Head injury, ED Anaesthetics Simulation

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Simulation report 2/2/23

Interdisciplinary SIM ED/ Anaesthetics

Summery:

Head injury requiring intubation post agitation and seizure, ambulance called by police to house with ongoing party

 

Hi everyone,

To reach out with our learning goals beyond the participant group I have formulated a sim report for this mornings first in situ sim with two disciplines involved.

Firstly thank you to the duty Consultants and Resus coordinator of the day Basil Muharb, Jude Penney and Jessica Hathaway enabling space and staff on a busy day. I would also like to thank Catherine Gale as out fantastic Sim coordinator for her great support and encouragement to get these Sims organized.

I felt the participants enjoyed the scenario especially the realistic interference between two specialties.

The case:

Summery:

Head injury requiring intubation post agitation and seizure, ambulance called by police to house with ongoing party

Stepwise approach and learning points to the patient:

 

  1. Gain control of situation  clear communication in chaotic situation

im Midazolam 0.15mg/kg /Ketamine 0.3mg/kg

  1. A-E assessment of patient  likely head injury

keep open minded alternative diagnosis, Tox?

  1. During assessment patient fitted  settled seizure, will require RSI

 if tox remains of concern, hyperventilation

and Nabicarb will not have negative effect

on head injury

  1. Who does ETT? Call a friend if available, be aware of likely difficult airway

 C-spine not cleared, possible aspiration, upper airway bleeding

 Anaesthetics for airway role, ED continues to team lead and conduct

(does not mean makes all decision but conducts and

communicates mutual decisions)

  1. Induction drug choice: Be aware of sympathetic stimulus of ETT

resulting in counterproductive vital signs in head injury

 variety of drugs suitable, suggestion:  High dose Fentanyl 300mcg (3-mcg/kg)

small dose Ketamine 50mg

large dose 1.5mg/kg Rocuronium

  1. Intubation technique: aim for first pass,

consider no apnoeic interval to prevent hypoxia

                                         and hypercarbia

  1. post intubation care:  A-E assessment systhematically

 tube position confirmation

 prevent and treat hypoxia and hypercarbia

 indentify and treat hypo and hypertension

(analgesia and antihypertensives)

 deep sedation and relaxation with appropriate agent

 prevent further seizures (Keppra load)

 IDC and possible NG tube

  1. prioritisation of life critical issues: contemplate length of panscan versus fast scan

and clinical correlation

If there are any queries or questions please feel free to ask.

The further two links I find very helpful if you would like to do further reading on this topic.

https://litfl.com/intubation-of-the-neurocritical-care-patient/

https://emcrit.org/ibcc/tbi/

I am looking forward to the next run the first Thursday of March.

Kind regards, Irene Pelletier