Rising airway pressure after chest trauma during femoral nailing31-year-old man, 80 kg, for urgent intramedullary nailing of a femoral shaft fracture after a motorbike crash 6 hours ago

The patient

The examiner asks

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1. Consider

   What are your concerns?

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   • A fit 31-year-old with chest trauma and a small undrained pneumothorax, for urgent femoral nailing. Patient
   • He is a trauma patient: I repeat his primary survey, with chest ultrasound for air and blood.
   • Positive pressure can turn his small pneumothorax into a tension. Disease
   • Reaming his femur pushes marrow fat into his veins: fat embolism is a real risk. Surgery
   • Rib fractures and contusion limit his breathing and need good analgesia after. After surgery

2. Prepare

   How do you prepare him?

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   • A left chest drain goes in before induction, since I'll be ventilating him. Disease
   • No nitrous oxide; it can double or triple his pneumothorax within 10–30 minutes. Stem trigger
   • He is 6 hours from injury, past the 3-hour window for tranexamic acid. Surgery
   • Two large-bore cannulae, crossmatched blood and an arterial line.
   • Ventilation at about 6 mL/kg with PEEP to protect his contused lung. Airway

3. Plan

   How do you induce and monitor him?

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   • RSI; ketamine 1–2 mg/kg is kinder to a bleeding trauma patient than full-dose propofol. Airway
   • Rocuronium 1.2 mg/kg; videolaryngoscope and tube confirmed by capnography.
   • I watch peak pressure, SpO2 and BP together; a rise in pressure means tension until proven otherwise. Disease
   • During reaming I watch for fat embolism: hypoxaemia and tachycardia, later petechiae and confusion. Surgery

4. Crisis

   During reaming, peak pressure climbs from 24 to 45 cmH2O. SpO2 86%, BP 72/40, HR 135. No breath sounds on the left; neck veins distended. What do you do?

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   • Left tension pneumothorax: surgeon stops, help called, FiO2 1.0. (Crisis)
   • I hand ventilate; stiff bag, silent left side, swollen neck veins confirm it.
   • His drain first: in, unclamped, swinging? If not, finger thoracostomy now, no imaging first.
   • Then a new or repositioned drain on that side.
   • Phenylephrine 50–100 mcg boluses and fluid while his venous return recovers.
   • If pressures stay high, I check the right side, the tube, and fat embolism.

5. Crisis

   Despite decompression he loses his pulse. ECG shows sinus rhythm at 130; ETCO2 is 12 mmHg. What do you do?

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   • Adult arrest algorithm, non-shockable: PEA in a ventilated trauma patient. Crisis
   • CPR at 100–120/min, 5–6 cm deep; ETCO2 under 10 means little output: improve compressions.
   • Adrenaline 1 mg IV now, with no shock to wait for, and every 3–5 minutes after.
   • His causes: tension on either side, bleeding from the femur, fat or clot embolism, tamponade.
   • So I decompress the right side too, and give blood fast.
   • Ultrasound during pulse checks only, without pausing compressions.
   • After return of circulation: secondary survey again, then ICU. After surgery