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SU11.1-6 | Anaesthesia and Pain Management — PBL Case

CLINICAL SETTING

A 24-year-old motorcyclist is brought to the emergency department after a high-speed collision. He is drowsy, has obvious facial trauma, and the paramedics report his oxygen saturation has been drifting down despite high-flow oxygen. He is being prepared for an urgent operation. You are the on-call surgical team working alongside the anaesthetist, and the case will test the whole chain from securing the airway to choosing and conducting anaesthesia safely and relieving pain afterwards.

Trigger 1: The drowsy patient with a failing airway

On arrival the patient is supine and making see-saw movements of his chest and abdomen with no audible breath sounds; his saturation is now 84%. There is blood in the oropharynx. The team must act immediately before anything else can happen.

DISCUSSION POINTS

  • Why is a silent chest with paradoxical see-saw movement more worrying than a noisy, snoring airway, and what is the commonest cause of obstruction in an obtunded supine patient?
  • Walk through the airway-management ladder for this patient — which simple manoeuvre comes first, what adjuncts could be used, and when does he need a definitive airway?
  • How does the facial trauma and possible cervical-spine injury change which manoeuvres and devices you choose (e.g. jaw thrust vs head tilt, LMA vs cuffed ETT)?
Click to reveal Trigger 2: Planning anaesthesia for the emergency operation (discuss previous trigger first!)

Trigger 2: Planning anaesthesia for the emergency operation

The airway is secured and the patient is taken for an emergency laparotomy for suspected intra-abdominal bleeding. He is hypovolaemic, has a full stomach, and was last assessed only minutes ago. The anaesthetist discusses the plan with you.

DISCUSSION POINTS

  • Why is this patient graded as an emergency (ASA 'E') and how does that, together with hypovolaemia and a full stomach, shape the anaesthetic plan?
  • Explain the triad of general anaesthesia and how balanced anaesthesia would be used here; why might a single deep dose of one agent be unsafe in a shocked patient?
  • Would regional or spinal anaesthesia be appropriate for this case, and why not? Contrast their characteristics with general anaesthesia in the unstable trauma patient.
Click to reveal Trigger 3: After surgery — pain that will not settle (discuss previous trigger first!)

Trigger 3: After surgery — pain that will not settle

The operation is successful. On the second post-operative day the patient's pain, which had been controlled, escalates sharply and now needs far more analgesia than expected; he is also tachycardic and his abdomen is more tender. The nursing staff ask you simply to increase his opioids.

DISCUSSION POINTS

  • Describe how post-operative pain should have been planned from the outset using the WHO ladder and multimodal analgesia, and how pain should be assessed and reassessed.
  • Why is it dangerous to respond to this escalation by simply increasing opioids? What complications must be actively excluded?
  • What would your structured response be — examination, investigations and escalation — when post-operative pain behaves as a warning sign rather than ordinary discomfort?

Group Task Assignments

  • Group A: Produce a one-page airway-management algorithm for the obtunded trauma patient, from recognition of obstruction through simple manoeuvres and adjuncts to a definitive airway, annotating where cervical-spine precautions modify each step.
  • Group B: Prepare a comparison table of general, spinal and epidural anaesthesia (mechanism, onset, density, dose, catheter use, sympathetic effects and suitability in the shocked patient), and present which you would choose for this case and why.
  • Group C: Design a multimodal post-operative analgesia and safety-netting protocol based on the WHO ladder, including the red flags that should convert 'more pain' into 'reassess for a complication'.

Learning Issues

Research these questions and bring your findings to the discussion.

  1. [SU11.3] What are the principles and the stepwise technique of maintaining a patent airway, and how do you recognise a patent versus an obstructed airway at the bedside?
  2. [SU11.2] What are the principles of general, regional and local anaesthesia, including the triad of general anaesthesia and the comparative features of spinal versus epidural blocks?
  3. [SU11.1] How is a structured preoperative assessment performed, and what does the ASA physical status grade (including 'E') signify in the emergency patient?
  4. [SU11.5] What are the principles of post-operative pain relief, and why is unexpectedly escalating pain a clinical sign of a complication?