Case from this weekend

[lushmd]

Advertisement - Members don't see this ad

So, I'm moonlighting at the Eye Center (attached but separate from the main university hospital; at least 5 min walk from main OR to eye center OR) and was called in for the following: 49 y/o M for left ruptured globe. Past medical history is notable for morbid obesity (BMI 46), OSA on nocturnal CPAP (not aware of settings), and osteoarthritis. Has had B/L corneal transplants and repair of right ruptured globe in the past. Last ate at 11:30 AM yesterday, accident causing open globe occured at ~2 AM today. With regards to functional status, can walk ~1/4 mile before becoming dyspneic. On exam, Mallampati 4 with limited mouth opening (two finger-breadths), reduced thyromental distance, and poor dentition. Has had prior general anesthetics and was not told anything re difficult intubation and has never undergone awake fiberoptic intubation. Unfortunately, these prior surgeries were done at the local VA medical center and the anesthetic records are not accessible. Baseline SpO2 81% on room air, lungs CTA B/L. Pt mentions that he was told that he has "small lungs." Surgeon has requested general anesthesia. How would you proceed?

 

[BLADEMDA]

So, I'm moonlighting at the Eye Center (attached but separate from the main university hospital; at least 5 min walk from main OR to eye center OR) and was called in for the following: 49 y/o M for left ruptured globe. Past medical history is notable for morbid obesity (BMI 46), OSA on nocturnal CPAP (not aware of settings), and osteoarthritis. Has had B/L corneal transplants and repair of right ruptured globe in the past. Last ate at 11:30 AM yesterday, accident causing open globe occured at ~2 AM today. With regards to functional status, can walk ~1/4 mile before becoming dyspneic. On exam, Mallampati 4 with limited mouth opening (two finger-breadths), reduced thyromental distance, and poor dentition. Has had prior general anesthetics and was not told anything re difficult intubation and has never undergone awake fiberoptic intubation. Unfortunately, these prior surgeries were done at the local VA medical center and the anesthetic records are not accessible. Baseline SpO2 81% on room air, lungs CTA B/L. Pt mentions that he was told that he has "small lungs." Surgeon has requested general anesthesia. How would you proceed?

To me the Sat of 81 percent is the biggest issue here. We need to find a reason for that Sat as nobody walks around at 81 percent (that I've ever met electively). CxR, ABG, maybe an Echo (but this is an emergency case). Differential includes PE, CHF due to poor LV function, pneumonia, severe end stage COPD (VA dude), other Pulm diseases

This guy won't be going home after the surgery 🙄

I'd use a glidescope here. LmA backup. Take a look with the glidescope then push the rocuronium. I'd consider him NPO.

The big issues are postop care with the sleep apnea and ****ty saturation. But, that's why they make ventilators.

I'd probably do an arterial line but I'm not sure if you can do that at your eye center. One other thing: can you transfer this dude to the main hospital if needed?

Quite a case. I see this protoplasm at least once a month and most do survive ... Most but not all.

 

[BLADEMDA]

http://www.pulmononline.org/pdf/2073095No1-04-case.pdf

http://radiographics.rsna.org/content/22/suppl_1/S25.full

I doubt it's hypoplasia of the lung but its in my differential.

 

[dremel7300]

fast track lma

 

[AnesThrow]

Morbidly obese and hasn't eaten in over 16 hours?

 

[chessknt]

What pushes obesity hypoventilation syndrome off your main differential?

 

[W222]

What pushes obesity hypoventilation syndrome off your main differential?

He could have OHS but I wouldn't think it would push his sat to 80%, not alone anyway. Maybe if he had severe plum HTN and right heart failure.

 

[Idiopathic]

what was the accident? the answer is probably prop/sux/tube

 

[lushmd]

what was the accident?

Low speed MVA. No other injuries.

the answer is probably prop/sux/tube

Probably, but for the sake of discussion/education, let's game it out a bit further. So, let's allow the trainees (med students, residents, fellows, etc...) and those taking the oral boards soon the opportunity to answer first. To lend a bit of structure to this discussion, let's consider the following points (keeping in mind that the case needs to be done now):

(1) Venue: Eye Center OR (surgi-center, where this is the only case on a weekend so there is minimal staffing, in terms of anesthesia personnel its you and a CRNA that you have never worked with before and also has never worked at the eye center before) vs main hospital OR?
(2) Low baseline SpO2. What are your thoughts about it and how do you plan on addressing it?
(3) Airway management. First, despite the surgeon request of GA, would you consider discussing doing this case with (light) MAC and a retrobulbar block (done by ophtho)? This pt will certainly be difficult to ventilate and may be difficult to intubate. Assuming that you decide on general anesthesia, what are your thoughts/plans re airway management? If you decide to intubate, sux or not (remember the open globe)?
(4) What would be your approach re analgesia?
(5) Disposition: Following recovery in the main hospital PACU, the surgeon would like to send the pt home. What are your thoughts on this?

 

[Agast]

Has had prior general anesthetics and was not told anything re difficult intubation and has never undergone awake fiberoptic intubation. Unfortunately, these prior surgeries were done at the local VA medical center and the anesthetic records are not accessible.

He's a vet? Well the good news is, nothing can kill him.

 

[ssmallz]

No chance this guy get's MAC.....his reserve is crap and he will likely go down quick and be a pain to intubate if necessary. Throw in the open globe and increase in IOP from coughing, bucking, and fighting and I'd rather him go to sleep too. Secure the airway from the get go, one less thing to worry about during the case

 

[Sublimazing]

I haven't done too many urgent/emergent eye cases, but i know IOP is the name of the game...however this guy was a mva and morbidly obese (and maybe diabetic...) so im assuming full stomach...so i'm going modified RSI (bc he sounds like he might be a tough mask)...but succs transiently increases IOP (i think from the fasc) so id either give a depol dose of roc first and then succs or just double down on my roc (glide available or primary)

Id probably keep him tubed post op bc i can't pull deep, can't go heavy on opioids, vets can wake up PTSD style and think i'm a charlie or a skinny, and id be worried about coughing/bucking/fightin


In lit review last week we looked at ASC recs for OSA and i know that if he's diagnosed we can still proceed but we'll need to have some PAP available peri op and we want to stay away from opioids...so toradol, decadron (low dose if dm), beta blockers, ofirmev, etc (no ketamine cuz of iop)...hopefully he got a rb block so immediate postop pain isn't top bad...and he def doesnt get opioids at d/c

I wouldn't dc this guy post op because of the OSA, and since he doesnt know the settings of his cpap prolly doesn't use it...and he's a big ol' vet so he's prolly divorced and got no one to watch him at night or help with post op compliance, so let him stay on the floor (maybe tell medicine there's a guy satting in the low 80s and wed like theyre opinion 😀 )...

Those things jump out at me

Please correct my poor calls!

 

[pgg]

81% sat needs an explanation. He was in an MVA - you said no other injuries, but was that workup/eval really complete?

I'm also not real thrilled about doing this in a surgicenter, attached to the hospital or no.

 

[92122]

I would be unwilling to take this thing on at a stand-alone eye center. It's not a true, life-or-death emergency that must be done "at this very moment." He can be transferred to an inpatient hospital where I would want:

1. CXR--PTX, PNA, etc. As others have pointed out, this low a sat likely means some other issues are afoot. If he has a pneumo, can you place a chest tube at the "eye center?"

2. A-line--unlikely to be available at outpatient place.

3. Possibility for post-op ventilator: again, outpatient place not suited for this. Easier to take him on NRB if needed to main OR than to get vent-dependent guy across town being bagged.

 

[cincincyreds]

So you thought you would make some easy coin doing eyeball cataracts in some little room. Now you are stuck with a case that is worse than a ruptured AAA.

This case needs to be done in a hospital where you have postop mechanical ventilation.

This is why I would only work at a hospital, not a rinky dinky ambulatory center. They push and push and push the envelope. And when something goes bad, boom you are the g-damn anesthesiologist who screws it up, and you get promptly fired and have to explain that on your next job application.

Do the right thing. Have him transferred to a real facility. He ain't going home afterwards, in fact, it sounds like with that sat of 81% he will be getting a trach and peg afterwards in the coming weeks.

 

[sevoflurane]

Low speed MVA. No other injuries.
(5) Disposition: Following recovery in the main hospital PACU, the surgeon would like to send the pt home. What are your thoughts on this?

Agree with everyone here. A resting Sat of 80% is an ASA IV and shouldn't be done on an outpatient basis.

A ruptured globe is an emergency. As someone mentioned, paralysis is the way to do this case. MAC is just asking for trouble. Sux raises IOP transiently and may not be significant. In this situation, where you have a potential diff. AW, low dose sux + glidescope is your friend.

Does the patient have pulmonary fiborsis? You might hear some carckling if he did... so maybe not.

 

[BLADEMDA]

Anyone willing to do this case at a stand alone surgicenter/eye center has more balls brains. That's my real word statement too.

Transfer emergently to the main hospital. Call your friendly radiologist up and get a CXR stat with his/her input if needed. After CXR discuss with radiology if CT scan of chest is indicated. . Place an arterial line. Get your transthoracic echo tech to help you with the stat bedside echo.

His airway doesn't scare me as much as the rest of him. This guy is a solid ASA4 and may be in for a prolonged hospital stay. A thorough discussion with patient, family and eye surgeon is a good idea because the patient may not walk out of the hospital.

 

[caligas]

So, I'm moonlighting at the Eye Center (attached but separate from the main university hospital; at least 5 min walk from main OR to eye center OR) and was called in for the following: 49 y/o M for left ruptured globe. Past medical history is notable for morbid obesity (BMI 46), OSA on nocturnal CPAP (not aware of settings), and osteoarthritis. Has had B/L corneal transplants and repair of right ruptured globe in the past. Last ate at 11:30 AM yesterday, accident causing open globe occured at ~2 AM today. With regards to functional status, can walk ~1/4 mile before becoming dyspneic. On exam, Mallampati 4 with limited mouth opening (two finger-breadths), reduced thyromental distance, and poor dentition. Has had prior general anesthetics and was not told anything re difficult intubation and has never undergone awake fiberoptic intubation. Unfortunately, these prior surgeries were done at the local VA medical center and the anesthetic records are not accessible. Baseline SpO2 81% on room air, lungs CTA B/L. Pt mentions that he was told that he has "small lungs." Surgeon has requested general anesthesia. How would you proceed?

Morbidly obese, osa, mp 4, short tmd, limited mouth opening. Glidescope is great but does nobody still do awake intubations?

 

[BLADEMDA]

Morbidly obese, osa, mp 4, short tmd, limited mouth opening. Glidescope is great but does nobody still do awake intubations?

Previous surgeries at the VA with no recall of being awake. I'd Use a glidescope here.
I would have an LMA with fiber optic scope as backup.

If you are that slick with awake fiber optic intubations and can keep IOP down then go for it. But, many think they can do it without raising the IOP but few can.

 

[BLADEMDA]

CONTRA-INDICATIONS FOR AFOI
Lack of airway skills
Difficult airway with impending airway obstruction
Allergy to local anaesthetic agents
Infection/contamination of the upper airway – blood, friable tumour, open abscess Grossly distorted anatomy
Fractured base of skull (CI to nasal route)
Penetrating eye injuries
Patient refusal or uncooperative patient



http://www.frca.co.uk/Documents/201 Awake fibreoptic intubation - the basics.pdf

 

[caligas]

CONTRA-INDICATIONS FOR AFOI
Lack of airway skills
Difficult airway with impending airway obstruction
Allergy to local anaesthetic agents
Infection/contamination of the upper airway – blood, friable tumour, open abscess Grossly distorted anatomy
Fractured base of skull (CI to nasal route)
Penetrating eye injuries
Patient refusal or uncooperative patient



http://www.frca.co.uk/Documents/201 Awake fibreoptic intubation - the basics.pdf

Fair enough but lets not kill the patient to protect an already mangled eye.

 

[Oggg]

Arrange for trach backup if it looks that scary.

 

[caligas]

Arrange for trach backup if it looks that scary.

Yes, maybe the eye doc could do it 🙂

 

[cincincyreds]

Anyone willing to do this case at a stand alone surgicenter/eye center has more balls brains. That's my real word statement too.

Transfer emergently to the main hospital. Call your friendly radiologist up and get a CXR stat with his/her input if needed. After CXR discuss with radiology if CT scan of chest is indicated. . Place an arterial line. Get your transthoracic echo tech to help you with the stat bedside echo.

His airway doesn't scare me as much as the rest of him. This guy is a solid ASA4 and may be in for a prolonged hospital stay. A thorough discussion with patient, family and eye surgeon is a good idea because the patient may not walk out of the hospital.

There is a good chance this guy could leave the hospital in a body bag. You really need a vent postop ready to go.

 

[Planktonmd]

CONTRA-INDICATIONS FOR AFOI
Lack of airway skills
Difficult airway with impending airway obstruction
Allergy to local anaesthetic agents
Infection/contamination of the upper airway – blood, friable tumour, open abscess Grossly distorted anatomy
Fractured base of skull (CI to nasal route)
Penetrating eye injuries
Patient refusal or uncooperative patient



http://www.frca.co.uk/Documents/201 Awake fibreoptic intubation - the basics.pdf

I find this list a little exaggerated and silly!

 

[Planktonmd]

Let's a get a blood gas and see what the numbers are then we can figure out if this is a chronic respiratory failure or acute.
It's funny we already decided the guy is almost dead with almost zero data!
If you are studying for the boards you need to be systematic in your thinking and try to rule out common things first.
Things like: Is the SPO2 reading actually correct?
And it actually doesn't hurt at all to get a history and do a physical exam!

 

[Idiopathic]

guys we do bigger cases than this on sicker patients than this fairly routinely. i dont think that they usually end up in body bags.

edit: and i echo planks concern that the SPO2 is not picking up accurately. someone with a RA sat of 80 is on oxygen at home, so if this patient made it through the ED (i assume he did) and he is on RA with a sat of 80, then I dont trust the sat monitor. also, i would expect him to be tachypneic and dyspneic unless this is very chronic, under which circumstances he would likely be followed and treated for hypoxemia.

 

[W222]

Another thing that could explain the hypoxemia is pulmonary contusion. He was in an Mva right and the airbag or steering wheel may have hit his chest, causing the injury. He needs an Abg and a cxr to start with.

 

[gasp]

Nice case, this is what I would do..
1. Move this case to the university. No way I'd do this in anything but a hospital setting (will more than likely need a vent post-op)
2. Excellent PreO2.
3. Propofol
4. Succ (yes I am aware that it increases IOP. However, studies have shown that the amount of IOP increase is pretty much the same as the increase in IOP you get when you blink. I would rather take my chances with short acting paralytic in-case I have trouble tubing him AND I don't believe this guy hasn't eaten for that long)
4. Tube preferrably with a Glidescope
6. Roc
7. OGT
8. A-line for ABG's
9. Begin case

Some people have been saying things like CXR, Echo.. etc. The only time I would do any of this in this setting is if I thought they missed a pneumo/tamponade/hemo..etc which they probably didn't when he first came to the ER but never say never. If he is awake and with it with a sat of 81%, he probably just lives there or its from the trauma/possible contusion.

 

[BLADEMDA]

Nice case, this is what I would do..
1. Move this case to the university. No way I'd do this in anything but a hospital setting (will more than likely need a vent post-op)
2. Excellent PreO2.
3. Propofol
4. Succ (yes I am aware that it increases IOP. However, studies have shown that the amount that the amount of IOP increase is pretty much the same as the increase in IOP you get when you blink. I would rather take my chances with short acting paralytic in-case I have trouble tubing him AND I don't believe this guy hasn't eaten for that long.
4. Tube preferrably with a Glidescope
6. Roc
7. OGT
8. A-line for ABG's
9. Begin case

Lots of people have been saying things like CXR, Echo.. etc. The only time I would do any of this in this setting is if I thought they missed a pneumo/tamponade/hemo..etc which they probably didn't when he first came to the ER but never say never. If he is awake and with it with a sat of 81%, he probably just lives there or its from the trauma/possible contusion.

Slim,

A Saturation of 81% sets off alarm bells. I'd place an arterial line right off the bat or at least send an ABG. Yes, I would make sure the pulse oximetry is functioning properly.
I would also get a CXR. At my institution I could get an ABG and CXR in under 10 minutes with a Radiologist assisting me (if needed) for the read. I could also get a CT scan in under 30 minutes (total time needed) if I spoke with the Radiologist. We need to rule out pneumothorax, rib fractures, pulmonary contusion, etc. so at least do a quick exam and get the CXR.

As for the bedside Echo I can call a tech or do the exam myself in under 5 minutes in the holding area. If I call the echo tech then it would take 20 minutes. This quick Transthoracic echo would provide additional info to me which may help in the care of this patient. (Pericardial Effusion from MVA, decreased LV or RV function, Significant MR, etc).

I could work this guy up pretty well in under an hour with labs, tests, etc. and if that Saturation is 81% then he needs some basic tests. Please note I didn't order a single consult except a quick conversation with a radiologist via phone.

I've been at this gig a long time including Trauma anesthesia and this guy shouldn't just be slamed off to sleep without any further work-up due to an eye injury.

Ultimately, he needs a General Anesthetic so you could argue then is no point in delay but I've seen more than one death in the O.R. due to poor preop workup in a trauma. So, It ain't gonna happen on my shift if I can help it.

One last thing I've seen EVERY thing imaginable missed by the ER over my career including Pneumos, Pericardial Tamponade, Cervical Fractures, etc so NEVER assume they didn't miss something.

 

[sevoflurane]

I find this list a little exaggerated and silly!

I don't know if I want to do an open globe with an AFOI on a BMI of 46 with OSA + sats of 80% if I can preoxygenate, then PVC with a glidescope and sux.

 

[pie944]

There is a significant possibility if you put him to sleep even with decent pre-oxygenation he will desaturate quickly. Now this doesn't matter if you can get the tube in quickly with the glidescope and presuming a patient who can recall his history with no difficult airway supports this decision. In addition, even a poor historian should remember an awake fiber optic, I hope.

However, what if one struggles with the view? A struggling attempt at laryngoscopy can significantly increase IOP. Furthermore, a poor view or inability to pass the tube will require one to mask ventilate. The guy has a decent BMI and OSA that argues for difficult mask ventilation and pushing the mask down on an open globe isn't ideal either. In a patient with a already tenuous oxygenation status there won't be significant time to adjust ventilatory techniques. So you place a LMA and use that as a conduit to intubate? Is an AFOI that great of a risk that one would go thru the above to avoid it? An AFOI with a slow methodical topicalization +/- dexmedetomidine seems like an option and not an absolute contraindication in this case as stated by FRCA.

Not saying I'd go one way or the other, I just don't find the use of an AFOI to be such an outlier in the management of this case. I understand why people would object to it, but to call it an absolute contraindication in this specific case seems a little odd.

Maybe oral board preparation is skewing my view?

 

[soonerfrog]

While I agree Sux might be okay here, I can't completely defend it in court if I permanently blind him with it. I've only been pushed into the RSI dose of roc twice before but this sure sounds like another one. Guy's probably on a postop vent anyway regardless. I'm not confident I won't appreciably increase his IOP with AFOI but i like my chances with GA-Roc-Glidescope. Blade is spot on with work up. People live with a PCO2 of 75. People don't sit around the house watching wheel of fortune with a PaO2 of 40. Something acute is going on or, more likely, there's a flaw in the story/pulse ox/ect. Great case. Thanks for sharing.

 

[Planktonmd]

I don't know if I want to do an open globe with an AFOI on a BMI of 46 with OSA + sats of 80% if I can preoxygenate, then PVC with a glidescope and sux.

I am not saying do an awake FOI on this patient!
I am saying that the list of "contraindications" that Blade posted is silly and based on no real science.

 

[jetproppilot]

Slim,

.

dude you stole my word!!!👍

 

[aredoubleyou]

The eye injury is his secondary issue, the hypoxia is #1. OHS is definitely likely, paco2 likely high. An abg is needed here, and shoulda been done in the er! Cxr is a good idea, especially if paco2 is not extremely high. I'd probably do an awake glydescope with propofol & sux just before the tube goes in (ensuring a good view). Been caught in the difficult airway for an elevated IOP case, and trust me, it's not pretty. Dont d*ck around with this prop/sux/tube BS - an lma is not going to cut it for a hypoxic fattie - you need to get that ett in the first time. I don't really see what we need an echo for, he undoubtedly has high pa pressures and walking a 1/4 mile at that weight is not bad.

 

[VentdependenT]

Causes of hypoxia:
1)low fio2
2)hypOventillation
3)dead space: will improve with 02 unless significant (i.e. large PE)
4)shunt: wont improve/minimally improve with o2
5)diffusion limitation

Lurking.

 

[BLADEMDA]

Causes of hypoxia:
1)low fio2
2)hypOventillation
3)dead space: will improve with 02 unless significant (i.e. large PE)
4)shunt: wont improve/minimally improve with o2
5)diffusion limitation

Lurking.

Great. Now let us be practical. We are about to do an anesthetic on patient wth a saturation of 81 percent. He was in a recent accident with injuries.

Does he have pneumo? Does he have rib fractures with splinting? Does his saturation improve with oxygen/non rebreather? What does his ABG show? Any acidos? Pa02?
What about cardiac function? Although this is less likely a reason for the saturation of 81 percent it is still in the differential.

You definitely don't want to miss an undiagnosed pneumothorax here and end up with a tension pneumo after intubation and positive pressure ventilation.

 

[Substance]

I'm not an anesthesiologist; not even close. But I think its fun to think these things through.

He's a real fat man with a lot of issues.

Eye: How did he rupture his globe the last time? For a man to break his eye twice is unusual. I want to know more about that. As for this eye, he broke it at 2AM while driving? Is he drunk, on benzos, etc? Or did he fall asleep behind the wheel because of his OHA/OSA?

Car accident: are we sure he's not injured? Is the globe a red herring and its hiding the teardrop fracture? He needs full workup for trauma post-haste, with imaging.

Lungs: so he can walk 25% of a mile before being dyspneic, has a sat of 81%, and has "small lungs"? My first thing in the diff is OHA. But I would love a CXR first, and an ECG to see if he has any right heart strain/cor pulmonale secondary to the OHA. ABG too.

Heart: as I mentioned previously, his huge size alone puts him at risk for cardiac complications. An ECG is essential, and I would not proceed without one. Does he have dependent edema?

Airway: its garbage. I don't know what kind of fancy stuff you guys use, but I'd want to go in with the quickest most accurate thing.

Paralysis: He needs his gag reflex stopped because of the eye injury. I don't know how you guys do that. That needs to happen before the airway goes in.

I also agree with whoever said that this needs to move to a hospital.

 

[gasp]

dude you stole my word!!!👍

He stole that? I thought it was his original special made up nickname for me... disappointed to say the least.

 

[gasp]

"He's a real fat man with a lot of issues" .

Are you an orthopedic surgeon?

 

[Mman]

I haven't done too many urgent/emergent eye cases, but i know IOP is the name of the game...

I would normally agree. In this patient, though, IOP is like 3rd or 4th on the list of things I care about.

Airway and Breathing are coming way before I care about his IOP. He's more likely to be dead today than go blind from some transient increase in IOP if I'm not careful. So while I'd consider what any intervention would do to his IOP, I'm considering more the necessity to control his airway and oxygenate and ventilate him.

Now if it was an ASA 1 healthy patient with a globe injury, that'd be a different story.

In this patient I'd probably give him some combination of propofol and sevo and get him deep but still breathing spontaneously as I assist him. Like get him real deep. If I felt comfortable that I could mask him, I'd then push some paralytic and glidescope the tube in. If I was sure how good the ventilation was going to be, I'd probably stick the glide in his mouth with him breathing and see what was down there and if I had anything close to a view I'd then push some paralytic as well knowing I could later get the tube in after the paralytic kicked in.

During that whole time I'd be internally debating pushing Roc or pushing Sux depending on how things were going.

But I'm getting the tube in first and asking questions about his IOP later.

 

[soonerfrog]

For those peeps who keep arguing for Sux>>>Roc, what benefit do you get over RSI dosed Roc? Do a few seconds quicker onset outweigh your side effect profile? You're likely gonna paralyze the guy intraop regardless. And while AssLoadOfRoc is gonna hang around for a while afterward, how many of you think it's highly probable you're gonna get this guy extubated at the case's conclusion anyhow? Thoughts?

 

[VentdependenT]

Are you an orthopedic surgeon?

I didnt say that. flippen misrepresentin me dog

 

[gasp]

For those peeps who keep arguing for Sux>>>Roc, what benefit do you get over RSI dosed Roc? Do a few seconds quicker onset outweigh your side effect profile? You're likely gonna paralyze the guy intraop regardless. And while AssLoadOfRoc is gonna hang around for a while afterward, how many of you think it's highly probable you're gonna get this guy extubated at the case's conclusion anyhow? Thoughts?

I would use succ. Not because I'm worried that Roc will stay on board for extubation. Not because I think it works a few seconds faster than the RSI dose of Roc (although a few seconds can be the difference between life and death in this specific patient). I use Succ because IF for some reason I am not able to Tube this guy or have trouble doing it and ventilating/LMA doesn't work well either, I know that at least he will start breathing spontaneously soon and I can come up with another plan once he does. I have run into this during emergent C/S where I could not intubate and ventilation was extremely hard and required help (a collegue) just to keep her sat >70. LMA was tried and did not seat well, no other size available at the time. Thankfully, this lady started breathing and simple masking brought her sats up and gave us time to get a fiberoptic scope in the room and intubate her. If Roc was given, oh lord..

 

[IlDestriero]

I would use succ. Not because I'm worried that Roc will stay on board for extubation. Not because I think it works a few seconds faster than the RSI dose of Roc (although a few seconds can be the difference between life and death in this specific patient). I use Succ because IF for some reason I am not able to Tube this guy or have trouble doing it and ventilating/LMA doesn't work well either, I know that at least he will start breathing spontaneously soon and I can come up with another plan once he does. I have run into this during emergent C/S where I could not intubate and ventilation was extremely hard and required help (a collegue) just to keep her sat >70. LMA was tried and did not seat well, no other size available at the time. Thankfully, this lady started breathing and simple masking brought her sats up and gave us time to get a fiberoptic scope in the room and intubate her. If Roc was given, oh lord..

Roc or sux, either way if you can't ventilate, this patient will be dead before he starts breathing again. Or, hopefully, you would cut his neck and secure his airway with a surgical cricoidotomy. I'm sure jet ventilation isn't available in the eyeball center.
I would absolutely transfer him to the big house. No question. If the surgeon kicked up a fuss, when I was done laughing at his/her stupidity, I'd say that on his best day he is unlikely to be able to be done there (and this ain't his best day). He shouldn't even be started anywhere without further (brief and directed) evaluation of his significant hypoxia. (Abg, cxr, etc.)
An open globe is an emergency, but not one that will kill him immediately if he's transferred to a real hospital. There are emergencies and there are EMERGENCIES. This is definitely a small e. Though it's a big E for eyeball guy, because he doesn't know any better. There is an open globe, I must fix it. The treatment for his (worsening?) hypoxia may well be a much more concerning E.
This is great board material, the eyeball and dullard surgeon are (possibly) distractors from the REAL emergency.
Don't assassinate him in the ASC.😱

 

[Substance]

I didnt say that. flippen misrepresentin me dog

Nope. That was me.

As for the case, I'd be more worried about an occult emergency than the eye. We haven't ruled everything out.

 

[Idiopathic]

okay, these are all great points; however, you have to assume that for him to get to you

ready to roll back to the OR

hes had a workup of his trauma. if he is sitting there talking to you, not short of breath, not hemodynamically unstable, its unlikely hes had a

big PE

pneumo

acute right heart failure

it is more likely that he has

acute monitor failure

with that said

obviously

do a full workup, H&P, etc. get a CXR...all the stuff that will be on your boards. then, the answer you will likely come up with is

prop/sux/tube

extubate to BIPAP if you have to, overnight in PACU/23 hour obs

 

[Idiopathic]

im usually not that cavalier. felt good.

 

[Idiopathic]

Roc or sux, either way if you can't ventilate, this patient will be dead before he starts breathing again. Or, hopefully, you would cut his neck and secure his airway with a surgical cricoidotomy. I'm sure jet ventilation isn't available in the eyeball center.
I would absolutely transfer him to the big house. No question. If the surgeon kicked up a fuss, when I was done laughing at his/her stupidity, I'd say that on his best day he is unlikely to be able to be done there (and this ain't his best day). He shouldn't even be started anywhere without further (brief and directed) evaluation of his significant hypoxia. (Abg, cxr, etc.)
An open globe is an emergency, but not one that will kill him immediately if he's transferred to a real hospital. There are emergencies and there are EMERGENCIES. This is definitely a small e. Though it's a big E for eyeball guy, because he doesn't know any better. There is an open globe, I must fix it. The treatment for his (worsening?) hypoxia may well be a much more concerning E.
This is great board material, the eyeball and dullard surgeon are (possibly) distractors from the REAL emergency.
Don't assassinate him in the ASC.😱

i think its a 100% given this patient goes to the main hospital, not to an "Eye Center connected to the main hospital". this case gets done in a regular OR with regular staff and backup help available