no place like home….

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. Continue reading

a difficult airway…

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. Continue reading