Multi-staged death.

Been mulling the wise post over at St. Emlyns about little white lies.  http://stemlynsblog.org/2012/09/little-white-lies-in-the-resus-room/

Then was having a discussion with a local vet about breaking bad news. He told me about his favourite method which he calls the multi-staged death.

So he will often get a cat/dog that has been hit by a car, usually arrive with a distraught owner who asks for him to do everything possible to save them. Firstly he explains its touch and go and that they should say their goodbyes and go home. Then he does what he can for the critter.

If it goes badly and they don’t survive or if the injuries are simply unsurvivable he initiates the multi stage death protocol. Sometimes  he will do this  after the animal has passed away.

(Stage one) First his nurse calls to tell them it’s not looking good. This gives them an early warning about the likely outcome.

(Stage two) A short while later he calls to tell them he’s going to take their pet to theatre and he will “Do what he can” further preparation of owner.

(Stage Three) Then finally he calls back and breaks the bad news that despite all the best efforts the injuries were not survivable. Gives closure, they feel all that could have been done has.

He swears by it as being a great way to prepare the owners for the likely outcome and is much better than the “Will call you when its done, either way” approach of his practice partner.

Now im not advocating this approach for patients but found it an interesting approach. Thoughts?

 

The dangers of chopping trees down.

 Have had an interesting run of trauma recently saw this on nights flying solo.

This patient was for me quite clinically challenging tho im sure some of those wise #FOAMites out there will get it in a flash.

Patient had been thinning trees  and one “twisted” and fell across him across his shoulder/neck. So thinning is cutting the smaller trees to allow good growth. No LOC at scene, witnessed by friend who called ambulance.

Running through the usual things,  A + C-spine immobilize, B seemed fine, C P 80 BP 120/75. Primary survey really nothing much to find. some haemotoma over his Left scapula but no other outward signs of injury.

Then his full assessment neuroexam, This guy works cutting trees for a living and he had weak grip on the right , like maybe 5- but if I was shaking his hand at the pub I would likely be grimacing. further exam I felt there was some weakness on his Left foot dorsiflexion. reflexes all present. He reported some parastesia in his Right forearm and possibly both arms at the scene but  thought it might have just been the cold.

So obviously he got squished, could be a few things. I really wasnt sure and my notes reflected this “?Brachial plexus injury on right, ??Spinal injury ”

So patient went through to CT which showed

Alignment is normal. No fracture is seen. No prevertebral haematoma seen. Spondylosis most severe at C5/6 and C6/7 and widespread facet joint arthropathy noted. If clinical findings suggest a cord injury, as discussed, MRI would be appropriate.

We don’t have MRI at our site and clearly it was needed so had the discussion with our spinal referral centre who were great. “It’s a probable spinal problem but if its brachial plexus we can sort it with the orthopods”

Patient was transferred for further investigations. I felt little bit happier that my confusion with the exam findings was not just me as pt had MRI of both brachial plexus and his C-spine.

 

Findings of: Normal alignment of vertebral bodies.  Posterior disc protrusion C3/4 with associated focal stenosis of the vertebral canal. Mild cord compression with mild focal T2 hyperintensity within the cord. Mild posterior disc bulge at C4/5 with mild focal narrowing of the canal. No evidence of cord impingement at this level. Mild vertebral canal and neural foraminal narrowing at C5/6. Mild bilateral formainal narrowing at C6/7. No abnormality of brachial plexus nerves bilaterally; no focal lesion or signal abnormality.

Summary of : Disc protrusion with mild cord compression and myelomalacia at C3/4.

Patient was taken to theatre for an Anterior decompression stabilisation C3/4

  

Post- op films.

Final diagnosis of  C5 ASIA D incomplete tetraparesis. Consistent with a  traumatic C3/C4 disc protrusion and resulting Central cord syndrome.

Patient had significant improvement with regards to strength. Gait returned to completely normal. Very mild residual reduced grip on his right hand. Only complaint of occasional Parastesia/Hyperastesia over Right forearm.

Had never seen a central cord syndrome before and only couple of brachial plexus injuries before. Thoughts anyone?

Good reference brief and clear http://www.wheelessonline.com/ortho/central_cord_syndrome_1

When Quick Meme and LITFL collide!

Good Guy Mike Cadogan

Rick Abbott, most interesting doctor in the world.

Michelle “Philosoraptor” Johnson.

Chris Nickson, Medically awesome ?penguin

John Larkin, makes me do this each week. (ECG problems)

Kane “Success” Guthrie, 

Conservatism Fails.

Had this patient through our department recently. Nice old bloke who fell at home onto a concrete step. Impact to left chest wall, mid axillary line.

He was sore but otherwise well, P 60 stats 98% RR 14 no other concerns, abdo SNT

Played with USS got my stratosphere on.

CXR for “size” which showed small pneumothorax, rib fractures. 

No Signifigant past medical history, never smoked or any occupation exposures.

Plan was conservative management, analgesia and to return if any concerns.

 Patient returned 2 days later with exertional dyspnoea, everything a bit harder to do around home.

Obs wise had RR 18 Sats were around 94% P 66

Examining him showed impressive subcutaneous emphysema, best I have ever seen outside of post op patients.

Repeat CXR showed the s/c emphysema and increase in size of pneumo. It is a bit harder to see as s/c emphysema on anterior chest gives an impression of lung markings.

CT scan was done after discussion with surgical colleagues. Wanted to better assess the size of the pneumothorax and rule out any other pathology.

I was impressed at how extensive the pneumothorax and s/c emphysema was. 

 So patient got his chest drain and was parked on the ward for a day. Then on his way.

Reflective stuff below:

So I was looking around at information on conservative management of traumatic pneumothorax and there is not really much evidence. (someone prove me wrong)

I’m just new at this game but it seems most opt for conservative management with majority of pneumothorasces. Provided they do not cause compromise and are “small” but it seems a little hazy. Some folks I have worked with like to do a needle drainage, feeling that it will reduce the morbidity.

So would you have imaged further earlier? would you have drained/needled him earlier?

Best reference I could find: http://www.bestbets.org/bets/bet.php?id=104

Where is that needle? Are you sure?

Saw this bloke about a month ago now.

Patient was brought into ED by a radiologist and nurse.

He was having an ultrasound guided hydrodilitation of his Left shoulder for adhesive capsulitis.

Radologist injected 20ml of ropivicaine within 30 seconds the patient complained of his tongue feeling numb. He then had difficulty speaking, by this time he was on a wheelchair and on his way to ED. Reports from both his wife and himself after was that he had dysarthria and no receptive or expressive dysphasia. He proceeded to have shaking and jerking of his arms and legs and decreased level of conciousness. no tongue biting or incontinence. no chest pain or palpitations (pt thinks)

So he was improved slightly by the time he got to ED GCS 14-15. speaking clearly but feeling “off” no focal deficits to be found.

Airway was good, Breathing fine, IV access gained whilst ECG taken which showed a sinus bradycardia without any specific conduction blocks. Had intralipid ready but didnt give as sx improving.
Within futher 5 minutes patient was completely normal again, he made his way home. but didnt feel that the procedure helped his shoulder pain except for the time he was “thinking he might die” when his shoulder wasnt such a worry.

So patient likely had LAST,
I had not seen it before and thought might share this.
Some changes from the case and discussion after, the MSK rad guys do their injections in clinic rooms by ED not at other end of hosp.

Ropivicaine. Intra-articular inj: 150 mg (7.5 mg/ml soln)

So a bit about Local Anestetic Systemic Toxicity:

The classic description of LAST includes subjective symptoms of CNS excitement such as auditory changes, circumoral numbness, metallic taste, and agitation that then progress to seizures and/or CNS depression (coma, respiratory arrest). In classic descriptions of LAST, cardiac toxicity does not occur without preceding CNS toxicity.

Futher Reading, its a good overview ect.

http://journals.lww.com/rapm/Fulltext/2010/03000/ASRA_Practice_Advisory_on_Local_Anesthetic.7.aspx