the case.
46 year old male is bought into your resuscitation bay by local ambulance following a three metre fall from a work platform onto a horizontal metal railing below.
pulling apart cases from the ED...
the case.
46 year old male is bought into your resuscitation bay by local ambulance following a three metre fall from a work platform onto a horizontal metal railing below.
Below is the main content discussed at an ultrasound workshop I ran this week at the Sydney HEMS Clinical Governance Day.
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).
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;
Crisis precipitates action;
Not over yet;
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….
2) There is no place like home….
3) Our ED training is great to fall back on…
4) The patient in haemorrhagic shock can fall in a heap on induction…
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.