Case 4: An Elderly Lady with a Fractured Neck of the Femur
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An 83-year-old lady (70 kg, 5’5” tall) is admitted to the emergency room after a fall in her nursing home. She has a fractured neck of the femur, but otherwise no trauma. In addition, she has many medical problems, including coronary artery disease, hypertension, and chronic obstructive lung disease. On examination she is cooperative, orientated for time and place. She has mild to moderate bilateral ankle and sacral edema, HR 100 atrial fibrillation, and BP 170/100. The EKG shows an old MI with left axis deviation. Room oxygen saturation is 91%. Her chest is clear except for crepitations at the bases and increased respiratory wheeze. She is orientated for time and place and requests a spinal anesthetic as she is worried about going to sleep. You are happy to oblige and explain that she must either sit up or lie on her side for you to do the spinal. She absolutely refuses to sit up or lie on her side claiming this will be very painful. She has received 10 mg of morphine in the emergency room. You attempt to sit her up but she complains of severe pain. You give her midazolam 0.5 mg and fentanyl 50 micrograms slowly. A little later she says she is feeling better. However, her oxygen saturation has now fallen to 87 % on room air. Supplemental oxygen improves to 93%. When you attempt to sit her up again, she refuses point blank. You consider giving her a small dose usage of ketamine so that you can place the spinal in a lateral position. However, ketamine can produce unacceptable increase in BP, and the prior use of atropine to prevent excessive salivation can produce an unwanted increase in heart rate.
KeywordsFractured neck of the femur Spinal anesthesia Ketamine Morphine Femoral nerve block
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