Patient 1. How would you like to work this patient up further? What are his risks right now? Is it important to determine his blood alcohol level? Why? How will you decide whether he can protect his airway? Do you have to wait until he is sober to go to the operating room? Is there anything about his situation for which he needs immediate surgery? What if he needs a head CT scan or MRI? What are your considerations?

Patient 2. The emergency medicine physicians would like to administer ketamine 1 mg/kg (the upper limit of the dose they are allowed to administer as procedural sedation) in order to obtain imaging studies of the head, chest, and abdomen. They call to give you a “heads up” but don’t want to bother you in the operating room because “you will probably be seeing this kid later.” Your thoughts? Your advice? Why is he hallucinating? What is the significance of his vital sign abnormalities? Do they have any specific implication for “sedation?” Any specific implications for anesthetic plan, assuming you would like to anesthetize him for these diagnostic, and possibly therapeutic, procedures? Does he need a rapid sequence induction of anesthesia? What are your concerns? What is the typical intoxication level for blood alcohol? Is this a national standard? How does it influence your anesthetic plan? How do you interpret his pain complaint with regard to his gunshot wound entry?

Patient 3. The maxillofacial surgeon and ophthalmologist both agree that the patient should go to the OR expeditiously to have the mandibular fracture put into fixation before it gets too swollen to obtain a good repair and that the orbit should be stabilized to prevent any chance of ocular injury or visual impairment. How will you proceed? How should this patient be counseled for her procedure? If she is intoxicated with ecstasy, can you/should you involve her parents in the consent? Is there an optimal anesthetic strategy in this circumstance? How would you counsel her for the risks of fetal wastage with a general anesthetic? Does it vary with the gestational age?

Patient 1. Concurrent injuries are a significant concern so a thorough primary and secondary survey is warranted, including imaging studies to rule out intracranial, intrathoracic, or intra-abdominal injury. His stupor may be attributable to his intoxication, but in order to be sure, it is prudent to obtain a blood alcohol level and a toxicology screen for other substances as well. However, his stupor can also represent a head injury, especially in the presence of vomiting. With attendance at a party, he is likely to have a full stomach, and if protective airway reflexes are impaired for any reason, it would be prudent to protect his airway during any diagnostic studies. If he has straightforward fractures without any other injuries, he will likely have an optimal surgical result if the time to the operating room is minimized because of local edema following injury; otherwise, he will have to wait at least several days for the swelling to decrease. His vital signs seem reasonable for someone in pain.

Patient 2. The disparity between the gunshot wound point of entry and the patient’s symptomatic complaint (although perhaps incoherent because of drugs or other factors) is immediately worrisome. Referred pain in the neck and right arm could represent diaphragmatic injury and therefore, with an abdominal entrance wound, liver injury, which can be life-threatening. In addition, he is hypertensive and tachycardic, so hemoperitoneum and intrathoracic and major vascular injuries need to be considered. The rigid J collar is a challenge for airway maintenance and tracheal intubation because by design it is intended to provide firm cervical spine fixation. It has a hole in the tracheal area, but that said, it does not make intubation of the airway any easier. If the collar needs to be kept in place, then a GlideScope would seem like a good option in order to improve the chances of visualizing the airway while maintaining neck neutrality. The other possibility would be removal of the J collar with in-line stabilization and then replacement of the collar, if possible and compatible with the scheduled procedure, following tracheal intubation. The hallucinations suggest a significant psychotropic effect from the cannabinoids and amphetamine, although the patient could be delirious for a variety of reasons including intracranial injury and hypoxia. He is hypertensive, tachycardic, and tachypneic which may be drug effects combined with the very considerable stress response, increase in oxygen consumption and carbon dioxide production, and any degree of pain. He already received a large dose of hydromorphone, the equivalent of over 20 mg of morphine, without much of an effect. However, with the induction of anesthesia, the effect of the hydromorphone may be magnified. His blood alcohol level is over twice the legal limit in most states. It is unlikely that 1 mg/kg of ketamine will be effective in providing motionlessness for the imaging studies required, and the lack of airway protection is a major consideration for patient safety as well. Similar anesthetic considerations for securing the airway apply to this patient as well; he is combative and should be treated as a full stomach, coming from a party. His hallucinations are probably from polypharmacy with the strong possibility that whatever he ingested likely had an admixture of hallucinogens, although hallucinations are common with this combination of substances anyway. A toxicology screen would be helpful to identify specific substances.