Thu18November0755PM 7

A previously fit 20-year-old man has been involved in a road traffic accident and is admitted to the Emergency department with a GCS of 7. He is intubated, ventilated and transferred to the radiology department for a CT scan of the head. This shows a large right-sided subdural haematoma.

A decision is made to transfer him to the nearest neurosurgical centre, some 100 miles away.

Thirty miles into the transfer by blue light ambulance he suddenly starts to deteriorate and you diagnose a tension pneumothorax.

What is the best course of action?

(Please select 1 option)

Cannula decompression of the pneumothorax and return to base hospital

Cannula decompression of the pneumothorax and divert to the nearest hospital

Cannula decompression of the pneumothorax and continue to neurosurgical centre Correct

Return to base hospital and insert a chest drain there

Insert a chest drain and continue to the neurosurgical centre

Explanation

An acute subdural haematoma usually results from acute head trauma. The haematoma accumulates between the surface of the brain and the dura mater. It is also associated with underlying cerebral contusions. The mortality rate ranges between 50% and 90%. A good outcome is most likely if surgical evacuation of the haematoma is prompt and secondary brain injury is prevented. Mortality is less likely in:

younger adults

patients with a GCS score above 6 or 7

those with pupil reactivity, and

those without cerebral contusions or uncontrolled rises in intracranial pressure.

A tension pneumothorax and attendant rises in intrathoracic pressure, rises in cerebral venous pressure and fall in mean arterial pressure is likely to cause severe falls in cerebral perfusion pressure. A tension pneumothorax will also lead to significant hypoxia. This will contribute significantly to the development of secondary brain injury and irreversible cerebral damage.

The first priority is needle decompression of the tension pneumothorax which can be simply done in the back of an ambulance in transit. Needle thoracostomy (NT) is the most rapid method of achieving lifesaving access to the pleural space. If successful, it is met with an audible release of air, as well as stabilisation of the patient's vital signs (hypoxia and/or hypotension).

Primary insertion of a chest drain into a patient in suboptimal conditions is not appropriate. A definitive chest drain can be inserted when the patient arrives at the tertiary centre. Returning to the base hospital or the nearest hospital (wherever that may be) will merely further delay surgery.

Answer Statistics

1

2%

2

56%

3

32%

4

1%

5

13%

Times answered: 347