A 53-year-old woman has been involved in a car accident, in which her car hit a lorry and she underwent a prolonged extrication from her car. You have been called to the Accident & Emergency Department to provide anaesthesia.
Heart rate: 100 bpm
Blood pressure: 90/45 mmHg
Temperature: 36 degrees C
The patient is tachypnoeic (40 breaths per min; shallow painful breathing)
The patient has paradoxical chest movement
SpO2: 98% on O2,
Glasgow coma scale: 15
A drip has been inserted and she has a right chest drain in situ.
Patient has a fractured pelvis and femur, and a positive diagnostic peritoneal lavage
CT of the brain and neck: normal
Haemoglobin: 11 g/dl
Urea: 12 mmol/L
Glucose: 11 mmol/L
Arterial blood gases: metabolic acidosis
Base excess: -7 mmol/L
CO2: 4.9 kPa
All other haematological and biochemical results normal
Height: 5' 6''; Weight: 90 kg
Chest X-ray: showed right chest drain and multiple right-sided rib fractures and a left-sided rib fracture.
1. Summarise the case.
2. Why would the glucose level have been 11 mmol/L?
3. Why would urea have been raised?
4. Would you be concerned about the haemoglobin level?
5. Why would she be acidotic?
6. Why would her CO2 level still be normal despite her high respiratory rate?
7. Discuss chest drain bubbling/swinging etc.
8. What fluids you would give?
9. Discuss your assessment of blood loss and dehydration.
10. What blood pressure would you aim for?
11. How urgently would you want to get her to the operating theatre, and what surgery would she need to undergo? Which repair would be the most urgent?
12. What other monitoring would you carry out?
13. Why was an arterial line inserted?
14. Interpret this patient’s ECG.
15. What general anaesthetic would you give, and why?