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    Assesment: Take Consideration About Patient Haemodynamic Stability

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    24 Narong Reed
    The patient, a 20-year old male, was in a motorcycle collision and is unconscious with head and abdominal injuries. He was intubated and scans showed a scalp laceration and free fluid in the abdomen. Vital signs were stable. The patient was deemed stable for CT but his oxygen saturation dropped during transfer to the CT scanner due to a low oxygen tank. CT scans were completed and a tension pneumothorax was found, treated with a chest tube. His condition deteriorated further and he now requires urgent surgery but safe transfer to the operating theater is important given his instability.

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    Assesment: Take Consideration About Patient Haemodynamic Stability

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    24 Narong Reed
    38 views6 pages
    The patient, a 20-year old male, was in a motorcycle collision and is unconscious with head and abdominal injuries. He was intubated and scans showed a scalp laceration and free fluid in the abdomen. Vital signs were stable. The patient was deemed stable for CT but his oxygen saturation dropped during transfer to the CT scanner due to a low oxygen tank. CT scans were completed and a tension pneumothorax was found, treated with a chest tube. His condition deteriorated further and he now requires urgent surgery but safe transfer to the operating theater is important given his instability.

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    The patient, a 20-year old male, was in a motorcycle collision and is unconscious with head and abdominal injuries. He was intubated and scans showed a scalp laceration and free fluid in the abdomen. Vital signs were stable. The patient was deemed stable for CT but his oxygen saturation dropped during transfer to the CT scanner due to a low oxygen tank. CT scans were completed and a tension pneumothorax was found, treated with a chest tube. His condition deteriorated further and he now requires urgent surgery but safe transfer to the operating theater is important given his instability.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    38 views6 pages

    Assesment: Take Consideration About Patient Haemodynamic Stability

    Uploaded by

    24 Narong Reed
    The patient, a 20-year old male, was in a motorcycle collision and is unconscious with head and abdominal injuries. He was intubated and scans showed a scalp laceration and free fluid in the abdomen. Vital signs were stable. The patient was deemed stable for CT but his oxygen saturation dropped during transfer to the CT scanner due to a low oxygen tank. CT scans were completed and a tension pneumothorax was found, treated with a chest tube. His condition deteriorated further and he now requires urgent surgery but safe transfer to the operating theater is important given his instability.

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    of 6

    Quiz: Transport of critically ill patients

    A 20 years old male was brought in to the red zone. He had a motorcycle collision
    with a lorry. He is unconscious with only responding to deep pain stimulation. His
    HR is 90/min, BP 120/70, SpO2 under room air is 90%.

    He was intubated for airway protection. Primary survey revealed a deep scalp
    laceration which has been sutured and free fluid was detected intra-abdominal
    during FAST scan. A part from that, the chest examination is unremarkable, pelvic
    bone examination show no instability and the limbs are not deformed. Portable
    chest and pelvic x-ray were done and cleared by the attending doctor. Vital signs
    remain similar as he first arrived to red zone.

    A diagnosis of severe head injury and intra-abdominal injury were made by the
    attending doctor.

    He was planned for CT brain and CT abdominal.

    Q1. Is the patient stable to be transfer to the CT suite? State your reasons.
    Based on the current clinical and haemodynamic condition of the
    patient ,I think the patient is suite for CT Brain.The current blood
    pressure is 120/70mmHg with MAP 87 and pulse rate
    90/min .Eventhough patient was diagnosed with severe head injury and
    intra-abdominal injury intubation was been done to protect the
    airway.The deep scalp laceration already sutured.In my judgement the
    patient haemodynamic now is suite for the patient to be transfer to CT.

    Q2. How do you prepare the patient for transport to the CT suite?
    Assesment: take consideration about patient haemodynamic stability
    before transferring, try to anticipate the worst case scenario that might
    happen during transportation to CT suite. Be sure about what has been
    done to the patient such as management that has been carried out and
    will be carried.

    Always reassess patient condition during transfer:

     What is the problem?


    Diagnosis – severe head injury and intra-abdominal injury(watch up for
    any deteriorate sign because of the complication)
     What has been done?
    Prevention of secondary brain injury.
     What was the effect?
    Maintaining the status quo and preventing secondary brain injury.
     What is needed now?
    Transfer for further assessment.
    There are potential problems that may arise during transfer

    Control: A comprehensive assessment by the clinician in charge and the


    decision has been made to transfer the patient.Become the team leader
    and try to manage calmly if something unexpected happen during
    transfer. Identify the task that need to be done and allocate task to team
    member according to their abilities and confident level.

    Communication: excellent communication within team


    and receiving end ,continuous assessment of effectiveness of
    resuscitation and stabilisation process,experienced staff in intensive
    care and transfer,clear chain of responsibility.

    Evaluate the need for transfer: The need for specialis care has already
    been determined as part of the initial assessment.Make sure the benefits
    is higher than the risk. If the risk is higher, try to identify the cause and
    investigate how to reduce the risk to the minimal level.

    Package and preparation: The patient has been stable before


    transfer .Organize properly before starting the process to transfer the
    patient to CT suite. All relevant equipment monitoring and treatment has
    been pre-packed and checked.Contingency equipment that should be
    required in case the patient deteriorates.

    Transfer: It is strongly recommended that a minimum of two


    people accompany a critically ill patient. It is strongly recommended that
    a staff with training in airway management and ACLS, and critical care
    training or equivalent, accompany unstable patients. Make sure all the
    document and consent are brought along with patient Continuous BP
    monitor, pulse oximeter, and cardiac monitor must accompany every
    patient without exception to CT suite to ensure no misunderstanding
    happen before, during, and after transport. Use the shortest and safest
    route towards the CT suite to hasten the journey.

    Q3. What problem would you anticipate in transporting this patient?


     Airway –airway obstruction,Hypoxaemia,hypoxia
     Breathing- Hypercarbia ,Respiratory arrest,dislodgement of
    ETT,pneumothorax
     Circulation - Cardiac arrest, hypotension, hypertension,
    cardiac arrythmias
     Disability -hypoglycemia, seizures or convulsion ,
    deterioration in Glasgow ComaScore,paralytic agent and
    sedation is enough during transportation

    You arrived at the CT suite, as the patient being transferred to the CT table, his
    SpO2 drop.

    Q4. How do you assess the sudden respiratory deterioration in intubated patient?

    The immediate life threats can be summarized as “DOPES”


     Displacement or dislodgement of the endotracheal tube (ETT) .Make sure
    to reassess back the ETT whether it is inflate enough or not and its anchor
    is accurate or not
     Obstruction of the ETT.Detect any blockage such as secretion ,blood
    cloot,ETT kinking ,notice the parameter alarm in the ventilator,try manual
    bagging the patient to detect any abnormalities when bagging ,suctioning
    regularly
     Pneumothorax-look for the asymmetrical chest movement. If there is
    reasonable chest movement, a patient problem is most likely. Perform a
    focused exam and urgently seek and treat the following life-threats
     Equipment — ventilator problems,make sure to notice every alarm in
    ventilator during transportation ,bring the proper set BVM during
    transportation .If the problem can not manageable bring back the patient
    to ED.
     ‘Stacked breaths’ — a reminder about bronchospasm and ventilator
    settings. if patient is suspected having air trapping or intrinsic PEEP,
    disconnect the ETT from the ventilator and hear for air gushing from the
    ETT. If it is present, gentle chest palpation may required to help extract the
    air out from lung. Tweak ventilator setting according to patient condition.
    After a quick examination, you noted that the oxygen tank connected to the
    ventilator is low. You quickly ask your assistant to bag this patient first, while you
    connected the ventilator to the oxygen wall port available at the CT suite.

    CT brain and CT abdomen are now completed. Patient is now back at the red zone.
    Unfortunately, his condition deteriorates. Right tension pneumothorax was
    suspected, needle thoracocentesis was performed followed with chest tube
    insertion. His blood pressure remained low and needing blood transfusion. Now he
    is planned for urgent laparotomy and need to be transferred to the OT.

    Q5. This time around, what would be different in term of the planning and
    strategy to transport this patient safely to the OT?

    Using ABC approach to help tackling this patient.

    Airway: Ensure the ETT is secure properly and to avoid the risk of
    dislodgement during transfer to OT.

    Breathing: Attach pulse oximeter to monitor oxygen saturation of the patient.


    Prevent secondary brain injury and prolong hypoxia. An arterial blood gas
    sample should be analysed just prior to transfer to assess adequacy of
    ventilation and to ensure appropriate blood gas targets are achieved prior to
    transportation.Secure chest tube site insertion to ensure the tube are firm in
    place and exterminate the chances of dislodge. Make sure water in the
    underwater seal in sufficient (300ml) to create the vaccum effect in the lung.
    Tweak the ventilator setting to reduce the chance of pneumothorax occur
    again.

    Circulation: A minimum of 3 lead ECG monitoring is needed. The rhythm


    should be stable, or if not, appropriate management. Adequate resuscitation to
    maintain a normal and stable pulse and blood pressure is mandatory.
    Whenever possible bleeding should be controlled. Invasive arterial monitoring
    is recommended for most critically ill and injured patients to allow accurate
    blood pressure assessment during transport. Circulating volume replace.Get 2
    pint of safe-O blood product to replenish patient blood volume to a normal
    level. If it is not enough, Medical Officer can activate Massive Transfusion
    Protocol (MTP). Ensure there is 2 large bore branula (14 Fr is preferable) is
    inserted at patient cubital forsa. This can guarantee the maximum amount of
    blood product can be given to patient in the shortest of time to replace the fluid
    that has loss from patient circulatory system. Insert urine catheter size 16FR to
    measure urine output.Continue blood product transfusion until the patient
    goes to OT.

    Disability. All intubated patients must be adequately sedated and paralysed. If


    the patient is having seizures, these should be controlled prior to transfer.
    Regular pupil checks should be performed and specialist advice sought should
    evidence of raised intracranial p
    ressure be detected before transfer.

    Then ,using the pneumonic ‘ACCEPT’


    Assesment: take consideration about patient haemodynamic stability before
    transferring, try to anticipate the worst case scenario that might happen during
    transportation to OT suite. Be sure about what has been done to the patient
    such as management that has been carried out and will be carried.

    Control: A comprehensive assessment by the clinician in charge and the


    decision has been made to transfer the patient.Become the team leader
    and try to manage calmly if something unexpected happen during
    transfer. Identify the task that need to be done and allocate task to team
    member according to their abilities and confident level.

    Communication: excellent communication within team


    and receiving end ,continuous assessment of effectiveness of
    resuscitation and stabilisation process,experienced staff in intensive
    care and transfer,clear chain of responsibility.

    Evaluate the need for transfer: The need for specialis care has already
    been determined as part of the initial assessment.Make sure the benefits
    is higher than the risk. If the risk is higher, try to identify the cause and
    investigate how to reduce the risk to the minimal level.

    Package and preparation: The patient has been stable before


    transfer .Organize properly before starting the process to transfer the
    patient to OT suite. All relevant equipment monitoring and treatment has
    been pre-packed and checked.Contingency equipment that should be
    required in case the patient deteriorates.
    Transfer: It is strongly recommended that a minimum of two
    people accompany a critically ill patient. It is strongly recommended that
    a staff with training in airway management and ACLS, and critical care
    training or equivalent, accompany unstable patients. Make sure all the
    document and consent are brought along with patient Continuous BP
    monitor, pulse oximeter, and cardiac monitor must accompany every
    patient without exception .

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