Download Update 11 - Update in Anaesthesia - WFSA

50Update in Anaesthesia7) Control ventilation during the procedure aimingfor low to normal end-tidal carbon dioxide.This may require the use of a longer actingmuscle relaxant (e.g. vecuronium 0.1mg/kg). Aslight head up tilt helps reduce intra-ocular pressure.8) At the end of the procedure the patient shouldbe extubated on their side and once airway protectivereflexes have returned. In patientsnot deemed at risk of aspiration extubation withthe patient deep and breathing spontaneouslymay prevent coughing. Severe coughing andstraining needs to be avoided as this increasesthe risk of ocular haemorrhage.9) If the patient does not have a full stomach and isnot deemed at risk of aspiration, general anaesthesiashould proceed as for an elective patient.Pre-oxygenate the patient for safety and inducewith an intravenous agent. Give a long actingmuscle once ability to hand ventilate is established.Laryngoscopy should be performed gently.Consider spraying the vocal cords with lignocaineto minimise the pressor response tointubation. This may also decrease the risk ofcoughing on intubation. Intubate, ventilate andmaintain anaesthesia as above.10) Post operatively nausea, vomiting and painshould be kept to a minimum as they can causerises in intra-ocular pressure. Prescribe regularoral analgesia and an anti-emetic. Some patientsmay need stronger analgesia early after surgery.Titrate small doses of intravenous opioid (morphine,pethidine) to control pain.References1. Mcgoldrick KE. The open globe: is an alternative tosuccinylcholine necessary ? J Clin Anaesth 1993, 5: 1-4.This article argues that suxamethonium is probably still the bestmuscle relaxant for the real emergency. It also discusses the useof pretreatment.2. Libonati MM, Leahy JJ, Ellison N: The use ofsuccinylcholine in open eye surgery. Anaesthesiology 1985, 62:637-40.This paper studied 100 patients needing “open eye” surgery withsuxamethanium.MANAGEMENT OF A HEAD INJURY - Case ReportDr. Frank J.M. Walters FRCA, Consultant Anaesthetist, Frenchay Hospital, Bristol BS16 1LE, UK,Frank_Walters@Compuserve.com and Dr. Ray Towey FRCA, Consultant Anaesthetist, Bugando MedicalCentre, Mwanza, Tanzania, emach@africaonline.co.tzThis is a report of a patient who has suffered a head injury.The purpose is to illustrate the practical application of thebasic physiological and pharmacological principlesexplained before (Neurophysiology-intracranial pressureand cerebral blood flow, Update in Anaesthesia1998;8:18-23 and Neuropharmacology-Intracranialpressure and cerebral blood flow. Update in Anaesthesia1998;9:29-37). The problem is presented with themanagement and a range of anaesthetic techniques.The CaseCycling to work in the morning, a fit 30 year old man hasan accident which causes severe damage to his head.Initially he is conscious but confused, and is taken to thelocal Accident Department. When he is admitted it is foundthat he has become unconscious.Initial ManagementAn initial assessment is performed urgently, in the sequencedescribed below.ABCDEAirway control including cervical spineimmobilisation with a stiff collar.BreathingCirculationDysfunction or DisabilityExternal ExaminationHis airway is clear. He is breathing adequately. His bloodpressure is 180/90mmHg and he has a regular pulse witha rate of 55 bpm. There was no report of blood loss at thescene. He is warm and well perfused. Thus his circulationis adequate.