QUESTION 6

6 The man shown in 6a fell heavily in a rural area and noted immediate, severe, left-
sided chest pain, worsened by inhalation. At a rural hospital no fractured ribs or
obvious pneumothorax were noted on CXR, but his O2 saturations on air were
86%. Oxygen therapy was commenced, a chest drain was inserted at the left 5th
intercostal space and he was airlifted to a trauma centre. The CXR performed on
arrival at the trauma centre with the patient supine is shown (6b).

6a 6b

i. Does this man have a pneumothorax?

ii. What clinical sign is associated with the appearance of the CXR shown?

iii. Does the patient have a tension pneumothorax?

iv. What are the clinical signs of a tension pneumothorax?

v. Was it necessary to insert a chest drain before being transported by air, and if so why?

vi. Would GA also mandate a chest drain?

vii. Does the absence of rib fractures on the radiograph conclusively prove their non-
existence?

9
 Answer 6

6i. Yes, a pneumothorax is present but a supine film fails to show it.

ii. The radiograph shows subcutaneous emphysema, proving a communication

between his lung and the underlying tissues; therefore, there must be a
pneumothorax. Palpation around the chest wall reveals a crackling sensation.

iii. No, although the potential for one exists, especially after air transport.

iv. Tension pneumothorax is detected clinically by respiratory distress accompanied

with the desire to sit up and forward, hyperresonance of the chest and absent
breath sounds on the affected side. A deviated trachea on neck palpation (deviating
to the opposite side from the lesion) is a late sign indicating marked mediastinal
shift. Radiographic diagnosis is unnecessary and dangerous, as the patient may
suffer cardiorespiratory arrest before the radiograph is obtained.

v. The pressure reduction associated with altitude may expand the pneumothorax,
which may become clinically significant. The referring medical team correctly
inserted a chest drain prior to air transport. A tension pneumothorax is life
threatening and should be treated by decompressing the chest at the 5th intercostal
space anterior to the mid-axillary line and positioning the chest drain cephalad
within the thorax.

vi. Sudden expansion of a small pneumothorax is possible under GA. Positive pressure
ventilation and use of nitrous oxide both increase the likelihood of expansion of
the pneumothorax, which may ‘tension’.

vii. The absence of rib fractures visible on a CXR proves nothing, especially if the
CXR was taken in the supine position (typical for a trauma patient). The X-ray
could have been taken when the rib ends were lying quite close together and the
fractures are then not visible. This patient had very obvious fractures on palpation
of the chest, but only one X-ray out of a series of five actually showed a fractured
rib.

10
 QUESTION 7

7 A 16-year-old 60 kg (132 lb) 180 cm (6 ft) patient is scheduled for scoliosis surgery
with instrumentation from T4 to S1 (7a). The patient plays soccer at a competitive
level and is a long distance runner. The surgeon has scheduled the surgery for 12
hours and has asked for a cross-match of 6 units of blood as well as for the cell saver.
The surgery is completed (7b) and 4 units of blood plus 3 units of cell saver are
transfused. Elective postoperative ventilation in an ICU is chosen because of swelling
of the airways due to the prone position, prolonged surgery and the large fluid
volumes needed for cardiovascular stability. Eight hours postoperatively the patient’s
back wound starts to bleed. Measured blood loss in the calibrated drains is 2,000 ml
and blood replacement is in progress. The wound is still bleeding 2 hours later. Hb is
70 g/l (7 g/dl) and Hct 21%. The urine output was 0.5 ml/kg over the last hour. The
surgeon requests emergency surgery to open up the wound to control the bleeding.

i. What are the letters 7a 7b

ASA PS commonly
used to classify in
anaesthesia practice?

ii. Write down exactly

what each class
represents.

iii. What is the ASA

classification of this
patient preopera-
tively?

iv. What is the ASA

classification of the
patient 10 hours
post surgery?

QUESTION 8

8 What are the 10 indications for referral of a head injured patient to the
neurosurgical unit?

11
 Answer 7

7i. American Society of Anesthesiologists Physical Status. The ASA classification was
designed in 1963 in an attempt to classify patients according to their degree of
abnormal physiology, with a scoring system known as the ASA Physical Status
Index. It is used as an objective way of defining patient health before anaesthesia
and surgery. It is also used as a means of retrospective review in patients who have
either had a better than expected or worse than expected outcome from surgery.

ii. I = a normal healthy patient; II = a patient with mild systemic disease; III = a
patient with severe systemic disease; IV = a patient with severe systemic disease
that is a constant threat to life; V = a moribund patient not expected to survive
without the operation; VI = a declared brain-dead patient whose organs are being
removed for transplant purposes. The suffix E is added to indicate Emergency cases.

iii. ASA I. Note that the extent of the proposed major surgery does not have any
bearing on the ASA status.

iv. ASA III E, by reason of the fact that the ASA status is worse than II, which is
‘mild systemic disease’, but the ASA status is not yet ‘life threatening’ as the urine
output is still reasonable. The patient requires surgery as an emergency, hence the E
designation.

Answer 8

8 The following 10 features in a patient with a head injury should be discussed with
a neurosurgeon:
•฀฀A CT scan that shows a recent intracranial lesion.
•฀฀The patient fulfils the criteria for CT scanning but this cannot be done within
an appropriate period.
•฀฀Persisting coma (GCS 8/15 or less) after initial resuscitation.
•฀฀Confusion that persists for more than 4 hours.
•฀฀A deterioration in the level of consciousness after admission determined by
a deteriorating GCS. A sustained drop of one point on the motor or verbal
subscales, or two points on the eye opening subscales of the GCS are sufficient.
Neurosurgeons appreciate hearing the components of the score rather than a
simple number. An accurate description of the GCS is ideal.
•฀฀Progressive focal neurological signs.
•฀฀A seizure without full recovery.
•฀฀Compound depressed skull fracture.
•฀฀Definitive or suspected penetrating injury.
•฀฀A CSF leak or other sign of a basal fracture (Battle’s sign, bruising behind the
ears or bilateral periorbital haematomas [Panda eyes]).

12
 QUESTION 9

9 A patient is brought to the operating room for cardiac surgery with an intra-aortic
balloon pump in place. The monitor displays the arterial wave form shown (9a).

9a
3

2
5

1
4

i. Match the following labels with the appropriate peak or trough on the trace: peak
systolic pressure (PSP), assisted peak systolic pressure (APSP), dicrotic notch (DN),
patient aortic end-diastolic pressure (PAEDP), balloon aortic end-diastolic pressure
(BAEDP) and peak diastolic pressure (PDP).

ii. Identify which of the following parameters is improperly set: balloon inflation or
balloon deflation?

iii. Also identify if the parameter is too early or too late.

iv. Identify the assist ratio.

v. What action should be taken? Explain your answer.

QUESTION 10
10
10 The Pin Index Safety System is shown (10).

i. What is this?

ii. Using the numbers shown, what are the pin

1234 56
configurations for: O2, N2O, CO2 and air?

13
 Answer 9
9b
9i. The labels for each PDP
peak are shown (9b)
and are as follows: 1 PSP APSP
= PAEDP; 2 = PSP
(produced by the DN
patient’s heart only); 3
= PDP; 4 = BAEDP; PAEDP
BAEDP
5 = APSP (patient’s
heart, assisted by balloon pump); 6 = DN.

ii. Balloon inflation is improperly set.

iii. Balloon inflation is set too early.

iv. The arterial wave form (9a) demonstrates intra-aortic balloon pumping in a 1:2
assist ratio. The balloon cycles (inflation and deflation) once for every two patient
systoles. This setting allows identification of landmarks on the patient’s arterial trace
to guide timing settings.

v. The appropriate action is to delay inflation until it occurs just prior to the DN.
A normally timed balloon on 1:2 assist ratio is demonstrated in 9b. The patient-
generated arterial upstroke is shown in the boxed area. The PSP and APSP peaks
are produced by the patient systolic ejection. PDP is a result of balloon inflation
in diastole. BAEDP is a result of balloon deflation just prior to systole. Trace 9a
demonstrates early inflation of the balloon. The goal of balloon inflation is to
produce a rapid rise in aortic diastolic pressure, thereby increasing oxygen supply
to coronary circulation. Balloon inflation should occur just prior to the DN of the
arterial wave. Properly timed inflation will result in a PDP greater than PSP. Early
balloon inflation results in premature closure of the aortic valve. This reduces stroke
volume and cardiac output.

Answer 10

10i. There is a specific pin configuration for each medical gas on the yoke of the
anaesthetic machine. The matching configuration of holes on the cylinder valve
block ensures that only the correct gas cylinder can be fitted in the yoke. The gas
exit port will not seal effectively unless the pins and the holes are aligned.

ii. The pins are at the following positions for the gases shown: O2 = 2 and 5; N2O
= 3 and 5; CO2 = 1 and 6*; air = 1 and 5. (* = no longer fitted to anaesthetic
machines.)

14