Ruptured AAA: What are the odds... really?

I agree with going straight to the OR, but I wouldn't let him put metal to the skin until I had all my crap ready.

AS you said acouple 14 and some fluids could have made all the difference, I think maybe waiting the 5 min to prep this could have made a difference.

I agree with no cutting until you are set up for replacement

The answer, Cop, is......

The only way this guys gonna live is for a scalpel to hit his belly.

And quick.

He is stable now, but may not be a minute from now. And thats evident by the fact that you said he had a ton of blood in his belly.

I had a somewhat similar, albeit worse case in previous gig. Transfer from Oakdale, Louisiana to our facility. Dude had a suspected leaking AAA so was thrown into an ambulance for the forty minute ride to our OR.

We knew he was coming so we were ready. The paramedics wheeled him from the ambulance right into the OR.

By then his skin was whiter than a Marilyn Manson groupie, he wasnt responding to commands, and was doing the dying-guppy breathing thing.

We threw on all our monitors, gave about 6mg etomidate, scopolamine .2mg, some sux, intubated cdazy fast,, jammed a 9.0 cordis into his IJ, by the grace of God somehow hit the no-pulse radial artery (BP was in the fifties), and watched T Mack the heart surgeon quickly throw some betadine on the guys belly, slice dudester open....ever seen those really fast fish-cleaning dudes run a machete-sized knife through the belly of a tuna?? Kinda like that.....T Mack being the stud that he is quickly gained proximal control which is what really saved the guys life. Cuz if the surgeon can't do that quickly the guy is goin' to the funeral home.

Had to be over 3 liters of blood in the guys belly.

So we do our thing.....which was mostly giving O- blood.

Once everything settled down a bit we did the rest of our thing....drew a buncha labs, sent down some blood for FFP/platelets/etc, started giving some real anesthesia when hemodynamics shaped up a bit, blah blah blah.

The reason I remember this case so well is I went and visited the guy a cuppla days later. He was extubated, doing fine. He eventually left the hospital.

I asked him what he remembered....he remembered some of the bumpy ambulance ride, and that was it. No recall of being removed from the ambulance. No recall of the OR.

All of our procedures were quick. And I'd like to make a judgement statement to the stud residents out there:

This is where you earn your five hundred large, ladies and gentlemen.

After youre out a while, your speed on the procedures we do will hasten. My mom could put in an IJ 9.0 cordis in a holding area with nice lighting, a holding room nurse handing her everything, Linkin Park playing on the background CD player, aromatherapy.....but she'd have a hard time intubating, starting a huge central line and an a-line in less than ten minutes.

But heres the message for the resident studs:

Don't get bogged down if you have trouble with a line. Don't hold up the surgery. Move on to your next task, and if you're totally striking out, tell the surgeon to proceed.

Theres a certain amount of luck in our trade. Luck was on my side with this case. The cordis and a-line went in cdazy fast. BUT, had they not, I would have told T Mack to go ahead and open.

Of course you have to intubate before he opens. But aside from that, take ONE SHOT at your other procedures. If you fail on the first shot, which we all do sometimes, well, you've gotta brave it with the one IV the patient arrived with, and work under the drapes for larger access/a-line while the surgeon opens. Our access, although vital, will not save a patient who is bleeding to death from an AAA rupture. A surgeon"s squeezing hand and subsequent cross clamp proximal to the aortic defect will, or at least may.

Nice case/thread.

Thanks for posting.

If he is hemodynamically stable, there was no reason start the operation emergently. Straight to the room yes, but cutting into the abdomen and removing the tamponade effect that was keeping this guy's pressure up was not a wise choice, without a pair of 14 gauges, a cordis, hell throw in a RIC if you can, along with enough products and personnel to administer the fluids.

You have to make the call as well to argue this point with the surgeon.

.

Not sure if I agree with this... but of course I have no where near the experience you do, Jet.. No FAT LINE in this guy when the belly opened, and THIS GUY DIES. Time should be spared to ensure appropriate access, unless the guy is crumping right there and then. You could get away without an a-line.. but NO NECK LINE??

Something else I've wondered about since med school.. of course, I'm not a surgeon, but why don't they do these things on CPB, if possible? Or how about opening the chest to gain proximal control in the thorax? Or maybe snaking a wire up the groin and inflating a balloon proximal to the aneurysm, as they do in endovascular repairs when something ruptures?

You did the right thing.

However, considering this guy was hanging on, I'd have him on the table. Prepped, draped, and order ASSLOADS OF EMERGENCY PRODUCT. 10 & 10 with platelets too.

Start preloading the guy with something. NS, LR, albumin, plasmalyte, whatever. You know whats comming holmes.

16 or 14g PIV, Left side single lumen cordis hooked up to a BELMONT. 4 units of PRBC and 4 units of FFP in it. Primed. Ready to rock. I hate having to friggen squeeze product because it effectively removes you from doing other more useful things. Right side double lumen cordis hooked up to hotline for other crud. Pressure bags for that stinker.

Once all thats ready and the guy hasn't taken a dip prior, then lets roll baby!

Induction? Fentanyl and scopolomine baby!

Sweet case man. It probably happened at 3 am when all the good ones do right?

Not to hijack, but what is your hospital policy on EMERGENCY PRODUCT.

It should just be type specific or type O- (or + if they got it...delayed transfusion reaction be damned).

DOes your hospital just do the first portion of the X-Match (basically combining your patients blood with some of the donor blood and seeing if it clots) without all the bells and whistles? Or do they just send the stuff up? Or do they bitch and moan?

powermd said:

Not sure if I agree with this... but of course I have no where near the experience you do, Jet.. No FAT LINE in this guy when the belly opened, and THIS GUY DIES. Time should be spared to ensure appropriate access, unless the guy is crumping right there and then. You could get away without an a-line.. but NO NECK LINE??

Something else I've wondered about since med school.. of course, I'm not a surgeon, but why don't they do these things on CPB, if possible? Or how about opening the chest to gain proximal control in the thorax? Or maybe snaking a wire up the groin and inflating a balloon proximal to the aneurysm, as they do in endovascular repairs when something ruptures?

Click to expand...

Yeah, I understand what youre saying.

My point though is I have seen clinicians waste precious time getting bogged down on a procedure....

So I'll say: What if, after (X) amount of time you're still striking out on the central line?

If the dude is crumping, I'm gonna push blood through the 16" or 18" peripheral while trying for more access and let the surgeon open to try and gain proximal control.

powermd said:

Or maybe snaking a wire up the groin and inflating a balloon proximal to the aneurysm, as they do in endovascular repairs when something ruptures?

Click to expand...

Thats a cool idea.

Will have to ask my interventional-rads buddy if that would work.

Maybe you could do that. Again, your gonna blast this dude with contrast for an aortagram when you know he's gonna need to be cut open anyways. Depending on what the stuff is, it could spell post-op disaster. ANyways it sounds like a lot of dickin around time on a dude who is living on borrowed time.

It certainly is an interesting idea and I have no clue if its worth doing. Anyways once that balloon goes up his afterloads gonna go up and his preload is gonna drop = whoops!

ASA 5's baby...

UTSouthwestern said:

If he is hemodynamically stable, there was no reason start the operation emergently. Straight to the room yes, but cutting into the abdomen and removing the tamponade effect that was keeping this guy's pressure up was not a wise choice, without a pair of 14 gauges, a cordis, hell throw in a RIC if you can, along with enough products and personnel to administer the fluids.

Click to expand...

I agree with getting the patient to the OR and on the table stat, but getting some key things in place before cutting. The tamponade effect of all that extravasated blood what was keeping him in a quasi-stable state. Once the surgeon cut, that effect was removed, and the exsanguination ensued.

Time had already been taken to place the RIJ cordis and a-line, and it would have taken a second more to connect the Level 1 transfuser. I would have activated our massive transfusion protocols and got uncrossmatched blood in the room before starting if possible. If the patient began to deteriorate in the meantime, I would have hung fluid and had my hand on the level one, ready to open it wide, before telling the surgeon to cut.

about 50% die before they reach the hospital.

out of the 50% who reach the hospital, another 50% die.

i'm not sure any surgeon has great outcomes with ruptured AAAs. sounds like you did everything you could.

VentdependenT said:

You did the right thing.

However, considering this guy was hanging on, I'd have him on the table. Prepped, draped, and order ASSLOADS OF EMERGENCY PRODUCT. 10 & 10 with platelets too.

Start preloading the guy with something. NS, LR, albumin, plasmalyte, whatever. You know whats comming holmes.

16 or 14g PIV, Left side single lumen cordis hooked up to a BELMONT. 4 units of PRBC and 4 units of FFP in it. Primed. Ready to rock. I hate having to friggen squeeze product because it effectively removes you from doing other more useful things. Right side double lumen cordis hooked up to hotline for other crud. Pressure bags for that stinker.

Once all thats ready and the guy hasn't taken a dip prior, then lets roll baby!

Induction? Fentanyl and scopolomine baby!

Sweet case man. It probably happened at 3 am when all the good ones do right?

Click to expand...

Agree on the belmot being the one thing I would have had ready. Having that firepower (500cc/min) could have made a difference in that patient.

powermd said:

Not sure if I agree with this... but of course I have no where near the experience you do, Jet.. No FAT LINE in this guy when the belly opened, and THIS GUY DIES. Time should be spared to ensure appropriate access, unless the guy is crumping right there and then. You could get away without an a-line.. but NO NECK LINE??

Click to expand...

Read Cop's narrative, Power.

They had all that stuff in place and the guy died anyway.

Ya gotta open the belly with or without lines.

This guy had lines, and he died.

I think the absolutely most important part of this whole equation is a deft surgeon.

Without that all the other stuff doesnt matter.

But I maintain to not waste precious time if you experience technical trouble.

Proximal control with a x-clamp in cdazy fast fashion is what'll save this guy.

coprolalia said:

Actually, I'm not familiar with the "Belmont".

http://www.belmontinstrument.com/fms2000/features.htm

We used a "Level 1".

I would assume they are similar. There is a head-to-head comparison in this article:

http://emergency-medicine.jwatch.org/cgi/content/citation/2003/1217/6

But, I can't get to it from home.

-copro

Click to expand...

You know that scene in Predator where Jessie the Body is friggen hosing down the forest with that kick a$$ gatling gun?

The Belmont is equivalent to that gatling gun. I even pat the damn thing like you'd pat a kids head after liver cases.

Its a huge bucket that you just dump blood into. You adjust the rate on it with a touch of a button. Bolus 200ml at the touch of a button. I've gone much HIGHER than 500ml/min. I don't remember how high you can go, but think its over 750cc. The thing starts rattling the IV pole its attached to. Its hard core. It removes the air bubbles atomatically.

Its our saving grace for liver transplants.

VentdependenT said:

You know that scene in Predator where Jessie the Body is friggen hosing down the forest with that kick a$$ gatling gun?

The thing starts rattling the IV pole its attached to. Its hard core. It removes the air bubbles atomatically.

Its our saving grace for liver transplants.

Click to expand...

Do you have to kick start it?

coprolalia said:

Well, this is what was (essentially) quoted to me at the time this happened. Do you happen to know where it comes from and/or have a source?

Click to expand...

hm, i've heard those numbers since med school...let me check.

VentdependenT said:

You know that scene in Predator where Jessie the Body is friggen hosing down the forest with that kick a$$ gatling gun?

The Belmont is equivalent to that gatling gun. I even pat the damn thing like you'd pat a kids head after liver cases.

Its a huge bucket that you just dump blood into. You adjust the rate on it with a touch of a button. Bolus 200ml at the touch of a button. I've gone much HIGHER than 500ml/min. I don't remember how high you can go, but think its over 750cc. The thing starts rattling the IV pole its attached to. Its hard core. It removes the air bubbles atomatically.

Its our saving grace for liver transplants.

Click to expand...

You guys still use the Belmont?

Dude that's the flintlock to the Stoner's that are the RSAS and RIS (Rapid Solution Administration Set, Rapid Infusion Set).

The RSAS can deliver fluids of any kind up to 2.2 LITERS PER MINUTE while the RIS can go up to 1.5 LPM.

Best of all these two devices can be preloaded with any product you wish in their massive reservoirs and the fluid will be heated and delivered at 37.5 deg Celsius.

These devices are the Vulcan machine guns to the Belmont's old west Gatling gun.

I have used the RSAS preloaded with 12 units of RBC's and 12 unites of FFP for a police officer Careflighted to a downtown Dallas hospital with a GSW to the abdominal aorta that had 3 liters of blood in his abdomen and came into the OR with a BP of 40. Sucker pumped it all in in 5 minutes and that dude ended up taking in 84 units of PRBC's , 34 FFP's, and assorted platelets and cryo, but he lived and left the hospital two months later.

The RSAS and RIS have massive reservoirs and you can load the products almost instantaneously through their huge reservoir filling lines and active suction that can draw in the units quickly and they have six to eight loading ports so you don't have to hang one, wait for it to empty then hang another.

Vulcan baby, VULCAN:

Vulcan baby, VULCAN:
[/QUOTE]

GEEZ NORM!!! PUT THAT FRIKKIN THING AWAY!!!!

BTW, I'll go out on a limb and say that hemodynamically stable dude in Cop's post wouldnt've died with a better surgeon.

Proximal control as soon as belly is open and dude lives. Specially since all lines were in, etc.

The game was over before it started, Cop.

jetproppilot said:

BTW, I'll go out on a limb and say that hemodynamically stable dude in Cop's post wouldnt've died with a better surgeon.

Click to expand...

i will respectfully disagree.

• Filipovic M. Seagroatt V. Goldacre MJ. Differences between women and men in surgical treatment and case fatality rates for ruptured aortic abdominal aneurysm in England. British Journal of Surgery. 94(9):1096-9, 2007 Sep. ​
  • The crude case fatality rates after surgery in the present study, of 48% in men and 52% in women.​

• Dillavou ED. Muluk SC. Makaroun MS. A decade of change in abdominal aortic aneurysm repair in the United States: Have we improved outcomes equally between men and women?. Journal of Vascular Surgery. 43(2):230-8; discussion 238, 2006 Feb.
  • Mortality for rupture repairs has remained largely unchanged over the past decade.​

• Thomas PR, Stewart RD. Abdominal aortic aneurysm. Br J Surg. Aug 1988;75(8):733-6.
  • As many as 2 of 3 patients with ruptured AAA die before arriving at the hospital.

• Holt PJ. Poloniecki JD. Gerrard D. Loftus IM. Thompson MM. Meta-analysis and systematic review of the relationship between volume and outcome in abdominal aortic aneurysm surgery. British Journal of Surgery. 94(4):395-403, 2007 Apr.
  • The perioperative mortality rate of ruptured aneurysm repair is between 40-65%.​

• J Vasc Surg. Operative mortality rates for intact and ruptured abdominal aortic aneurysms in Michigan: an eleven-year statewide experience. 1994 May;19(5):804-15; discussion 816-7.
  • Mortality rates for surgical repair of ruptured AAA averaged 49.8% and did not improve significantly over the 11 years studied.

• Ann Surg. 1996 May;223(5):492-502; discussion 503-5. A statewide, population-based time-series analysis of the outcome of ruptured abdominal aortic aneurysm. Rutledge R, Oller DW, Meyer AA, Johnson GJ Jr.
  • The mortality rate for ruptured AAA was 54%.
  • Ruptured abdominal aortic aneurysm remains a highly lethal lesion, even in the best of hands.

is there a reason that you didn't go to sleep after he was prepped and draped?

UTSouthwestern said:

You guys still use the Belmont?

Dude that's the flintlock to the Stoner's that are the RSAS and RIS (Rapid Solution Administration Set, Rapid Infusion Set).

The RSAS can deliver fluids of any kind up to 2.2 LITERS PER MINUTE while the RIS can go up to 1.5 LPM.

Best of all these two devices can be preloaded with any product you wish in their massive reservoirs and the fluid will be heated and delivered at 37.5 deg Celsius.

These devices are the Vulcan machine guns to the Belmont's old west Gatling gun.

I have used the RSAS preloaded with 12 units of RBC's and 12 unites of FFP for a police officer Careflighted to a downtown Dallas hospital with a GSW to the abdominal aorta that had 3 liters of blood in his abdomen and came into the OR with a BP of 40. Sucker pumped it all in in 5 minutes and that dude ended up taking in 84 units of PRBC's , 34 FFP's, and assorted platelets and cryo, but he lived and left the hospital two months later.

The RSAS and RIS have massive reservoirs and you can load the products almost instantaneously through their huge reservoir filling lines and active suction that can draw in the units quickly and they have six to eight loading ports so you don't have to hang one, wait for it to empty then hang another.

Click to expand...

I want to get my hands on one of them there things. Until then, ye old Belmont will have to suffice.

jetproppilot said:

Do you have to kick start it?

Click to expand...

NO, but I buy it a beer after pushin 60L of pink sludge and keeping the patient alive.

The surgeon's skill is the most important factor here no question about it.
There are guys out there who can clamp the aorta blindly in seconds after skin incision, these are the surgeons who can save this guy's life.
On the other hand, no matter how prepared you are, if proximal control is not done fast enough the guy is going to die.
Nothing can compensate for a freely bleeding aorta.

yeah, i wasn't criticizing you. just wondering. that's how we do it.

Planktonmd said:

The surgeon's skill is the most important factor here no question about it.
There are guys out there who can clamp the aorta blindly in seconds after skin incision, these are the surgeons who can save this guy's life.

Click to expand...

OKAY!!! OKAY!!! OKAY!!!!

what was the Joe Peschi movie where he kept saying "okay! okay! okay!"

Read Plank's response.

Over and over.

Truly, we cant compensate for a surgeon dude who aint got THE FORCE.

No matter what we do.

Thats something I'm gonna hammer into you resident studs.....that all our efforts, skill and desire on a case like this don't mean s hit without a deft surgeon.

In other words, you can deliver the absolute best anesthetic care possible.....but if the surgical component is not present wielding the force, you're wasting your time.

Our outcomes, and the study outcomes depicted in an above post, are totally dependent on the surgeon's skill.

How does a study control for surgical skill? Uhhhhhhh,,,, both you guys and I know....after a few cases with surgeon dude.....whether he yields THE FORCE or not.

I've yet to see an outcome study that has separated the deft surgeons from the dudes that shouldda went into psychiatry.

So take those outcome studies concerning an emergent surgery like ruptured AAA repair with a grain of salt.

So like I said before Cop, you are beating yourself up for things that were beyond your control.

John Tinker couldnt've helped saved this dude

jetproppilot said:

OKAY!!! OKAY!!! OKAY!!!!

what was the Joe Peschi movie where he kept saying "okay! okay! okay!"

Read Plank's response.

Over and over.

Truly, we cant compensate for a surgeon dude who aint got THE FORCE.

No matter what we do.

So like I said before Cop, you are beating yourself up for things that were beyond your control.

John Tinker couldnt've helped saved this dude

Click to expand...

It was one of the lethal weapons.

coprolalia said:

The thing we should've done is had more blood in the room and/or not futzed around waiting to get a crossmatch, also put a better rapid infusion access line (or two) in before cutting the belly, and perhaps even "pre-infused" a unit or two.

-copro

Click to expand...

And one more time for emphasis, Dude,

you are dead wrong here.

You didnt have a deft surgeon.

So blood wouldnt've mattered. A better rapid infusion access line wouldnt've mattered.

Pre-infusion wouldnt've mattered.

The only thing that could've saved this dude would've been Jesus Christ showing up in the OR.

jetproppilot said:

And one more time for emphasis, Dude,

you are dead wrong here.

You didnt have a deft surgeon.

So blood wouldnt've mattered. A better rapid infusion access line wouldnt've mattered.

Pre-infusion wouldnt've mattered.

The only thing that could've saved this dude would've been Jesus Christ showing up in the OR.

Click to expand...

We were gonna get Jesus on staff at Rush but he gave up on medicine. He now runs a club in Ibiza.

coprolalia said:

Again, thanks man. I guess it just sucks when someone dies on your watch, no matter who's fault it actually was or whether or not it was just his time. Especially true when you're the primary (resident). I'm just glad I had help. And, a lot of it.

-copro

Click to expand...

Well, It will happen to you again during your career, you can bet on it.
Once a while people do die and there is nothing anyone can do about it.

VentdependenT said:

We were gonna get Jesus on staff at Rush but he gave up on medicine. He now runs a club in Ibiza.

Click to expand...

He probably gave up on medicine after Medicare denied payment for his services.