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ICU Fellowship Vivas – SAH, LA toxicity, Difficult Airway
Dr Swapnil Pawar
1. Previously well 55-year old female WFNS 1, Fisher 3 SAH from an Acom aneurysm which occurred yesterday. She has been stable in ICU with a GCS of 15, a BP of 120/80mmHg and no focal neurological deficit since her admission. She has just returned from an endovascular procedure to secure the aneurysm with GCS 14 (confused), HR 59, BP 140/80mmHg. How would you assess this patient?
I am concerned that she has had a deterioration in neurology which may be secondary to complications from the subarachnoid itself such as rebleed, complications from the intervention such as bleeding, thromboembolism or the anaesthetic, or secondary to another medical cause such as a metabolic disturbance. The assessment would involve a focused history, examination and further investigations.
Describe your initial management.
What are the potential complications from aneurysmal SAH?
From ICU stay
What is the role of Nimodipine in the management of aneurysmal SAH?
Nimodipine is part of the current standard of care in aneurysmal SAH.
What are the advantages and disadvantages of coiling compared to clipping of an aneurysm after SAH?
2. You are caring for a previously well 60M after an MBA yesterday. He has isolated chest injuries (bilateral rib fractures and pulmonary contusions). He has been stable in the ICU overnight receiving HFNP with multimodal analgesia including PCA. The anaesthetic registrar has just left after inserting a thoracic epidural when the bedside nurse calls for assistance. The patient has become disoriented and agitated with HR 55 in SR, BP 78/39, sats 88% on 40% HFNP with poor trace. Explain the likely causes for the deterioration.
My primary differential is local anaesthetic toxicity. Other likely causes include
What factors increase the risk of local anaesthetic toxicity?
This patient is thought to have local anaesthetic toxicity. How would you manage them?
3. A previously well 33M (90kg 182cm tall) is admitted post handing attempt. The paramedics were only able to pass a standard size 6 ETT. This is secured at 24cm and shortened to a total length of 27cm (pre-hospital transport policy). What are the potential airway problems in a patient after a hanging attempt?
What problems might you encounter with a size 6 ETT in this patient?
Problems with size 6 ETT: