1. Know When To Intubate It may sound strange, but we should have an approach as to when it’s appropriate to intubate. My choice is when there is failure of ( whether this is now or imminent) of oxygenation and ventilation, maintenance of airway or airway protection.
The typical case is a patient presents with trauma to the wrist and wrist pain. You do an x-ray. What do you think? This is a Scapholunate dissociation, also called rotatory subluxation of the scaphoid and sometimes knows as the Terry Thomas sign. It is a disruption of the scapholunate ligament with resultant instability. The cause is usually trauma and the complication is degenerative arthritis of the joint. The x-ray of the wrist will demonstrate a widened scapholunate space, usually greater than 4mm. This is best seen on a clenched fist view. Image from www.radiopaedia.com The scapholunate ligament is U shaped and divided into three compartments. A complete fear of the dorsal part, results in dissociation.
CASE A 70 year old man, is brought to the Emergency Department by ambulance. He was drinking a coffee with friends and developed sudden severe chest pain. His past medical history is coronary artery disease and hypertension. He became hypotensive in the ambulance and was in some distress. He has had a bolus of fluid and has now stabilised with a blood pressure of 115/72. The ambulance report no clinical findings. He has been awake and alert, but as he arrives in the department he finds he cannot speak. He has an expressive aphasia.