Case Discussion: What Would You Do?By Amit Pawa, BSc(Hons), MBBS(Hons), FRCA, EDRA May 30, 2017
The August 2017 issue of ASRA News will feature a case discussion regarding a 76-year-old patient with bilateral rib fractures, T3 on the right and T4-T9 on the left after falling off a ladder. The article will include a summary of the case and expert opinions.
What would you do in this scenario? Contribute to the poll and discussion here.
We will feature anecdotal feedback and discussion from Twitter in the article as well.
Please retweet the post to get more people involved. We learn best when we all contribute!
You are called by the trauma service to see a 76-year-old male who was recently admitted with bilateral rib fractures, T3 on the right and T4-T9 on the left (no other injuries) after falling off a ladder. He is currently on Bilevel Positive Airway Pressure (bipap) treatment. The trauma service requests a block for pain control. The only medical history they can obtain from him is that he has diabetes, hypertension, and a non-debilitating stroke many years ago that left him with a slightly clumsy left foot and hand. He states he can’t remember all the medications he is currently taking but that they include insulin and metoprolol. His family is not currently available but should be at some point later today. He has not received care at your facility in the past. The trauma service would like a block to provide pain control in this patient because they feel that pain is impairing adequate ventilation. The trauma service is hopeful that an epidural may help him avoid intubation.
Part 1: What would you use? Epidural, paravertebrals, MMA/ketamine infusion, or fascial plane block? Vote and comment here.
Part 2: Labs: INR 1.4; platelets 9.2k. Surgeons will transfuse platelets so count >100 k for epidural placement if you want. Will you give platelets and then site epidural, repeat labs in 2 hours and review, site a block anyway, or wait for the full medication list? Vote and comment here.
Part 3: Do you have institutional guidelines for placement of blocks in trauma patients? Vote and comment here.
Part 4: Would required coagulation parameters be difficult for a paravertebral versus epidural catheter insertion?: Vote and comment here.
Dr. Amit Pawa, BSc(Hons) MBBS(Hons) FRCA EDRA, is a consultant anaesthetist, Specialty & Educational Lead for Regional Anaesthesia, at Guy's & St Thomas' NHS Foundation Trust, Department of Anaesthesia, St Thomas' Hospital, in London. He is also an Academic Lead for the London Society of Regional Anaesthesia (LSORA) and president-elect of Regional Anaesthesia - UK (RA-UK). @amit_pawa