Monday, 28 May 2007

Never Move An Unstable Patient

This story is anonymised and is from the UK.

A very sick patient who was admitted following an out of hospital cardiac arrest with a substantial time without effective CPR before arrival of paramedics, rendering the patient with likely global hypoxic-ischaemic brain damage.

The admission ECG showed diffuse anterior ST depression and with resolution there was persistent ST change consistent with a N0n-ST Elevation MI (NSTEMI) which is an acute coronary syndrome (ACS).

Following admission, the patient developed recurrent generalised seizures requiring intubation to protect the airway.

The CT head scan showed an old infarct and frontal cerebral wasting but no SAH or intracerebral haemorrhage.

Diazepam was given followed by phenytoin rapid infusion, but both failed to curtail the seizure activity.

There were recurrent Jacksonian seizures every 2-3 minutes and lasting up to one minute, and the junior doctor was not completely certain how to proceed from there.

However, because a bed was then ready on another ward, the staff were hastily collecting the notes to transfer the patient despite recurrent seizures being present. Despite a protected airway, this did not prevent the patient from developing possible complications of seizures such as recurrence of a cardiorespiratory arrest, intracerebral haemorrhage etc...

The junior doctor was advised that a patient must be stable prior to being moved and when eventually moved, they should be accompanied by doctors and nurses who can perform CPR and they should have the correct resuscitation equipment with them in the case that the patient was to have a further cardiorespiratory arrest en route.

Sometimes, the eagerness to clear a bed space and move the patient from an emergency department to reduce nursing work can actually place the patient in a dangerous predicament.

One must always remember that the patient comes first.

The ultimate responsibility lies with the doctor overseeing the patient's care and it is the duty of the doctor to ensure that the patient is stable before moving them.

In this case, the junior doctor gave an infusion of midazolam which terminated the recurrent generalised seizures providing a hiatus of stability thereby allowing the patient to be moved safely.

This case demonstrates the importance of stabilising patients and although each situation is different, the general principle applies.

There are sometimes exceptions to the rule such as the patients with severe haemorrhage who require immediate surgery and patients in an unstable environment e.g. war zone.

However, patients with upper GI bleeding who require an emergency gastroscopy who are haemodynamically unstable should not be moved and such patients should have this examination with gastroscope done in the emergency room.

As a doctor, you are responsible for the patient and other staff rely on you to make a plan of action. It is your responsibility to ensure that the patients can be stabilised and if you need help then ask your senior to come.

Never be pressurised to move an unstable patient when you know it is the wrong thing to do.

Sometimes standing your ground and reasoning the point with staff who do not fully appreciate the problem can save your patient from complications.

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