Case of acute and evolving intrinsic cord lesion in pregnancy presenting as unusually bizarre, but evolving neurology, referred as ‘cauda equina?’
When faced with an unusual presentation, particularly if it does not fit with anything ever seen before, and even if on probability it is very unlikely to be pathalogical, need to exclude the relevant and not be biased towards preliminary diagnosis planted by others. Consider Bayesian modelling.
Have an open mind and think broader than the problem presented. Is this something that we have neither yet considered nor ever seen before? How to prove/disprove this? Consider safety nets and worst case scenario. Accept uncertainty in an uncommon, undeclared situation rather than over-confidence. Observe evolution over time with multiple snap shots and opinions.
1. Assume nothing and trust no one.
2. No matter how bad your day is, at least you do not have pancreatic cancer.
3. Breathe and smile.
Bolus propofol, thio, midazolam +/- opiod
Infusion propofol +/- alfentanil, midazolam +/- morphine
Adv: Best for ventilation/control of each side.
Dis: bulky therefore not in difficult intubation, tracheostomy
2. Single lumen ETT with bronchial blocker
Adv: Use in (pot.) difficult airway, tracheostomy, if ETT already in situ e.g. ICU.
Dis: More specialised kit and technique. Needs fibreoptic scope.
3. Single lumen ETT advanced into main bronchus ( + fibreoptic if left sided)
Adv: Useful in emergency with most simple/available kit.
Dis: no control over non-intubated lung.
Oral/pharnygeal surgery if surgeon agreeable, experienced, understanding of LMA issues
e.g. Adeno-tonsillectomy, Frenuloplasty, Dental extraction
I tended to attempt intubation prematurely… 3 minutes feels like a long time. That’s why, when starting at least, the second person came along and stuck the tube down with ease due to the improved intubating conditions i.e. muscle relaxation! As for sux, if possible, wait for longer than ‘end of fasciculations’ . JC enforces timing 60 seconds! Especially important in difficult intubations in elective situations.
Obs anaesthesia is the doing a handful of simple things well:
And find problems before they find you!
Reasons not to extubate light:
Delicate oral/throat surgery
Reasons not to extubate deep:
Full stomach/aspiration risk
‘no touch technique’ – let them wake up peacefully and pull out tube themselves e.g. T&A