Everyday case

[dhb]

16y/o healthy male comes in at 8pm with a broken wrist he ate at 7pm it's now 11pm. Ortho on call is the hand guy so it's going to be a 30-40min case tops.

What's your approach?
RSI, LMA, regional US or NS, postpone how long?

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[Planktonmd]

This age group are not good candidates for surgery under regional anesthesia.
They tend to be nervous and could get agitated easily which might end up requiring close to GA level of sedation.
I say RSI, ETT.

16y/o healthy male comes in at 8pm with a broken wrist he ate at 7pm it's now 11pm. Ortho on call is the hand guy so it's going to be a 30-40min case tops.

What's your approach?
RSI, LMA, regional US or NS, postpone how long?

 

[Arch Guillotti]

pent, sux, tube

 

[hoyden]

16y/o healthy male comes in at 8pm with a broken wrist he ate at 7pm it's now 11pm. Ortho on call is the hand guy so it's going to be a 30-40min case tops.

What's your approach?
RSI, LMA, regional US or NS, postpone how long?

depends on the fx - if open - needs to go - RSI.

If not open - may wait until the morning, however, it is hard to predict, that in pain/with narcotics on board he will empty his stomach even in 8 hours.

In real life all of us have to go - and then it will be GA with RSI.

As a board question I am not quite sure, since those NPO guidelines are very far from being clear-cut.

 

[Arch Guillotti]

As a board question I am not quite sure, since those NPO guidelines are very far from being clear-cut.

NPO guidelines are just that, guidelines. They are subject to interpretation.

I still would do pent, sux, tube.

If ortho dude posts the case as urgent I am not going to argue with him unless there is a compelling reason to do so, which is unlikely with this pt. You could have the case done by the time you are finished arguing.

 

[hoyden]

NPO guidelines are just that, guidelines. They are subject to interpretation.

I still would do pent, sux, tube.

If ortho dude posts the case as urgent I am not going to argue with him unless there is a compelling reason to do so, which is unlikely with this pt. You could have the case done by the time you are finished arguing.

I absolutely agree and that's what we all do all the time. But since I am still before my orals, I always keep in mind the ways to answer the question as for orals( they do not coincide 100% and you know that).

 

[Arch Guillotti]

I absolutely agree and that's what we all do all the time. But since I am still before my orals, I always keep in mind the ways to answer the question as for orals( they do not coincide 100% and you know that).

My best advice for the orals: just do what you normally would. The examiners (for the most part) are not out to fry you. If you try and play mind games you run the risk of being hosed.

 

[hoyden]

My best advice for the orals: just do what you normally would. The examiners (for the most part) are not out to fry you. If you try and play mind games you run the risk of being hosed.

thanks.

 

[nap$ter]

pent, sux, tube

agreed

 

[bostonblaz]

did an almost the same case 4 hours ago. His fracture as a distal humorous. He had just had a late lunch 2 hrs before he hurt himself slipping on the ice outside his parents house walking the dog. He even went as far as to say that he felt full. I spoke with the ortho on call and he didn't care what we did as long as he could get out and get some sleep cause he was leaving to go ski early in the morning. I spoke with the kid and he felt he could tolerate sitting still as lomng as he had something to do. I did a supraclavicular block and an intercostal brachial sans sedation and let him bring his iphone into the or. We watched some epidodes of the office he downloaded and hung out. In my opinion this was the best care he could have gotten and no matter what a board examiner says it worked. I agree that regional is sometimes not the best answer cause they will throw the failed block at you, or the uncomfortable in there that needs to go to sleep. The one thing that you never have in an exam is the feeling the patient gives you whe you meet face to face that will let you know what they can handle. blaz.

 

[leviathan]

did an almost the same case 4 hours ago. His fracture as a distal humorous. He had just had a late lunch 2 hrs before he hurt himself slipping on the ice outside his parents house walking the dog. He even went as far as to say that he felt full. I spoke with the ortho on call and he didn't care what we did as long as he could get out and get some sleep cause he was leaving to go ski early in the morning. I spoke with the kid and he felt he could tolerate sitting still as lomng as he had something to do. I did a supraclavicular block and an intercostal brachial sans sedation and let him bring his iphone into the or. We watched some epidodes of the office he downloaded and hung out. In my opinion this was the best care he could have gotten and no matter what a board examiner says it worked. I agree that regional is sometimes not the best answer cause they will throw the failed block at you, or the uncomfortable in there that needs to go to sleep. The one thing that you never have in an exam is the feeling the patient gives you whe you meet face to face that will let you know what they can handle. blaz.

Nice story.

 

[dhb]

Well i went for the regional too: US guided axillary block. He wasn't the most cooperative patient but once his arm went numb and with a little midaz he tolerated the surgery fine.

The case wasn't an emergency so it could have been delayed but the hand guy was ready to go. I felt the most comfortable option for the patient was to have his wrist fixed earlier rather than the next day or the day after, to avoid airway problems and have a good post-op analgesia.

Incidence of aspiration or intravascular injection are very low but whatever your approach you can always be faulted if you have a bad outcome.

 

[coprolalia]

Regional is only as good as the hands doing it. If you suck at regional, then to you the obvious answer is GA.

I would have first approached this case with surgical-level regional block. You can always convert if the case goes longer than expected, or you have a patchy block. Not that, in my hands, you'd need to. Plus, regional gives you added benefit of post-operative pain relief and better PACU stay, especially important in this age group. The only immediate contraindications would be allergy to LA, need to have sensation/peripheral nerve intact (e.g., to monitor for compartment syndrome, etc.), or inability of the patient to tolerate the block.

Nice case, bostonblaz. That's really thinking about the whole patient, not just getting the job done.

-copro

 

[cchoukal]

Well i went for the regional too: US guided axillary block. He wasn't the most cooperative patient but once his arm went numb and with a little midaz he tolerated the surgery fine.

The case wasn't an emergency so it could have been delayed but the hand guy was ready to go. I felt the most comfortable option for the patient was to have his wrist fixed earlier rather than the next day or the day after, to avoid airway problems and have a good post-op analgesia.

Incidence of aspiration or intravascular injection are very low but whatever your approach you can always be faulted if you have a bad outcome.

I LOVE the u/s guided axillary, and I add a separate musculocutanous block. It's easy to see anatomically lateral to the axillary bundle and looks like the sort of curved stem of a jalapeno pepper (and it will still twitch). The block helps with the tourniquet, but my opinion is that what it REALLY adds is weakness to arm flexion so the surgeon will feel more confident that the block is good (because the arm is limp).

 

[dhb]

I LOVE the u/s guided axillary

I agree i hated the nerve stimulation axillary but now with US i think it's a great block.