Trauma Case

[CodeBlu]

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40 something year old guy, from outside hospital. Transferred to your facility with an unstable C-spine fracture from trauma. No other injuries except for scrapes and bruises.
PMHx: Ank spon, HTN, DLD, EtOH abuse, Chronic opioid use (Hydromorph contin 12mg TID and 4 mg PO q4h PRN)
Previous C-spine fusion/instrumentation C4-T1

Patient is anxious, uncooperative... surgeon wants to do neurological exam after proning patient.

Some kind soul has secured 16 ga IV x 2.

Induction? Maintenance? Disposition?

Go.

 

[deleted697535]

Fairly Straightforward case to talk about I would've thought but difficult to implement. Remi midaz afoi, gas maintenance.

Neck is gonna be fused post op so goes to wards with home opiates plus ketamine/hm pca and a ciwa

 

[Timeoutofmind]

40 something year old guy, from outside hospital. Transferred to your facility with an unstable C-spine fracture from trauma. No other injuries except for scrapes and bruises.
PMHx: Ank spon, HTN, DLD, EtOH abuse, Chronic opioid use (Hydromorph contin 12mg TID and 4 mg PO q4h PRN)
Previous C-spine fusion/instrumentation C4-T1

Patient is anxious, uncooperative... surgeon wants to do neurological exam after proning patient.

Some kind soul has secured 16 ga IV x 2.

Induction? Maintenance? Disposition?

Go.

Pt uncooperative
AFOI and awake post intubation neuro exam both out

Also all the bucking and coughing with AFOI will cause more C spine movement than VL

Explain that to surgeon
And
Asleep glidescipe with manual stabilization, RSI

 

[woopedazz]

Retrograde wire 😎

 

[deleted697535]

Pt uncooperative
AFOI and awake post intubation neuro exam both out

Also all the bucking and coughing with AFOI will cause more C spine movement than VL

I respect your rationale but no patient is cooperative for afoi when the scope goes into their oropharynx , that's why were around!

 

[Lecithin5]

I respect your rationale but no patient is cooperative for afoi when the scope goes into their oropharynx , that's why were around!

But being uncooperative due to drunkenness is another thing...

 

[PainDrain]

First off, this can be done awake even if he is drunk and uncooperative. Awake doesn’t mean you can’t sedate him. You start by topicalizint the hell out of him. Start with viscous lido and have him swallow. Next, use 4% lido in an atomizer and spray the hell out of his mouth, throat and nasal passages; each time getting the atomizer further and further back. Lastly if possible you can block the glosopharyngeal nerve in the posterior oropharynx using a 25g spinal needle and 2-5mls lido 2% per side. For sedation go with either 2-4mg midazolam10-20mcg blouses of precedex and Ketamine 10mg. The ketamine is the trick here, it keeps him sedated enough that he won’t care about the FOB but he isn’t apneic. I do the intubation with him at about 45 degrees and have remifenayl in line to bolus once the tube is in. You keep him asleep for pinning or tong placement and the flip. Shut the remi off and let him wake up for the neuro exam and then back to sleep he goes.

 

[sevoflurane]

I just did this case a few weeks ago in the middle of the night.. 16 y/o comes in as a quad from a trampoline accident at summer camp.
My neurosurgeon demanded an AFOI due to his cord taking a 90 degree turn at c3/c4. I said... hell no. Talked to the patient, gave him some heavy atomized lido and did an awake glidesope look with the c collar in place. Saw cords easily. Proceeded with RSI with c collar in place and in line stabilization. Easy and controlled without any drama. Unfortunately for this patient we had almost zero signals to start and almost zero signals at the end.

 

[sevoflurane]

Did a similar induction on a drunk self inflected GSW to the front of the face a few years back. Worked out just as well. No spinal cord injury, but very messed up face/eye socket... loosing aw, ent on the way in from home.

 

[Lecithin5]

Of course you can do an afoi on a drunkard with sedation- it just depends of level of drunkenness (specifically about whether he/she is uncooperative/belligerent) and level of sedation you would need- obviously if too wild and would need lots of sedation, I’d be weary

 

[deleted162650]

16 y/o comes in as a quad from a trampoline accident at summer camp.

Well thanks for ruining my F’in day and making me second guess the flush in ground trampoline they are 1/2 way through installing in my back yard.

 

[sevoflurane]

Well thanks for ruining my F’in day and making me second guess the flush in ground trampoline they are 1/2 way through installing in my back yard.

Well at least yours is a flush with the ground. Another recent sobering trampoline incident was that of a trampoline taking flight under high gust winds with a bunch of kids in it. One was tossed into a telephone pole causing her to get electrocuted. I’ll spare you the details of how that ended. That one sucked worse.

 

[PainDrain]

Trampolines are a device of the devil. I saw a similar case like the one Sevo describes. 14 yo M fell backward on a trampoline and was briefly knocked out after hitting the side of the frame. He gets up and looks down, ligaments give way and immediately collapses.

 

[Timeoutofmind]

I just did this case a few weeks ago in the middle of the night.. 16 y/o comes in as a quad from a trampoline accident at summer camp.
My neurosurgeon demanded an AFOI due to his cord taking a 90 degree turn at c3/c4. I said... hell no. Talked to the patient, gave him some heavy atomized lido and did an awake glidesope look with the c collar in place. Saw cords easily. Proceeded with RSI with c collar in place and in line stabilization. Easy and controlled without any drama. Unfortunately for this patient we had almost zero signals to start and almost zero signals at the end.

Why did you take an awake look with the glide scope? As opposed to just inducing? Airway looked difficult?

 

[sevoflurane]

Why did you take an awake look with the glide scope? As opposed to just inducing? Airway looked difficult?

AW could have been difficult... especially with a full stomach and a c clar that cant be removed in any way.

Essentially risk stratification with big upside and no downside.

 

[MoMoGesiologist]

I just did this case a few weeks ago in the middle of the night.. 16 y/o comes in as a quad from a trampoline accident at summer camp.
My neurosurgeon demanded an AFOI due to his cord taking a 90 degree turn at c3/c4. I said... hell no. Talked to the patient, gave him some heavy atomized lido and did an awake glidesope look with the c collar in place. Saw cords easily. Proceeded with RSI with c collar in place and in line stabilization. Easy and controlled without any drama. Unfortunately for this patient we had almost zero signals to start and almost zero signals at the end.

U think for pts with C-collars, glidescope will usually give a good view when leaving the collar on?

 

[sevoflurane]

Yes. I can nearly always get a good view with a glidescope and minimal neck movement. If it turns out to be an impossible view with a glidescope, then I’m upping my AW game.

 

[Noyac]

First off, this can be done awake even if he is drunk and uncooperative. Awake doesn’t mean you can’t sedate him. You start by topicalizint the hell out of him. Start with viscous lido and have him swallow. Next, use 4% lido in an atomizer and spray the hell out of his mouth, throat and nasal passages; each time getting the atomizer further and further back. Lastly if possible you can block the glosopharyngeal nerve in the posterior oropharynx using a 25g spinal needle and 2-5mls lido 2% per side. For sedation go with either 2-4mg midazolam10-20mcg blouses of precedex and Ketamine 10mg. The ketamine is the trick here, it keeps him sedated enough that he won’t care about the FOB but he isn’t apneic. I do the intubation with him at about 45 degrees and have remifenayl in line to bolus once the tube is in. You keep him asleep for pinning or tong placement and the flip. Shut the remi off and let him wake up for the neuro exam and then back to sleep he goes.

That’s how to topicalization an airway but this pt was reported to be uncooperative. In my book that means they won’t do any or most of this.

I like the fully asleep glidescope approach like Sevo did best.

Just have neuromonitoring person confirm good motor signals post intubation if surgeon needs something.

 

[anbuitachi]

For the OP's case. Prop sux tube w Inline stablization. Can attempt to wake patient up after flip with remi on board