It was a cool day yesterday ; Gong Xi Fa Chai i suppose. I was a bit busy in the morning though , resuscitating a post Angioplasty fella who had a bad MI the day before. How he got the MI was a very interesting story which I think i should reserve it at the moment !! Hahahah
I got a call from the orthopods team at midnight ; requesting my assessment of a young boy who was thought to be suffering from a possible fat embolism syndrome. According to her , he had became more breathless withconfusion and disorientation.His blood investigation certainly pointed to the provisional diagnosis. He had polytrauma the day before , found on the NPE highway and sustained multiple pelvic and bilateral femur fracture. He was unfortunate to have an unstable ordonthoid fracture displacement which is bad news. As if the severe lung contusion is not bad enough and now he is suspected to have bad V/Q mismatch !
Of course , if fat embolism is the immediate diagnosis , we do need to protect his airway before disaster beckons. His unstable cervical spine fracture complicated the matter and the oncall team had to brain-storm in thinking of the best airway management.
Fibre-optic intubation with our ENT colleague
Ultimately , he needed a tracheostomy as his recovery will take months especially with all the fixations. As the spine team were planning to fix the hangman's type of fracture ; we were left to intubate the patient fibreopticly while the patient is awake. His head was not to be mobilized at all and that is a big challenge ! We had doc Hisyam ( from ENT ) to standby , in case we had to proceed with emergency tracheostomy. He was a big help , assisting us with his expertise.
We had difficulties ,( broke one paeds scope in the process !! ) but managed to secure the airway as planned. We had to improvise and reached our goal. His lungs were deteriorating and we had few panic attacks when he desaturated. Luckily he is young and ventilation was never a problem. The fastrach was a wonder , having to help us maintain his oxygenation while manipulating the airway without destabilizing the neck.
Its good to have scenarios like this , but of course the management would be an interesting topic to be discussed during our weekly morbidity and mortality meeting.
securing the airway
Mind u..this picture was taken at 4am in the morning ;despite the fresh faces ! post adrenaline rush ...