What systems do these various signs and symptoms point to? Why? What is the most important monitor in the ER? Why? What are you most worried about? Should the patient receive supplemental oxygen en route to the OR? Does the patient need a head CT scan as part of his work-up? A body CT scan? A C-spine series? Chest x-ray? EKG? Fundoscopic examination?

If he lost consciousness for a period of time, would this influence your work-up and plan? Why?

What is the significance of bleeding from the ear? What if he had a clear discharge from his nose as well as bleeding from the ear?

Starting from the top down, you would have to be concerned about any secondary head and cervical spine injuries, although his mental status seems all right [1]. The hearing impairment and bleeding from the ear suggest tympanic membrane rupture from the shock wave injury, which would also rupture other gas-containing structures like the lung and bowel [2]. The stomach pain suggests that might be the case with intestinal disruption. The shortness of breath and tachypnea may reflect lung injury, but could also reflect myocardial contusion and impaired myocardial performance as a result of the chest wall trauma [3]. The blood pressure is lower than expected and the heart rate higher than normal, which could represent volume depletion or myocardial impairment which might include a hemopericardium with tamponade. The hematocrit is moderately decreased, but this could also be artifactually high if he was hemoconcentrated or artifactually low if he was aggressively fluid resuscitated with crystalloid. The mental status exam is probably the most important “monitor” in the ER, followed by the cardiovascular system. Supplemental oxygen would be advisable; at the very least, it would provide a margin of safety should further interventions be required on an urgent basis. If there is time, a head and body CT scan and C-spine series might reveal additional areas of injury, but the yield might be low. A chest x-ray would be helpful for rib fractures, cardiac size, and contour as well as pneumo- or hemothorax or abnormalities in the cardiac silhouette. A KUB of the abdomen might also reveal free air and could be obtained at the same time as the chest x-ray in the ER; this strategy would probably have a higher yield than the CT scan. An ECG is necessary to look for myocardial injury. The fundoscopic examination might reveal retinal hemorrhages, which reflect the severity of the blast injury as well as retinal detachment.

A loss of consciousness should prompt more aggressive investigation for closed head injury and the C-spine.

Bleeding from the ear is highly suggestive of moderately severe blast injury, and gas-containing body systems (ear, sinuses, lungs, bowel) should be carefully examined. A clear discharge from the nose, in the absence of recent symptoms of an URI, should be suspicious for a CSF leak from the skull base.

Does this patient need an arterial line? Why/why not? Prior to induction, or after? What about stat mode on automated blood pressure cuff? Is it the same? What about a central line? The patient’s neck veins are distended and don’t appear to be varying with respirations; what is the significance? What is the differential diagnosis; most likely diagnosis? Does the patient need a chest tube prior to induction of anesthesia, or can one be placed after rapid sequence induction and intubation? What if there was subcutaneous emphysema? Clinical significance and implication for anesthesia plan.

Assume no pneumothorax; how would you proceed with induction? Would you leave the saphenous vein IV in place, or insert one above the diaphragm prior to induction; just after induction? Why?

Does this patient need a rapid sequence induction? With what? Why not inhalation induction with sevoflurane? What about use of nitrous oxide? Why/why not?

Exploratory lap reveals a large hepatic subcapsular hematoma and a fractured spleen. Unfortunately, the vascular clamp has come off the splenic pedicle, and the capsule has ruptured; there is a unit of blood in the belly; the BP is 53/20 and the HR 200. What to do next? Get an ABG? Give bicarb? Can the surgeons help you at all? How? Is the saphenous vein IV of any use? How much?

Following vigorous resuscitation, the patient is now 31.2 °C. How did this happen? Why did it happen? What mechanisms of heat loss are most significant? Is it worthwhile putting in a heat and moisture exchanger in the breathing circuit at this time? Earlier? What advantage over heated humidifier? What are some of the problems with both? How can you warm the patient? Is this desirable? Should your goal be normothermia? You begin to see a widening of the QRS complex; clinical significance?