It is a quiet Sunday morning and you are thankful that most of your community is either in Church, still hungover from the night before or otherwise enjoying an illness-free day off…
…until the local ambulance rings to advise that they are 15 minutes out with a young woman who has been kicked by her horse and suffered a head injury.
There is ‘lots of blood and she is unconscious’. They request that the Duty Doctor be present at the hospital on their arrival. You arrive at the hospital with about 7 minutes to spare. Your team is the usual day shift complement of two RNs, plus a carer.
Q1: How will you use this time to prepare?ANSWER – preparation of self, team, environment…then patient On the phone advise the nursing team that you are leaving immediately and will be with them shortly. On the meanwhile they need to contact the oncall theatre team and any available extra staff. They need to prepare personal protective equipment (gown/glove/goggles) for what is essentially a trauma call. They should ensure the resus bed is clear, adequate space and lighting, and have available oxygen-suction-airway adjuncts-warmed fluids etc. They should draw up intubation agents I would encourage them to use the RSI kit dump and bring both standard resus trolley and difficult airway trolley’s to the resus bay. On drive in, mentally prepare for management of head injury sing standard C_ABC approach. Unless peri-arrest, take 45 secs to get a structured ISBAR handover from the paramedics, then perform own assessment as a team. - cervical collar : may make intubation attempts difficult, may need MILS - airway threatened through loss of protective airway reflexes; will need RSI. I’d opt for ketamine/roc. Run through plans A_B_C_D in head and be prepared to articulate this shared mental model to the team - breathing; will need to optimise to avoid hypoxia and hypercarbia. Consider vent settings and post-intubation sedation. Exclude HTX, pTX, flail. - circulation: “find the bleeding, stop the bleeding” IV access will be needed. Avoid hypotension in TBI. Identify any obvious sources (scalp, long bones, abdo, pelvis and Rx accordingly). Two good IVs, plus possible minimum volume extension sets for infusions, via sideport - diasability: initial GCS on scene and subsequent changes. Look for evidence of base of skull fracture, maxillary injuries and pupil inequality - exposure : log roll, glucose etc Use this shared mental model on arrival to manage the patient
On arrival the patient is a previously well 19 yo whom you recognise. She has a Guedel oropharyngeal airway in situ, RR is 18 and noisy, SpO2 on NRB is 97%. Pulse is 90, BP is 130. Her eyes remain closed even to painful stimuli, she makes incomprehensible noises and withdraws from pain. She has matted blood on her left scalp and on palpation you suspect a depressed skull fracture. Pupils are equal but sluggish.
Q2: What next?
ANSWER : At present A,B.C are covered – but D is a concern. Obtain IV access and have IV fluids running. She clearly is “big sick” and her needs outstrip the available capabilities of your hospital. Having the retrieval service on speakerphone is helpful – again an ISBAR handover to explain the situation, and share decision-making. An ideal retrieval service will coordinate patient disposition, meaning you dont have to waste time rnging around neurosurgicl units but can focus on the task in hand.
Priorities therefore will be around anticipated clinical course – airway needs to be secured without causing any of hypoxia, hypercarbia or hypotension. ketamine is an ideal induction agent in head injury (despite previous concerns of raised ICP). Suxamethonium is a short acting paralysing agent – potential advantages of wearing off if CICO, but this is falsely reassuring. Once decision made to secure the airway, then this course of action is what needs to occur – many would now use rocuronium (also diminishes risk of incr O2 consumption through fasiculation).
Team brief – RSI kit dump – challenge response check list
Standard pre-oxygenation 4 minutes, have high flow nasal cannulae for apnoeic diffusion oxygenation during intubation attempt
Ketamine 1-2 mg/kg induction with rocuronium 1.2mg/kg for paralysis
MILS & Cricoid – convert to ELM if view hard
Plan A – direct laryngoscopy with a bougie, pre-loaded Kiwi grip or the new ‘D grip”
Plan B- consider VL
Plan C – place a SGA iLMA and intubate through that
Plan D – surgical airway
Once intubated, maintain normocarbia and normotension. Regular neuro obs – DO NOT TAPE THE EYES as will obscure pupillary changes. Continue to package for transfer – NGT, IDC, A line etc
20 minutes later you notice that her left pupil is dilated to 6mm and unresponsive to light. The retrieval team are about 3 hrs away. You are still trying to get through switchboard to get neurosurgical advice from the nearest tertiary centre.
Q3: What is going on and what can you do about it?
ANSWER : she has an extra-axial haematoma causing pupillary inequality. She needs a hole in the head. Mannitol or HTS will buy you some time, whilst you consider your options.
Will you do this? Or wait for transfer?
WATCH THIS VIDEO FROM NEUROSURGEON AND HEMS DOCTOR, MARK WILSON
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