece of white-yellow food (possibly nut?) just at the laryngeal inlet below the epiglottis.
What would you like to do at this point?
Case 2: General surgery has booked a 2 mo boy for pyloromyotomy. They have asked for a preop consult because of a diagnosis of sickle cell disease.
What are your considerations for this surgery? What are your goals for preoptimization?
Thanks for all the responses! Common themes seemed to be:
– this is non urgent surgery and patient’s fluid status and electrolytes should be preoptimized
– concerns for sickle cell disease: warm, hydrated, good analgesia (? Regional techniques), crossmatch may be difficult if previous transfusions and alloantibodies
– consultation with hematology for optimization preop (physiologic anemia of infancy, preop transfusion)
– might benefit from postop ICU monitoring?
Case 3: you are doing a tonsils and adenoids list.
What are your criteria for suitability for outpatient T&A vs inpatient admission? How do you assess for pediatric OSA?
The next child, a 4yo boy, has been snoring so loudly his parents say “the walls shake” as well as having overall daytime somnolence, decrease in activities and witnessed “breath holding” spells when asleep. He has not had any investigations (sleep study, overnight oximetry) or treatments. He is average weight but parents feel he would not be cooperative with a preinduction IV. He has grade IV kissing tonsils on exam, with audible noisey breathing at rest.
What investigations (if any) would you like? What is your anesthetic plan?
Remember to tag your tweets with #gasclass! There are no right or wrong answers.