A 58 year old man presents with a displaced fracture of the wrist that will need to be reduced.
A.) List 4 options for providing anaesthesia to reduce his fracture.
- Regional – IV Regional anaesthesia or Biers block
- Regional – Haematoma block
- Regional – Nerve block e.g. Axillary nerve block
- Procedural sedation – Ketamine
- Procedural sedation – Propofol
- General anaesthetic in theatre
B.) What issues will you consider in deciding which anaesthetic option to use?
- Resource factors
- How busy the ED is
- Availability of staff
- Skill mix of staff
- Patient factors
- Ability to tolerate regional approach
- Fitness for procedural sedation
- Patient choice
4 marks (4 factors)
C.) What are the pros and cons of IV regional anaesthesia (Biers block)?
- Often well tolerated
- No risk of sedation
- May fail
- Risk of IV local anaesthetic and LA toxicity
- Poor tolerance of pressure cuff
4 marks (2 each)
D.) What are the pros and cons of procedural sedation?
- Risk of airway loss
- Risk of CVS collapse
- Risk of intubation
- Risk of aspiration
- Failure to provide adequate analgesia/amnesia
6 marks (3 each)
Author: J Haire
A 47 year old man is brought to the emergency department with fever, throat pain and difficulty swallowing.
A.) Describe the abnormalities in this x-ray
- Significant pre-vertebral soft tissue swelling C1 to C6
- Neck held in extension
- Epiglottis and arytenoids possibly swollen
B.) What is the differential diagnosis?
- Retropharyngeal abscess
- Bacterial tracheitis
- Malignancy e.g. lymphoma
C.) What further steps could be taken to make a diagnosis and how?
- CT neck soft tissues but likely will need intubation
- Indirect laryngoscopy by ENT
D.) List the main features of management in this man
- Control of airway if needed
- Sepsis management
- Surgical drainage of collection if present
E.) Which antibiotics would you give and why?
Ceftriaxone (3rd Gen Cephalosporin) to cover Haemophilus influenzae and Streptococcus pneumoniae
F.) What would be your indications for intubation in this man?
- Signs of airway compromise
- Increased work of breathing
- Change in phonation
- Other causes of airway compromise e.g. Decreased LOC secondary to sepsis
G.) List your options for intubation in order of preference in this patient.
- Gaseous induction in OT with ENT standing by to do surgical airway
- Awake fibreoptic intubation by anaesthetics in ED with ENT standing by to do surgical airway
- RSI in ED with anaesthetic and ENT support
- RSI in ED with another consultant ready to do surgical airway
3 marks (options need justification and need to be safe)
Author: J Haire