thebluntdissection

pulling apart cases from the ED...

no place like home…

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I am now 6 weeks into my 6 month anaesthetic secondment. There have been some interesting challenges settling into the new job but I am largely enjoying my time perfecting basic airway manoeuvers, laryngoscopy and playing with some brilliant airway toys (McGrath video laryngoscopes, the AirTraq, intubating LMAs etc). I thought I’d share with you a case (from Anaesthetic week 2) that presenting some multifaceted challenges & several points of reflection …

The Case.

A 59 year old male undergoes an elective radical prostatectomy. He is previously well, however takes some ‘herbal Chinese medicines’ that he stopped 2 weeks prior to surgery. His surgery appears to go without a hitch, except for the 1200mL of blood in the surgical suction container at the end of the case. He has received 2 liters of Hartmann’s & 500mL Volvuven during his OT time. He is extubated and taken to recovery at the end of the case where he reports feeling quite comfortable.

I am called back to recovery about 20-25 minutes later to address his hypotension.

On return to recovery, he looks pretty horrible. He is pale & clammy with cool hands. His pulse rate is 95 (sinus rhythm) with a blood pressure of 82/40. I give him two boluses of fluid (500mL each) & his BP promptly improves to 105 systolic….

…..If only it was that simple! I am called 10 minutes later for further hypotension. 80’s on 40’s again…. This time I take a Hemocue which shows a Hb of 68 (was 128 pre-op).

      • 4 units of PRBCs are cross-matched; 2 units given stat
      • repeat Hb 84.
      • Surgeon’s asked to review [blames Chinese medicines, mutters something about post-anaesthetic hypotension, venous oozing & need for further resuscitation, heads back to do the next cystoscopy]…

By this time my boss perches me in recovery to keep a permanent eye on this fella whom I am confident has haemorrhagic shock…

Morning becomes afternoon;

      • Ongoing episodes of hypotension, responding to fluids
      • Declining urine output.
      • Patient remains clammy and at times frankly diaphoretic
      • Bedside USS showed a flat IVC and a hyperdynamic left-ventricle. There was free fluid (~0.6cm) in Morrison’s pouch as well as over the diaphragmatic surface of the liver & spleen…
      • Hb drops back to 60.
      • Massive transfusion formally commenced… (he needs to go back to theatre)
      • Anaesthetic consultant agrees… Urology registrar notified again & again (no action, very reluctant to consider a return to theatre)…

Crisis precipitates action;

      • With ongoing periods of hypotension, our patient eventually reaches a peri-arrest state following an episode of abdominal pain and vomiting, with altered mental state and a systolic BP of 50-something.
      • Anaesthetic consultant and fellow join me at the bedside…
      • MTP continues….
      • Formal repeat bloods show worsening metabolic acidosis with acute kidney injury and hyperkalaemia.
      • Sick of waiting for the registrar to take action, I call the Urologist himself & we finally get a decision to go back to theatre for exploration.

Not over yet;

      • He has one of the more scary inductions I have witnessed.
          • 2mg Midazolam, 100mcg Fentanyl & Cisatracurium (he had received Sugammadex for reversal at the end of his first surgery).
          • This was enough to drop his BP from 130 –> 65 mmHg.
      • He has a large pelvic haematoma evacuated and a further 1500mL of blood in his suction container.
      • Before leaving to theatre (destination: ICU) he has received;
          • 12 units RBC
          • 12 units FFP
          • 2 pools of PLTs
          • 18 units of cryoprecipitate
          • Calcium (20mmol gluconate)
          • Tranexamic acid….

The Reflection

This case was obviously frustrating for a lot of people involved (and incredibly emotional  & exhausting for the recovery staff who provided him with so much time and attention). My subsequent reflection on this scenario has lead to a few realisations….

1) You are a much stronger performer in your own environment….

      • This diagnosis was easy. There was very little else that could have explained this patients’ clinical state, but I appeared to doubt my diagnosis of haemorrhagic shock over & over. Was this because I was in the post-op setting now ?? Bleeding is bleeding….
      • I was obviously uncomfortable in the new surroundings, particularly when it came to escalating my concerns for this patient and advocating for his return to the OT. Perhaps I was afraid of ‘ruffling to many feathers’. I strongly believe that in the face of a registrar’s inaction I would have called a Consultant sooner had I been in my ED.
      • I have no doubt that if this scenario took place  on my home-turf of the ED resus bay, that my assertiveness and push for action would have been with a louder and more confident voice.

2) There is no place like home….

      • When the proverbial hit the fan and this guy decompensated I quickly realised that I had absolutely no idea where the resuscitation equipment, drugs & fluids etc were & I had to rely solely on the staff around me to ‘go fetch’ as I kept barking orders.
      • This was a stark reminder of what Cliff Reid has been talking about for years, in the need to know and control your resuscitation environment.
      • I have subsequently spent my own time going through various parts of the department familiarising myself with the resus equipment and its location (not only in the operating theaters and recovery, but also on the ward resus-trollies where we attend medical emergencies).

3) Our ED training is great to fall back on…

      • Faced with a persistently hypotensive patient, I did what felt comfortable and what came naturally… I took ultrasound to the bedside.
      • Whilst this didn’t add anything new to the case, it backed up my suspicions at a time when I was doubting myself…

4) The patient in haemorrhagic shock can fall in a heap on induction…

      • Midaz/Fentanyl was all that was needed to reach reasonable sedation for induction.
      • I am left to ponder what would have happened if he was given a more ‘generous’ induction agent (eg. ketamine).

The Conclusion

Well, this is fortunately the boring part of the story. Our fella is delivered to ICU with stable haemodynamics, a temperature of 36.2*C & a normal pH/bicarb. His INR is 1.1 & Hb is 72.

He receives a further 2 units of RBCs overnight in the ICU & is extubated the following day.

By day 3 (post-op) he is back on the ward and makes a progressively uneventful recovery to hospital discharge.

 

So, there you go.

I’d love to hear peoples feedback and comments on this case.

 

a twisting tale…

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the case.

It’s night shift & you’ve received handover of an entire department. You plug on and start chipping away at the waiting-list that doesn’t seem to ever get any shorter….

At 3am your nursing staff alert you to an 11 year old female who just isn’t getting any better. She was admitted under Paediatrics on the evening shift with 24 hours of vomiting (no diarrhoea) & had failed her trial of fluid. Whilst she is waiting for a paediatric ward bed she has continued to vomit a further 8-10 times and is complaining of severe epigastric pain. She had used up all her available antiemetics and analgesics on her medication chart…

She looks miserable, crying in pain and clutching at her abdomen. She is slightly tachycardic (otherwise normal observations). Her abdomen is non-distended but exquisitely tender with percussion tenderness and rebound. She has reduced bowels sounds. There is a scar in her RIF indicating a previous open appendicectomy ( ~18 months earlier).

You review her bloods (WCC 16, otherwise unremarkable) and her urinalysis is normal.

Despite further boluses of morphine, she continues to vomit and complain of severe pain…

IMG_1870

The Questions

What’s going on here ?
What are you going to do now ??

The Discussion

Upon reviewing the film, my immediate concerns was of a closed-loop obstruction. On further questioning, the young patient had not opened her bowels for 2 days, and had not passed flatus for at least 24 hours. Our surgical registrar agreed to review the patient….

Paediatric Bowel Obstruction.

The symptoms are generally non-specific with irritability, persistent vomiting, abdominal pain and distention. There are many different causes and pathological processes behind paediatric bowel obstruction. They include the following….

Congenital Causes.

      • atresia (duodenum, jejunum, oesophagus)
      • pyloric stenosis
      • meconium ileus
      • aganglionic megacolon
      • malrotation
      • constriction bands
      • intraabdominal hernias

Intussusceptions.

      • Ages 3 months – 6 years.
      • Requires a lead point (only found in 2-8% of cases)
          • Viral illness / gastroenteritis / rotavirus –> lymphoid tissue swelling.
          • Meckel’s
          • Peutz-Jaghers Syndrome

Incarcerated Hernias.

      • Umbilical – very common. rarely incarcerate.
      • Inguinal – very common. 10x more common in boys. more common in prematurity.
      • Femoral – rare in children. females >> males.

Malrotation with midgut volvulus.

      • 1 in 500 infants.
      • Error of rotation around the SMA axis.

Postoperative Adhesions.

      • Responsible for 3-8% of intestinal obstructions in infants/children.
      • Incidence lower after laparoscopic procedures than after laparotomy.

Annular Pancreas.

      • Rare congenital anomaly
      • Pancreatic tissue fully encircles the 2nd part of duodenum (leaving a non-distensible ring and a functional stenosis).

the conclusion.

The surgical registrar is agreeable with suspicion of bowel obstruction & the patient is consented for a diagnostic laparotomy. As the patient rolls off to theatre, I go home to bed….

My phone beeps midway through the day and I receive the following picture in an MMS.

IMG_1876

Following surgical release, her bowel immediately reperfused & remained viable. She is discharged home 4 days later without complication…

my thoughts…

In the ED, we are often faced with a never-ending ‘To-Do’ list and are asked to meet time-lines for decisions and dispositions that seem to be getting shorter & shorter…

For me, this case is a reminder that if your patient:

  1. isn’t following the expected path of the proposed diagnosis
  2. isn’t getting better with the therapy instituted to date.

Take a step back and start from scratch, reviewing the case from the very beginning…

 

a difficult airway…

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The Case.

The ‘Batphone’ alerted us of a 68 year old female who is postictal following two seizures in rapid succession. She has a history of ‘a brain tumour’.

P 120. BP 176 systolic !! GCS 8/15. Afebrile. Sats 98% (15L NRB + guedel airway).

She arrives direct to your resus bay 4-5 minutes later and she is actively seizing.

A) Obstructed (Guedel on floor). Trismus ++.

  • Bilateral nasopharyngeal airways inserted
  • Two-handed jaw thrust
  • Ventilating well on 100% BVM.

 B) Bilateral air entry. Sats 99% on O2. No added sounds.

 C) P 130 (sinus) BP 185 systolic. Diaphoretic. Warm peripheries.

  • 2x IVC inserted
  • 500mL N.Saline bolus

D) Actively seizing (GTCS with movement in all 4 limbs). Pupils 4mm (L+R).

  • 2x 5mg IV Midazolam (seizure resolved)
  • 1gram IV Phenytoin (loading commenced at cessation of seizure)

E) Temp 37*C. BSL 13. No rashes, contusions etc.

Impression:

Status Epilepticus (3x seizures with no return to normal mental state)

  • ? secondary to ‘brain tumour’ or associated haemorrhage
  • No other medical history available
  • “Family are bringing in her medications”

Following resolution of her seizure she remains obtunded, GCS (E1V1M4) 6/15 and still obstructing her airway. A decision is made to RSI for airway control and prevention of secondary brain injury, followed by urgent CT. [Read more…]