QUESTION 20

20 This 24-year-old man has presented in the emergency department with pain
and swelling around his neck (20). He is confused and his BP is 75/40 mmHg.
His white cell count is 23 × 109 cells/mm3 and he has a temperature of 39ºC
(102.2ºF).

20

i. Would you define this man’s condition as sepsis, severe sepsis or septic shock?

ii. What six tasks should occur within the first hour of presentation?

iii. Why is anaesthesia challenging for this patient?

iv. How would you anaesthetise him?

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 Answer 20

20i. He has sepsis because he has SIRS with infection. The sepsis is severe, as he
has signs of organ failure (confusion), but there is insufficient information to
say whether he has septic shock. If his BP is unresponsive to a 30 ml/kg bolus
of crystalloid solution (e.g. Hartmanns solution) given over the first 3 hours of
treatment, he has septic shock.

ii. The six tasks, known as the Sepsis Six (Survive™ Sepsis campaign), are: give high-
flow oxygen; take blood cultures; give antibiotics; start IV fluid resuscitation (often
large volumes, as much as 10–20 ml/kg are needed over the 1st hour); check
haemoglobin level and venous lactate (Hb should be >70 g/l [7 g/dl] and lactate
should be <4 mmol/l [36 mg/dl]); monitor accurate urine output.

iii. Anaesthesia is challenging in this patient for two reasons:

•฀฀The systemic effects of the abscess as a septic focus. Further resuscitation must
be weighed against the urgency of taking the patient to the operating room.
Until the abscess is drained, he may not fully recover; therefore, after initial
resuscitation surgery is required without delay.
•฀฀The physical effects of the abscess. Although appearing to discharge outwards
onto the skin, deeper tissues of the neck may be involved. The abscess may
suddenly discharge into the airway, leading to an aspiration of abscess contents
and subsequent aspiration pneumonia. Fistulation may form into the trachea
or oesophagus, which can have unexpected effects with positive pressure
ventilation. The mass effect of the abscess could obstruct the airway from within.

iv. After resuscitation, patient anaesthesia should start with inhalational induction with
an agent such as sevoflurane. This is safer than an IV (rapid sequence) induction, as
the airway may suddenly obstruct upon onset of paralysis if the abscess is large and
compressing the trachea. The airway can be inspected when the patient is deeply
asleep and then either intubated under deep inhalational anaesthesia or a muscle
relaxant given when it is clear that the airway can be maintained. Endotracheal
intubation should be performed as soon as possible to prevent contamination of
the airway by abscess rupture. Surgery can then continue safely. Postoperative care
could be complicated because of the presence of severe sepsis and ICU or high-
dependency admission should be arranged.

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 QUESTION 21

21 A CXR is taken (21a) of an 18-year-old front seat passenger in a car travelling at

45 mph (70 kph) that has collided with a tree. He was not wearing a seat belt and
the airbag only partially inflated.

21a

i. How would likely injuries be predicted?

ii. What are the immediate priorities when dealing with this patient?

iii. What does the radiograph show?

iv. What other investigation needs to be carried out to confirm or refute the
potentially life-threatening provisional diagnosis?

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 Answer 21

21i. The mechanism of injury predicts likely pathology. Severe injuries (head, neck,
thorax, abdomen, pelvis and limb) can be sustained by an unbelted front seat
passenger who collides with the dashboard of the car at 40 mph (64 kph).
Expulsion from the vehicle increases mortality by 300%.

ii. Airway, breathing and circulatory stabilisation should be established along ATLS
guidelines as the X-rays are being taken. The CXR shows important signs for
subsequent definitive management.

iii. A widened mediastinum (with abnormal contour), depression of the left mainstem
bronchus and a small left-sided pleural cap (an area of opacity over the top of the
lung parenchyma at the lung apex) all suggest a ruptured aorta. Other features on
the CXR are:
•฀฀Hardware, multiple lines, ECG electrodes.
•฀฀Widespread subcutaneous emphysema suggesting pneumothorax.
•฀฀The left pleural drain is inadequate. Only a few centimetres of drain are inside
the chest and a drain orifice appears to be at the skin. The drain needs to be
re-sited deeper within the chest.
•฀฀A right-sided pleural drain is in place.
•฀฀Bilateral pulmonary contusions.

iv. Urgent aortic angiography and a cardiac/thoracic surgical opinion is required.

Chest CT to diagnose aortic rupture is less invasive than angiography, but an
angiogram should determine the precise site of the aortic tear. This patient’s
angiogram (21b) shows a typical tear (arrow) at the junction where the
ductus arteriosis existed
embryologically and inserts 21b
into the aorta alongside
the superior aspect of the
pulmonary artery. This is the
weakest point along the aortic
arch. Only the adventitial layers
are preventing a massive bleed
from this point of the rupture.

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