Clinical Case 055: Tolchock to the gulliver
The title for this post comes from Anthony Burgess’ classic dystopian novel A Clockwork Orange. In the lingo of the novel’s antihero a “tolchock to the gulliver” is a blow to the head – it is a violent, fascinating book, with a great moral. Check it out if you have not already. Anyway onto the case…
42 yo. man presents to the ED after a domestic argument resulting in a bit of a brawl. He was wrestling with his brother-in-law when a ‘bysander’ struck him with a cricket bat to the head. Being a little bit drunk, and dazed he then layed on the ground fro 5 minutes before getting up to rejoin the party. Having lost the battle he then drank another 6 cans before vomiting and having a syncopal collapse.
On arrival by ambulance he is very drunk, slurring his words and uncoordinated. An initial GCS is calculated at 13 (E4, V4, M5). He is a bit combative and not keen to be examined. He has a small laceration to his right temple with underlying haematoma. As you try and get some IV access he pulls the blanket over his head and grumbles about the bloke with the cricket bat.
On closer examination – his pupils are symmetrical and reactive. He has no palpable skull fracture, but a growing haematoma above his ear. No haemotympanum, no Battle’s sign etc. You leave him in peace for a few minutes to see a sick-looking baby in the next bay.
When you return to the bedside he is drowsy he is now GCS 8 (E1, V3, M4) and maybe his right pupil is a little bigger than the left. A bedside US of his ONSD shows 7.5mm on the right and 6 on the left (average 6.75mm)… see UltraSound for ICP post
Not good – we need to do something pronto. Broome has a CT machine, but the closest neurosurgeon is ~2000 km away.
Intubation seems like a good idea – he is dropping his GCS and might have an intracranial bleed – he needs either a CT or transfer soon, but both of these need a secure airway.
So here is the first clinical question from this case – what is the evidence for achieving an intubated airway in this scenario? Which drugs? Strategies for maintaining cerebral perfusion? Ventilation options?
I think most of us are already using an opiate such as fentanyl pre-induction for other reasons. Evidence for using it in TBI? – once again – no direct evidence. If you are trying to block the catecholamine surge – then you need big doses – 3mcg/kg. But beware of the potential for hypotension
If you want detail – check out Brain Lin’s lecture on Neuroprotective RSI via Free Emergency Talks (here).
Now with the trend towards using rocuronium as 1st line in RSI – is this debate obsolete? Can we just use roc and not worry about the sux issues?
Traditionally agents such as thiopentone and propofol have been used in Australia – we do not have etomidate. Ketamine has been widely not used due to the theory that it increases ICP. But what does the evidence show? Flianovsky et al did a nice lit review on the topic in CJEM in 2010 – they concluded it did no harm and had ideal haemodynamic profile to maintain CPP – so no positive evidence, but sounds like a good agent.
Avoid any constrictive ties / dressings around the neck that can impede venous drainage of the skull
Preferably no CVC in the jugulars
Monitor – BP (MAP), RR, heart rate closely – an arterial line will assist with accurate BP assessment and gas monitoring
Monitor ECG for arrhythmias
OK. That is enough for one post. Case 055 is to be continued…. oodles of evidence in the next part. Sorry there is not much in the literature for the stuff above.
Love to hear your comments on the management thus far.
There is a great twitter debate going on if you are keen to follow – @broomedocs 6/6/12
Headache headaches! A podcast from the PHARM
Clinical Case 099: To Lose One’s Marbles
Case 0003 – Beyond opiates in Chronic pain
About The Author
Casey Parker
I am a GP working in Broome, NW of Western Australia. I work as a hospital DMO (District Med Officer) doing Emergency, Anaesthestics, some Obstetrics and a lot of miscellaneous primary care. Also on the web as @broomedocs | + Casey Parker | Contact
I’m generally a big fan of rocuronium, but this may be a case where sux is a better idea as the neuro exam will be lost for an additional 30-50 minutes with roc. Something to consider.
Hi Seth, I hear what you are saying. Neuro exam would be nice, but for a lot of remoe docs this case is really about getting them out to the bigger centre intact . In our retrieval services the mantra is for continous paralysis – I know it is frowned on in ICU land.
Maybe the best ting to do is a quick neuro assessment of gross motor function, reflexes etc up front before intubation. None of my colleagues would be happy to have these patients light enought to do a neuro exam on in the ED, that would wait until they are in the ICU
valid point. if you’re already giving maximal care etc then change in exam won’t mean change in management. but you might miss the chance for a burr hole!