Thank you everyone for your thought-provoking comments.
To summarise, we had a young woman present with a possible (later discounted) story of substance
abuse fitting with decerebrate posturing and a slightly dilated pupil on one side. Fitting was
terminated with a general anaesthetic, and scan showed a massive hyperacute extradural (I'm still
trying to obtain copies of the scan) as she became haemodynamically unstable, demonstrating
Cushing's reflex with bradycardia and hypertension.
At this stage, I wanted the clot out and now, as she was dying in front of me. I teach that mannitol
intravenously has only one application; acute time purchase in the desperate situation while you find
a neurosurgeon. I decided to practice what I preach and requested 500ml 20% mannitol stat while I
rang the neurosurgeon. I entertained hopes of getting him to the patient as she was 50m from our
operating theatres, but he said that he would get the best shot at her in his own theatre with his own
equipment and staff. Fifteen frantic minutes ensued while I managed to assemble a paramedic crew,
an anaesthetic SHO and a box of drugs. Her pulse had risen by now, and she seemed more settled.
Apart from ringing the neurosurgical theatre with an ETA my active involvement ended at this point,
but for the record we got from scan to table in 55 minutes, with one very ill and selfless anaesthetic
SHO by the end. She was operated on at once, and at craniotomy a large extradural clot of the
consistency of strawberry jam was evacuated. There was a single fine fracture into the foramen
spinosum. The mannitol had done such a good job that her brain stayed where it was and did not
pour out of the hole.
I went to see the patient four days later, and she was eating grapes and chatting to her family. Her
short-term memory is still a bit ragged, and one arm is a little weak, but she is quite clearly recovering.
I learned a lot from this case. Firstly, maintain a high index of suspicion over a second hand story.
Secondly, I was forcibly reminded of the truth of a mantra I teach - "Look for what kills first, and
exclude that first." The pupil was a subtle but unmistakable sign. Thirdly, don't feel guilty for not
dotting all the i's and crossing all the t's in a crisis - no, I didn't do every test imaginable (and never
looked at her fundi) but did enough to satisfy myself of the diagnosis that needed sorting. Fourthly,
sometimes treatments (i.e. mannitol) really do have the desired effect. Finally, you still need a huge
slice of luck, and you do need to keep the pressure on. A lot of people have to do their job very well
for a patient to escape from a situation like that, and it drives home the message that modern medicine
is a team effort.
For the record, parts of this story may have been changed, but the essential clinical story is accurate.
Best wishes,
Rowley Cottingham
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http://www.emergencyunit.com
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