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SU10.1-4 | Perioperative Management — PBL Case

CLINICAL SETTING

It is a busy evening in the emergency department of a district hospital. A 24-year-old motorcyclist, Mr T, is brought in after a road traffic accident. He is conscious but in pain, with a deep, contaminated laceration to his right forearm that is bleeding, and a smaller wound on his thigh. He smells of alcohol and is reluctant to let anyone touch him, saying he 'just wants to go home'. The only surgical resident is in theatre. You are the intern, supervised remotely by the on-call consultant by phone. You must decide how to manage his wounds, how to handle consent in this situation, and how to keep everything safe.

Trigger 1: First aid, bleeding control and the contaminated wound

Mr T's forearm wound is bleeding steadily and is visibly contaminated with road grit. He is alert. Before anything else you must apply the principles of first aid and decide how to manage the wound itself.

DISCUSSION POINTS

  • Walk through the ABCDE primary survey for this injured patient. What must you assess and treat before focusing on the wound itself?
  • How would you control the external bleeding from the forearm, and when (if ever) would a tourniquet be appropriate?
  • This is a dirty, contaminated wound. Should it be closed by primary intention? Justify your decision in terms of healing type, and outline tetanus prophylaxis based on wound type and immunisation status.
Click to reveal Trigger 2: Local anaesthesia and safe suturing (discuss previous trigger first!)

Trigger 2: Local anaesthesia and safe suturing

You plan to clean, explore and close the appropriate wound under local anaesthesia. Mr T weighs about 60 kg. You have plain lignocaine and lignocaine with adrenaline available, and you must do this safely and aseptically.

DISCUSSION POINTS

  • Calculate the maximum safe dose of plain lignocaine and of lignocaine with adrenaline for this 60 kg patient. Why does the addition of adrenaline change the ceiling, and where would you avoid adrenaline-containing solutions?
  • What are the early features of local anaesthetic systemic toxicity, and how would you recognise that you are approaching or exceeding the safe dose?
  • Describe the aseptic technique and the steps of simple interrupted suturing you would use, and how you would decide which wound to close and which to manage by delayed closure.
Click to reveal Trigger 3: Consent, capacity and the reluctant intoxicated patient (discuss previous trigger first!)

Trigger 3: Consent, capacity and the reluctant intoxicated patient

Mr T is intoxicated, in pain, and now says he refuses treatment and wants to leave. You believe he needs wound care to avoid serious infection and possible loss of function. You must decide how to handle consent and capacity lawfully and ethically.

DISCUSSION POINTS

  • How would you assess Mr T's capacity to refuse treatment right now? What specifically must he be able to do for his refusal to be valid, and how does intoxication affect this?
  • Apply the three pillars of consent — capacity, voluntariness and disclosure — to this situation. If he genuinely lacks capacity and faces serious harm, what lawful route allows you to provide necessary treatment?
  • How would you communicate with him to maximise the chance of valid, voluntary consent — and how would you document the encounter and involve the consultant?

Group Task Assignments

  • Group A: Produce a step-by-step ABCDE-to-wound-closure algorithm for the acutely injured patient with a contaminated limb wound, including bleeding control and tetanus prophylaxis decision points.
  • Group B: Create a quick-reference card of local anaesthetic maximum doses (lignocaine plain and with adrenaline, bupivacaine) with worked calculations for a 60 kg patient and the signs of systemic toxicity.
  • Group C: Role-play the consent conversation with the reluctant, intoxicated patient, then critique it against capacity assessment and the three pillars of consent, including how the emergency/necessity route would apply if capacity is lacking.

Learning Issues

Research these questions and bring your findings to the discussion.

  1. [SU10.4] What are the ABCDE first-aid priorities and bleeding-control measures in an injured patient, and how do you decide between primary, delayed primary and secondary wound closure?
  2. [SU10.4] What are the maximum safe doses of lignocaine (plain and with adrenaline) and bupivacaine, and what are the features of local anaesthetic systemic toxicity?
  3. [SU10.2] How is capacity assessed, and how do intoxication, pain and distress affect a patient's ability to give or refuse valid consent?
  4. [SU10.2] When a patient lacks capacity and faces serious harm, what lawful route (emergency/necessity, best interests) permits treatment, and how should it be documented?