This hypothetical case was simulated today with resident medical staff and nursing staff.
An obese 40 year male with type 2 diabetes mellitus presented in status epilepticus.
He had taken an oral hypoglycaemic agent but rather than have breakfast he went on a pub crawl to celebrate his 40th birthday. He then collapsed and had tonic clonic seizures. He had been given intramuscular midazolam by paramedics.
Prepare for patient arrival, organise team and allocate roles. Manage airway, control seizures, identify and treat the underlying cause.
The Learning Points – Clinical
1. Position is EVERYTHING in airway management. Don’t forget to align the external auditory meatus with the suprasternal notch horizontally (this applies to all ages and sizes of patient), with the face parallel to the ceiling.
2. Optimal bag mask ventilation involves a two person technique, allowing maintenance of an effective jaw thrust and good mask seal, with the use of airway adjuncts (oro- or naso-pharyngeal airways, or both):
3. Although the intraosseous route is preferred if there are delays in securing vascular access, it is not ideal for sampling for laboratory investigations. Blood can be taken from a large venous or arterial stab (eg. femoral vein) simultaneous to intraosseous insertion.
4. Intraosseous access does not have to be limited to the tibia! In some patients, the humeral head site may be preferable.
5. Not every comatose patient needs to be intubated. Plot the trajectory of their clinical state: if they’re improving and you’ve fixed the underlying cause, they may wake up (eg. post-hypoglycaemia or post-ictal). Actively support the airway in the meantime and if you need to set up for intubation use the checklist as a guide.
The Learning Points – Non-Clinical
1. Having a nursing and medical team leader working side by side works well in resuscitation due to the multiple tasks needing to be allocated to staff who are at various points on the skill-mix spectrum.
2. Medication orders should be written down to minimise misunderstanding and drug errors. It is the medical team leader’s responsibility to make this happen.