Trauma Case

[gtb]

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So, you are saying that the best way to secure an airway in a morbidly obese patient with a cervical fracture and a facial fracture is to make him apneic and abolish all his airway reflexes and then hope you could intubate him before he dies?

I am definitely not intending to say that this is the best way, and only given my other concerns, in this particular case, this is my strategy. Many aspects of this patient concern me, including but not limited to:
- Major trauma.
- Smashed his face hard enough to break bones and therefore has potentially injured his C-spine
- Likely has some blood in his mouth that might start profusely bleeding the minute I open his mouth
- An obese diabetic that very likely has delayed gastric emptying and an unknown NPO status. Is he going to pull into his lungs pieces of his super-sized lunch?
- He is on close to 100% O2 with a nonrebreather satting 99%. Maybe the paramedics/lifeflight folks are there to answer questions, but probably not. Why did somebody put him on a nonrebreather vs. nasal canula or simple mask?
- Can he cooperate with an awake FOB? Any signs of elevated ICP? Does he have an occult or obvious TBI?
- Likely a "fixed" heart given 4-vessel revascularization, but grafts might occlude.

If he vomits or bleeds during awake or asleep FOB, then I have quickly paralyze and DL though a mess. Glidescope is probably useless in that case. If I RSI w/ paralytic, then he might regurgitate, but since the diaphragm and accessory muscles are paralyzed, there should not be chunks in the airway. Another concern is getting a glidescope blade in the mouth with a rigid collar on and the patient on a backboard or maybe even sandbagged. I've always removed the anterior half of the collar immediately before inducing.

Realistically there are no guarantees, regardless of approach, in securing his airway. My thinking is that there are opposing goals for this particular patient; that of securing the airway while also minimizing the risk of secondary injury to his spine, lungs, brain, and heart. In the resuscitation bay, I personally do not feel comfortable predicting whether the airway will be free of blood, saliva, vomit, chewing tobacco etc.. And, with a HR of 125, I am concerned that he might soon start to experience ischemia. For me, DL with the backup GS -> +/- FOB vs. SA. ENT has already seen him; how about a thorough PreO2, prep and partially drape the neck, have a surgical airway kit open, ENT holding a blade then induce, and do not wait until the SpO2 drops to 60 before requesting the surgeon incise.

Thanks to all for an excellent discussion. I'm personally never comfortable when these patients come in. I wish that I would never see a case similar to this, but I will, and I appreciate the various approaches presented.

 

[Arch Guillotti]

I would not do an awake fiber on this guy. He is lying on his back in a collar - getting the neb to work properly can be a pain in this position. He hasd a bull neck and a ZZ Topp beard so landmarks may be difficult to find. He will probably gag and cough when you are fooling around with the transtracheal. Nebs don't seem like they would really work when his mouth is full of blood. If he has less than inadequate scope tolerance he runs the risk of regurgitation and aspiration while on his back strapped to a gurney.

Pre-O2, in-line stabilization, etomidate, sux, glidescope, fiberscope assistance if glidescope fails. I don't require an aline prior (I would be stunned if I knew in advance that a patient like this had a low EF). Trach kit somewhere nearby but I would not require an ENT on standby, let alone with a knife in hand poised to strike.

Put the tube in and get this guy to the OR.

 

[Idiopathic]

yeah like many things it boils down to XXX/sux/tube 😉

 

[gtb]

Does anyone have direct experience w/ volatile anesthetics for porphyria patients? Anything concerning to worry about?

Trach kit somewhere nearby but I would not require an ENT on standby, let alone with a knife in hand poised to strike.

Completely agree. I got defensive after the concerns voiced about laryngoscopy as a first choice. Very unlikely to be necessary.

 

[BLADEMDA]

I would not do an awake fiber on this guy. He is lying on his back in a collar - getting the neb to work properly can be a pain in this position. He hasd a bull neck and a ZZ Topp beard so landmarks may be difficult to find. He will probably gag and cough when you are fooling around with the transtracheal. Nebs don't seem like they would really work when his mouth is full of blood. If he has less than inadequate scope tolerance he runs the risk of regurgitation and aspiration while on his back strapped to a gurney.

Pre-O2, in-line stabilization, etomidate, sux, glidescope, fiberscope assistance if glidescope fails. I don't require an aline prior (I would be stunned if I knew in advance that a patient like this had a low EF). Trach kit somewhere nearby but I would not require an ENT on standby, let alone with a knife in hand poised to strike.

Put the tube in and get this guy to the OR.

Arch,

I appreciate the post. The patient in this case was reported to be a tough intubation at our institution. I had a good idea who intubated this guy in 2001. I felt it prudent to ask the General Surgeon to stand-by in the O.R. while I got him intubated. Scalpel was not in hand but the trach instruments were ready.

Propofol was chosen as the induction agent because Etomidate is "questionable" in AIP. I was able to get his EF because he was in our computer database and there was an Echo report (2 years old).

A-line was placed due to his known EF of 35%, massive blood loss with hypovolemia and morbid obesity. Auto BP Cuffs aren't always reliable in hypotensive Obese patients and may not give a consistent reading (sometimes it just cycles with no reading). A-line took 35 seconds.

Subclavian central line was placed after intubation for intraop/postop use.

Blade

 

[IlDestriero]

I would not do an awake fiber on this guy. He is lying on his back in a collar - getting the neb to work properly can be a pain in this position. He hasd a bull neck and a ZZ Topp beard so landmarks may be difficult to find. He will probably gag and cough when you are fooling around with the transtracheal. Nebs don't seem like they would really work when his mouth is full of blood. If he has less than inadequate scope tolerance he runs the risk of regurgitation and aspiration while on his back strapped to a gurney.

Pre-O2, in-line stabilization, etomidate, sux, glidescope, fiberscope assistance if glidescope fails. I don't require an aline prior (I would be stunned if I knew in advance that a patient like this had a low EF). Trach kit somewhere nearby but I would not require an ENT on standby, let alone with a knife in hand poised to strike.

Put the tube in and get this guy to the OR.

I'm with you. I'd almost certainly do the same thing. Add some scissors to trim the dumb beard back if I have to cut the neck. Topicalizing this guy would be a problem, and injections can work great if you can get the anatomy right. That's not a given here, and my skills there are likely gone. My laryngoscopy skills are not. You could probably fiber through an LMA if you couldn't secure the airway and were reluctant to cut. The likelihood of getting ENT to stand by with a scalpel is close to zero. They're either slaving away in the OR or bombing around in their 911s. They'd send a resident. I'd rather do it myself.

 

[BLADEMDA]

Does anyone have direct experience w/ volatile anesthetics for porphyria patients? Anything concerning to worry about?



Completely agree. I got defensive after the concerns voiced about laryngoscopy as a first choice. Very unlikely to be necessary.

Yes. No problems with Sevo or Iso based on my first hand case experiences.

 

[Planktonmd]

People seem to be confusing awake intubation with awake Fiberoptic intubation.
An anesthesiologist should know how to do an awake intubation on a patient like the one described here, it does not have to be fiberoptic but it has to be awake.
Topical anesthesia and airway blocks are something that every practicing anesthesiologist should know how to do IMHO.
You have plenty of time to prepare the patient and the airway, clean the blood out, examine the airway, give Glyco, topicalize, do airway blocks then proceed gently without burning any bridges.
I never regretted intubating a patient awake.
There are instances when you don't have the luxury of time and then you do what you need to do but this is not one of them, this is not an emergency so you don't have to turn it into one.

 

[BLADEMDA]

http://books.google.com/books?id=3y...rane and acute intermittent porphyria&f=false

Read pages 317 and 318. Etomidate is questionable but Isoflurane is probably safe.

 

[BLADEMDA]

People seem to be confusing awake intubation with awake Fiberoptic intubation.
An anesthesiologist should know how to do an awake intubation on a patient like the one described here, it does not have to be fiberoptic but it has to be awake.
Topical anesthesia and airway blocks are something that every practicing anesthesiologist should know how to do IMHO.
You have plenty of time to prepare the patient and the airway, clean the blood out, examine the airway, give Glyco, topicalize, do airway blocks then proceed gently without burning any bridges.
I never regretted intubating a patient awake.
There are instances when you don't have the luxury of time and then you do what you need to do but this is not one of them, this is not an emergency so you don't have to turn it into one.

Why does it have to be awake? Where is your peer reviewed evidence for that statement? Our experiences in thousands of these case show "asleep" works fine. This case like others is a judgement call for the Attending. Plan B and C are in the room ready to go.

Your definition of "emergency" is different than the study out of Shock trauma in Baltimore. They chose "intubation in less than one hour after arrival to the E.R." This guy was intubated 38 minutes after arriving to our trauma bay.

I respect your decision to choose to do an awake intubation. However, for anyone to say that a RSI with a good backup plan isn't reasonable in this type of case without actually examining the airway seems presumptuous at best.

 

[BLADEMDA]

Does anyone have direct experience w/ volatile anesthetics for porphyria patients? Anything concerning to worry about?



Completely agree. I got defensive after the concerns voiced about laryngoscopy as a first choice. Very unlikely to be necessary.

http://www.ncbi.nlm.nih.gov/pubmed/15021955

Avoid Enflurane. Isoflurane has the most number of "safe" case reports.

 

[gtb]

Topical anesthesia and airway blocks are something that every practicing anesthesiologist should know how to do IMHO.
You have plenty of time to prepare the patient and the airway, clean the blood out, examine the airway, give Glyco, topicalize, do airway blocks then

Except for transmembrane blocks, in my residency, I have never, and I am not going to get a chance to do any airway related nerve blocks. It is just the reality of my program. I know where to stick the needle, I just will come out of residency with zero real experience. I recognize that I will need to acquire these skills at workshops post residency. Having said that, in the many months that I have been at a busy level I center covering 4 states, I have not heard of an urgent intubation for a polytrauma patient being accomplished with with awake FOB or awake intubation. An awake trach yes, but not intubation. I also recognize that this is a center dependent idiosyncrasy, although here it has not been necessary for at least 3 years of my training.

Glycopyrolate would be nice to quickly dry up the airway in case urgent FOB is needed. However, he's a diabetic with known CAD and a current HR of 125. I personally feel uncomfortable further exacerbating his tachycardia with glycopyrolate. I am already concerned about demand ischemia causing him problems. Running through the DDx for tachycardia, it is likely pain, but hypovolemia is high, high, high on my differential in the polytrauma patient. Also, scopolamine is going to confuse his neuro exam, and piss off the neurosurgeons.

 

[BLADEMDA]

Quote:
Originally Posted by BLADEMDA

What about intraoperative monitoring and the patient's hypovolemia? Does everyone concur with Amyl?
Any concern with AIP?

Does his EF of 35% alter your plan in anyway? If so, how?

Blood bank just sent you 2 units of 0+ emergency release blood. They haven't got type specific blood but patient tells you he is AB-. Are you going to give the emergency blood or wait for AB-?


So, I put the arterial line in. Takes 35 seconds. ABG comes back with the following: 7.29/34/146 BE-14 Hemoglobin now 7.7

Careful induction with Propofol, 200 ug phenylephrine and Sux. Miller Blade and RSI (if it works🙄). Cervical immobilization. Posterior Collar left in place. 8.0 et tube placed on first attempt. ETCO2, BBS.

Now, what about the ABG and the hemoglobin?


How about a Resident/Fellow giving his/her answer? (Plank let them post before you chime in).

Can we move on already. Any takers on the above?

 

[Planktonmd]

Here is the ASA algorithm for airway management with cervical spine injury.
The only time an RSI is recommended is if you think that the airway is seen as easy (easy might mean not having a facial fracture and a broken nose)

 

[urge]

Am I the only one who thinks the coughing and jumping around during an awake intubation is far worse than an asleep DL?

 

[Planktonmd]

Am I the only one who thinks the coughing and jumping around during an awake intubation is far worse than an asleep DL?

Coughing and jumping happens when your airway anesthesia is sub optimal.
Also with an awake techique you can leave the collar on for extra protection.

 

[Southpaw]

Coughing and jumping happens when your airway anesthesia is sub optimal.
Also with an awake techique you can leave the collar on for extra protection.

In your awake technique, what do you do to avoid/minimize the risk of aspiration between the time you anesthetize the airway and secure the airway?

 

[gtb]

Can we move on already. Any takers on the above?

The patient is has bled, is further going to bleed when surgery begins. Also seems to have been under resuscitated based on based deficit. Maybe a Hct for this porphyria pt is chronically low, but I'll give blood now, because he seems to be showing signs of under perfusion (tachy, large neg BD), and his Hb of 7.7 is going lower once I resuscitate further with crystalloids. Needs coags, and platelet count to go with Hct. Probably is on ASA, maybe plavix, so at least order 1 platelet to go w/ cross-matched blood. No FFP kept at our level 1 center (no kidding), so I'll T&C and order 8 units PRBC, 4 FFP, and 1 platelet. For now. More products PRN based on evolving coags and Hct.

So yes, a-line, if for no other reason than frequent ABG. Could also hook up a litco monitor to track his cardiac output. Last EF measured is 35%, might have improved since revascularization, might be worse. Probably okay heart function or his BP would not be so high. Would also have used Cordis with TLC for central line to ensure access for pressors, inotropes, CVP monitoring. Very unlikley that I would float a PA cath, but if possible if later needed in the ICU which is where this guy is headed once surgery if finished. Put the order in for a bed now.

Mildly acidotic, hyperventilation, and not great oxygenation on a NRB. Mixed deficit - many possible causes. W/ respect to O2, I'm concerned about lung injury (contusion, hemotx, . . .,bronchospasm), and the trauma CT along with the trauma series plain films may reveal etiology. Low CO2 is likely resulting from pain (as is the HR =125 and hypertension). Cautious opioids until tubed, more when the airway is protected. Always concerned about the triad of death for a trauma patient (acidosis, coagulopathy, and hypotermia). Fix ABCD's as identified, warm the patient, ventilate, and stay on top of Hct, coags and electrolytes.

Other ideas?

 

[Planktonmd]

In your awake technique, what do you do to avoid/minimize the risk of aspiration between the time you anesthetize the airway and secure the airway?

If you anesthetize the airway and the oral cavity properly they should not gag and since you are maintaining spontaneous ventilation then you are not inflating the stomach which also minimizes the risk of vomiting.
You could even put the patient in a semi sitting position to decrease the pressure on the abdomen.
You can not eliminate that risk but in my opinion they are less likely to aspirate than a patient who received RSI especially if you could not intubate on the first attempt and had to mask ventilate.

 

[Southpaw]

If you anesthetize the airway and the oral cavity properly they should not gag and since you are maintaining spontaneous ventilation then you are not inflating the stomach which also minimizes the risk of vomiting.
You could even put the patient in a semi sitting position to decrease the pressure on the abdomen.
You can not eliminate that risk but in my opinion they are less likely to aspirate than a patient who received RSI especially if you could not intubate on the first attempt and had to mask ventilate.

That sounds like a nice approach. Thanks for the explanation. 🙂

 

[Ronin2258]

RE: Blood.

If you have it, give it. Just make sure you have a good draw for the type and cross prior to giving the mismatch. Under-resuscitation, and the potential for future bleeding are definite concerns.

My logistical concern about blood stems from the fact that once that clot is down in the bank, most places I have worked at won't release more O-neg or O-pos until the type and cross is complete. I have seen that take up to an hour. If he bleeds more in that hour, and the blood bank is refusing to release the O blood, that definitely puts you behind the curve.

Had to realize that with a liver GSW I had before I left surgery. Bleeding bad, and I was helping anesthesia push blood and fluids like it was going out of style (4 attendings and 1 chief scrubbed in, I'm on call, and they booted a 3rd year from the case, knew I could help up north.) We had to wait until we got (I believe,) 4-6 units of O-neg from the blood bank before sending the T&C tube, because we knew how long it took to do the T&C. Ended up running the last O unit in right at the time the type-specific units came down about an hour or so later. Managed to get him off the table alive and out of the hospital under the care of psych and surgery (guy tried to off himself with a low-calibre rifle.)

Anyone else had this problem, or have I just been hanging around the wrong hospitals in training?

 

[amyl]

how long does the blood bank say for type specific blood?

 

[IlDestriero]

RE: Blood.

If you have it, give it. Just make sure you have a good draw for the type and cross prior to giving the mismatch. Under-resuscitation, and the potential for future bleeding are definite concerns.

My logistical concern about blood stems from the fact that once that clot is down in the bank, most places I have worked at won't release more O-neg or O-pos until the type and cross is complete. I have seen that take up to an hour. If he bleeds more in that hour, and the blood bank is refusing to release the O blood, that definitely puts you behind the curve.

Had to realize that with a liver GSW I had before I left surgery. Bleeding bad, and I was helping anesthesia push blood and fluids like it was going out of style (4 attendings and 1 chief scrubbed in, I'm on call, and they booted a 3rd year from the case, knew I could help up north.) We had to wait until we got (I believe,) 4-6 units of O-neg from the blood bank before sending the T&C tube, because we knew how long it took to do the T&C. Ended up running the last O unit in right at the time the type-specific units came down about an hour or so later. Managed to get him off the table alive and out of the hospital under the care of psych and surgery (guy tried to off himself with a low-calibre rifle.)

Anyone else had this problem, or have I just been hanging around the wrong hospitals in training?

We have both an emergency release blood protocol and a massive transfusion protocol. They will release O neg or uncrossed type specific immediately. If you have a level 1 trauma center w/o the above, the blood bank's going to assassinate someone. Your dept should get the policy changed.

 

[BLADEMDA]

We have both an emergency release blood protocol and a massive transfusion protocol. They will release O neg or uncrossed type specific immediately. If you have a level 1 trauma center w/o the above, the blood bank's going to assassinate someone. Your dept should get the policy changed.

Agreed. I can get as much uncrossed blood as needed and type specific within 30 min.

What do you think of O pos blood for this patient who has AB neg. blood type? Would you give these 2 units?

 

[BLADEMDA]

Here is the ASA algorithm for airway management with cervical spine injury.
The only time an RSI is recommended is if you think that the airway is seen as easy (easy might mean not having a facial fracture and a broken nose)

A guy who wrecked his Motorcycle and lost massive amounts of blood going to the O.R. EMERGENTLY is not an urgent case. The guy was a major trauma who some would intubate in the E.R. immediately. Due to his obesity and possible diff. intubation I chose to wait 38 min. and do it in the O.R.

I would not classify this patient as "stable" and my record noted him as a "3E".

This guy can not be cancelled or delayed. In my experience I haven't found "awake" views to be any better than RSI with Glidescope backup. I guess if you don't see anything "awake" you must be planning on a trach. I would still prefer other alternatives to a trach including LMA assisted intubation, light wand, retrograde, etc.

The patient had no neuro deficits. In my opinion, this "unstable" patient qualifies for an RSI.

 

[pgg]

What do you think of O pos blood for this patient who has AB neg. blood type? Would you give these 2 units?

If it's a male, it's fine.

If female past childbearing age, it's fine.

If female of childbearing age, it's fine for now but there are risks related to future pregnancies resulting in hemolytic disease of the newborn because she may develop anti-D antibodies.

There is some risk in giving O+ to non-childbearing-age females and males because they may have previously been exposed and have anti-D antibodies. But in the worst case you're looking at a delayed transfusion reaction about a week later, so it's fine for now.


To answer your followup question, there's no need to "stick with" uncrossed type O blood after X number of units if you go down the massive transfusion road.

 

[Ronin2258]

A guy who wrecked his Motorcycle and lost massive amounts of blood going to the O.R. EMERGENTLY is not an urgent case. The guy was a major trauma who some would intubate in the E.R. immediately. Due to his obesity and possible diff. intubation I chose to wait 38 min. and do it in the O.R.

I would not classify this patient as "stable" and my record noted him as a "3E".

This guy can not be cancelled or delayed. In my experience I haven't found "awake" views to be any better than RSI with Glidescope backup. I guess if you don't see anything "awake" you must be planning on a trach. I would still prefer other alternatives to a trach including LMA assisted intubation, light wand, retrograde, etc.

The patient had no neuro deficits. In my opinion, this "unstable" patient qualifies for an RSI.

Just by going by guidelines and your description, he is both unstable, and could potentially not cooperate if he either decompensates or he is just being a rowdy/difficult biker (though most of my experience is if they are in the trauma bay, they will listen, but you never know. A rectal/Foley if they are going by ATLS may change his pleasant demeanor.) Both of those lean towards RSI.

My hospital at the time was the regional level 2. I don't know if the blood policy changed since I left (and don't get me started on MRI and codes.)

As for giving O-pos; Only if my hand was forced, which it seems to be in this case. I would much rather have O-neg if I had to give O.

I worry if he had O-pos before and having a reaction to the Rh factor. The history of heart surgery and being AB- would make me concerned about having to give mis-matched blood during his CABG due to availability issues, or if he needed platelets during the procedure, which I have seen usually coming from A-positive donors (at least in the 4 packs I gave my liver person.)

 

[Planktonmd]

So far we know that the guy has a bad injury to his leg and might require an amputation.
Why is he going to need a massive transfusion???
IMHO this case became a routine minor trauma case the moment blade so heroically secured the airway.
Send blood for type and cross match, wait for the blood to become available then proceed.
Transfuse conservatively to maintain a stable hemodynamic status.

 

[Ronin2258]

So far we know that the guy has a bad injury to his leg and might require an amputation.
Why is he going to need a massive transfusion???
IMHO this case became a routine minor trauma case the moment blade so heroically secured the airway.
Send blood for type and cross match, wait for the blood to become available then proceed.
Transfuse conservatively to maintain a stable hemodynamic status.

So, I put the arterial line in. Takes 35 seconds. ABG comes back with the following: 7.29/34/146 BE-14 Hemoglobin now 7.7

Now, what about the ABG and the hemoglobin?

This is what concerns me about the need for blood in a cardiac patient with tachycardia. Too low for someone out and about in motorcycle weather (I would think he would be dehydrated and bit behind the curve.)

The leg is the obvious source of blood loss, but with his size, he could be hiding an abdominal injury which pain could be confused for an AIP attack. I would like to hear about what he was complaining about before the RSI. Failing that, I would like to see the trauma CT scan. The leg and neck could easily be a distractor from something serious going on where we can't see.

 

[BLADEMDA]

So far we know that the guy has a bad injury to his leg and might require an amputation.
Why is he going to need a massive transfusion???
IMHO this case became a routine minor trauma case the moment blade so heroically secured the airway.
Send blood for type and cross match, wait for the blood to become available then proceed.
Transfuse conservatively to maintain a stable hemodynamic status.

Minor? He has already lost half his blood volume. He may lose his leg.

Anyway, Hgb is now 7.7 and as you know the actual hgb is probably even lower as it takes several hours to reflect acute blood loss.

I usually accept O+ blood but in this guy's case I called and demanded O- immediately and cross-matched blood asap. I decided not to give the O+ but 6 minutes later I had O- avail. and I gave him 2 units.

Fortunately, I had type matched blood avail. about 20 minutes after intubating him in the O.R.

 

[BLADEMDA]

This is what concerns me about the need for blood in a cardiac patient with tachycardia. Too low for someone out and about in motorcycle weather (I would think he would be dehydrated and bit behind the curve.)

The leg is the obvious source of blood loss, but with his size, he could be hiding an abdominal injury which pain could be confused for an AIP attack. I would like to hear about what he was complaining about before the RSI. Failing that, I would like to see the trauma CT scan. The leg and neck could easily be a distractor from something serious going on where we can't see.

Good Call. He is complaining of Abdominal pain but he says "it's not too bad." What are your thoughts?

 

[BLADEMDA]

Although we aren't hematologists when I suspected the patient may be RH- I got concerned about the O+ blood. I have been told that in an emergency situation O+ is fine for male patients and females past child bearing age.

Was I over-cautious in demanding O- blood here? Would you give O+ blood to this AB- patient?

 

[Ronin2258]

Good Call. He is complaining of Abdominal pain but he says "it's not too bad." What are your thoughts?

Trauma CT scan. Chest to pelvis. Now.

I don't care if he has a baseline abdominal pain with AIP, I want to see blood where it should be; in the vascular system and not free in the retroperitoneum or around the spleen and free in the peritoneum. Also, with the AIP, he may think the pain was a mild attack, and discounting it as such.

If blood is anywhere outside of vasculature, I would want Trauma surgeons called for the exploration. Ortho can wait; the ruptured vessels/organs will kill him faster than bleeding out of an already tourniquet leg.

 

[Ronin2258]

Although we aren't hematologists when I suspected the patient may be RH- I got concerned about the O+ blood. I have been told that in an emergency situation O+ is fine for male patients and females past child bearing age.

Was I over-cautious in demanding O- blood here? Would you give O+ blood to this AB- patient?

I don't think so. I know it is a long shot, but if he had platelets in his CABG, he could be sensitized to the Rh factor, as most commonly the platelets are from A-pos people.

 

[Planktonmd]

Minor? He has already lost half his blood volume. He may lose his leg.

How do you know that he lost half his blood volume?
When you say that you are taking the guy to the OR to fix his leg I am assuming you did the usual trauma evaluation, but if you did not rule out a thoracic or abdominal injury then I don't know what to say to you.
Are you waiting for us to tell you that every patient who had a motorcycle accident needs to be examined and evaluated for traumatic abdominal or thoracic injury?

 

[BLADEMDA]

How do you know that he lost half his blood volume?
When you say that you are taking the guy to the OR to fix his leg I am assuming you did the usual trauma evaluation, but if you did not rule out a thoracic or abdominal injury then I don't know what to say to you.
Are you waiting for us to tell you that every patient who had a motorcycle accident needs to be examined and evaluated for traumatic abdominal or thoracic injury?

No. But, in this case we missed something. By the way in the real world I work with the trauma surgeon and manage the airway/lines. I don't usually make the "call" on traumas regarding abdominal/thoracic radiological exams.
However, they are receptive to Anesthesiology input.😉

 

[BLADEMDA]

Trauma CT scan. Chest to pelvis. Now.

I don't care if he has a baseline abdominal pain with AIP, I want to see blood where it should be; in the vascular system and not free in the retroperitoneum or around the spleen and free in the peritoneum. Also, with the AIP, he may think the pain was a mild attack, and discounting it as such.

If blood is anywhere outside of vasculature, I would want Trauma surgeons called for the exploration. Ortho can wait; the ruptured vessels/organs will kill him faster than bleeding out of an already tourniquet leg.

I must be getting older and just plain tired. I have seen many many traumas and this was just another one. An overweight, Diabetic biker who wrecked and now needs emergency ortho surgery and then an ACF. But, after an hour into the case I knew we missed something in the trauma bay and the rush to the O.R.... 6 units of Prbcs, 3 units of FFP and some platelets later the Hemoglobin comes back at 8.1 😱😱 The ortho MD was quick and got and the bleeding controlled and the Ext. Fixator in place while we were stabilizing the patient. The Abdomen was getting firm and I knew the case wasn't over.

Good Call. It goes to show you that there can always be a suprise waiting around the corner.

 

[Ronin2258]

How do you know that he lost half his blood volume?
When you say that you are taking the guy to the OR to fix his leg I am assuming you did the usual trauma evaluation, but if you did not rule out a thoracic or abdominal injury then I don't know what to say to you.
Are you waiting for us to tell you that every patient who had a motorcycle accident needs to be examined and evaluated for traumatic abdominal or thoracic injury?

A guy this heavy I would have strong suspicions of sleep apnea, and the possible associated polycythemia. His hemoglobin should be sitting well above 10. In any case, considering he was out and about on his Harley, I would expect him to be hemoconcentrated, not anemic.

No. But, in this case we missed something. By the way in the real world I work with the trauma surgeon and manage the airway/lines. I don't usually make the "call" on traumas regarding abdominal/thoracic radiological exams.
However, they are receptive to Anesthesiology input.😉

It's my surgical years calling me with the ATLS. You got A and B. C shows anemia, D is WTF is causing C? I want a FAST or the CT scan. We are definitely missing the elephant in the room here.

 

[Planktonmd]

No. But, in this case we missed something. By the way in the real world I work with the trauma surgeon and manage the airway/lines. I don't usually make the "call" on traumas regarding abdominal/thoracic radiological exams.
However, they are receptive to Anesthesiology input.😉

You don't have to "make the call", you just say that you will not take a patient to the OR to fix a leg after a motorcycle accident if no one had examined the abdomen and the chest.
I am sure they would understand your concerns.
And please don't tell me that you are trying to steer this thread towards an acute porphyric episode and hemolysis.
😀

 

[BLADEMDA]

You don't have to "make the call", you just say that you will not take a patient to the OR to fix a leg after a motorcycle accident if no one had examined the abdomen and the chest.
I am sure they would understand your concerns.
And please don't tell me that you are trying to steer this thread towards an acute porphyric episode and hemolysis.
😀

No. This was a simple "missed call." The patient didn't complain of Abdominal pain (not much diff. than usual) and his abdomen was soft. Due to the hemorrhage, obesity, neck pain, etc. we rushed him through quickly.

 

[BLADEMDA]

Pathophysiology


Compared with other injuries, blunt injury to the spleen has a more deceptive and subtle presentation. Abdominal tenderness and distention are apparent in approximately 50% of patients, and hypotension is a presenting symptom in only 25-30% of patients. The patient's age and medical background also dictate the presentation and workup. The older, less healthy patient has a tendency to develop rapidly progressive hemodynamic instability, as compared with the younger, healthy patient. However, patients in unstable condition are not referred to the radiology department for diagnosis. Instead, they usually undergo peritoneal lavage, are referred for surgery, or both. Patients with blunt abdominal trauma who are hemodynamically stable and who have minor or no symptoms can be found to have splenic injury radiographically, which is not to say that the workup serves little purpose. Diagnosing splenic trauma before the patient becomes significantly symptomatic is imperative. With the exception of splenic avulsion or shatter, lesser degrees of splenic rupture classically result in a delayed presentation with increased morbidity and mortality. Stable patients with splenic rupture require prompt diagnosis so that treatment can be initiated before systemic compromise ensues. In fact, the conservative treatment of splenic rupture has gained favor over recent years, and radiographic evaluation is more important now than ever. The role of the radiologist has continued to expand along with the data concerning splenic injuries and treatment options

 

[Ronin2258]

At a guess, most likely Blade is wanting us to realize ATLS protocol, and make sure we didn't miss anything.

Airway-done
Breathing-examined when Airway was secured
Circulation-low Hgb+tachycardic=shock and bleeding aside from the leg
Disability-yes, the leg is obvious, but high speed impacts (>=20mph) can cause some seriously bad juju that would only be found on exam and radiology studies.
Exposure-hopefully this was done, and the patient is now nude under a blanket.

Then the secondary survey of an exam head to toe, then the CT/flat films. Did anyone push on the abdomen?

This guy would not be sent over to Ortho where I was training unless the CT scan was done.

The porphyria and the leg are distractors.

Please forgive me Blade, if I am putting words in your mouth. Not my intention.

 

[BLADEMDA]

At a guess, most likely Blade is wanting us to realize ATLS protocol, and make sure we didn't miss anything.

Airway-done
Breathing-examined when Airway was secured
Circulation-low Hgb+tachycardic=shock and bleeding aside from the leg
Disability-yes, the leg is obvious, but high speed impacts (>=20mph) can cause some seriously bad juju that would only be found on exam and radiology studies.
Exposure-hopefully this was done, and the patient is now nude under a blanket.

Then the secondary survey of an exam head to toe, then the CT/flat films. Did anyone push on the abdomen?

This guy would not be sent over to Ortho where I was training unless the CT scan was done.

The porphyria and the leg are distractors.

Please forgive me Blade, if I am putting words in your mouth. Not my intention.

Well,

I am just presenting an interesting case. You don't see that type of patient very often. But, we do see "limited splenic injury" or Stable splenic hematoma all the time; yet, those injuries are sometimes far from stable.

We missed the "call" because the quick CT scan reported no major bleeding but a small splenic hematoma was noted. Of course, I wonder just how "small" this hematoma was. Anyway, Ortho was on scene with the trauma surgeon and pressing to go to the O.R. ASAP. Yes, the Trauma surgeon gets the final call.


http://radiology.rsna.org/content/238/2/473.full

 

[BLADEMDA]

Have many of you seen "stable splenic injuries" or Small hematomas just go to the pooper quickly? This was my third case where the Radiologist/CT Scan reported minor/stable splenic injury but the patient required emergent laparotomy.

Good Call Ronin 2258.


After the emergent laparotomy by the general surgeon the patient stabilized and did fine. He had an inpatient stay of around 11 days.

While I would have loved to play with his glucose levels in the O.R. I was simply too busy. I realize that proper glucose management would be important in the trauma/ICU patient.

 

[pgg]

Although we aren't hematologists when I suspected the patient may be RH- I got concerned about the O+ blood. I have been told that in an emergency situation O+ is fine for male patients and females past child bearing age.

Was I over-cautious in demanding O- blood here? Would you give O+ blood to this AB- patient?

You got the O- blood 6 minutes later, so it certainly wasn't unreasonable to wait for it. But O+ is OK if someone needs blood now. At worst you get a delayed transfusion reaction days later from the amnestic response. He won't get a hemolytic transfusion reaction now and crump because of the O+ blood.

His CABG puts him at relatively low risk IMO, and only because he may have received platelets. He would've received T&C'd red cells then so essentially no risk of anti-D from that.

 

[BLADEMDA]

http://www.nordictraumarad.com/oslo08/SPLENIC INJURY – HOW MDCT GUIDES TREATMENT.pdf


I guess getting the "right call" on Splenic Injury isn't as easy as we think it is.

 

[Arch Guillotti]

I can intubate a gravid fire ant with a Miller 2.

Forget the awake intubation. RSI all the way.

 

[Ronin2258]

Have many of you seen "stable splenic injuries" or Small hematomas just go to the pooper quickly? This was my third case where the Radiologist/CT Scan reported minor/stable splenic injury but the patient required emergent laparotomy.

Good Call Ronin 2258.


After the emergent laparotomy by the general surgeon the patient stabilized and did fine. He had an inpatient stay of around 11 days.

While I would have loved to play with his glucose levels in the O.R. I was simply too busy. I realize that proper glucose management would be important in the trauma/ICU patient.

Had a 11-year old kid come in with one after falling against a hand rail on my south-of-the-curtain years. I saw the lac and I wanted to grade III or IV, which meant I wanted this spleen repaired or out. Senior resident graded it a II. No one wants to take a kid's spleen unless absolutely necessary due to the maturing immune system.

Sat on the kid in the ICU overnight with q4h H/H. AM CT scan showed blood around the spleen, down into the pelvis, exam showed the belly was still soft. H/H only downtrended a couple of points. We had to send pediatric trauma to another hospital, which is what I would have done had I been allowed to make the call initially, and which we eventually did. Our attending who approved the initial plan was kicking himself about how this was a close miss.

Had another one, woman was a week out from a car crash, with abdominal pain and a blush in her spleen on CT. We took her to the OR that night to remove it. Started bleeding from the hilum as we pulled it out.

Both patients turned out fine.

Link to splenic injury pictures here: https://www.socialtext.net:443/m/page/acs-demo-wiki/spleen_injuries

 

[BLADEMDA]

Had a 11-year old kid come in with one after falling against a hand rail on my south-of-the-curtain years. I saw the lac and I wanted to grade III or IV, which meant I wanted this spleen repaired or out. Senior resident graded it a II. No one wants to take a kid's spleen unless absolutely necessary due to the maturing immune system.

Sat on the kid in the ICU overnight with q4h H/H. AM CT scan showed blood around the spleen, down into the pelvis, exam showed the belly was still soft. H/H only downtrended a couple of points. We had to send pediatric trauma to another hospital, which is what I would have done had I been allowed to make the call initially, and which we eventually did. Our attending who approved the initial plan was kicking himself about how this was a close miss.

Had another one, woman was a week out from a car crash, with abdominal pain and a blush in her spleen on CT. We took her to the OR that night to remove it. Started bleeding from the hilum as we pulled it out.

Both patients turned out fine.

Link to splenic injury pictures here: https://www.socialtext.net:443/m/page/acs-demo-wiki/spleen_injuries

Thanks for the post. But, it was my fault as well for failing to recognize FASTER that we had a problem requiring emergent intervention other than the leg. You picked up on it quickly with less info. than I had at the time. I was fortunate to escape this escape without any significant post op complications.

Your surgical training will serve you well in these types of cases.

 

[Ronin2258]

Thanks for the post. But, it was my fault as well for failing to recognize FASTER that we had a problem requiring emergent intervention other than the leg. You picked up on it quickly with less info. than I had at the time. I was fortunate to escape this escape without any significant post op complications.

Your surgical training will serve you well in these types of cases.

Thanks. Liked the delayed scan idea in your links, it would have been good here. Everyone got real skittish about calling splenic lacs after that kid.

As much as I have seen discussion in other threads in this part of the forum, I have been seduced by the Dark Side of Anesthesiology. I just hope I can get in somewhere to train.