A case for the residents

[TheLoneWolf]

Wanted to share a case from when I was a CA-3. Good learning points I will share later.

Working all day over a weekend, major tertiary center. CA-1 who is still quite new and you are the only anesthesia service over the weekend. Attending went home after the last case ends. Place does everything except peds, OB. It specializes in complex vascular, neuro and cardiac. Starts calming down at midnight. go to get some sleep in call room.

Called an hour later from nurse saying they have an 82 year old male with CAD, Afib, CHF, DMII and ruptured AAA coming in from another facility. You run to setup the room, call the attending who is 30 minutes out, send your CA-1 to try to get some history and consent once they arrive to the ED.

Hang pressors, look quickly in computer for any info, almost nothing, no labs. Turn around to see OR doors open, your CA-1 is wheeling in the patient. Rupture is so severe and abdomen so tense, more protuberant than a large pregnant lady at term. On NRB, 15 L/min, agonal breathing, RR 40, very poor chest excursion secondary to protuberant abdomen. Accessory muscle use and tracheal tugging. Sats mid 80s to low 90s. HR 70s from beta blockade meds, monitor shows A fib, BP is 50/30 despite large fluid bolus and pressors. Altered and minimally responsive but does open eyes. Has a 20 gauge in each arm from ED, hanging low dose dopamine.

your junior resident somehow got talked into rushing the patient into the OR, likely by the vascular surgery team, without an anaesthesia attending in house for emergency surgery. Patient is so unstable, he could likely code just moving him from the gurney to the OR bed. Sending him by elevator back to the ED until the attending can arrive, very likely to code before getting to or in the elevator with no cart or backup. Vascular wants to start endovascular repair and stenting immediately. Patient is incontinent and covered the gourney and his legs, pelvis in stool and urine. OR nurse refuses to move him to the OR bed without first cleaning him up.

What would you do?
What lines would you start?
Which infusions would you begin?
Send back to ED or attempt resuscitation in OR?
Do you start the case or wait for your attending? What are the liabilities or waiting or proceeding?

Lets give the residents a try at this before the big boys/ and girls give their inputs.

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[norski]

I'll bite.

Ketamine (or etomidate/alfentanil) delayed sequence induction, atropine, try to pull his sats(and bp) up, then roc/sux+tube. Low or no PEEP, Brachial or radial art line, IJ if possible,if not, RIC one of the PIVs.

By the time you've gotten this far,patient is already dead or even closer, OR nurse/circulator better have cleaned him up as well as possible, somehow transfer him to the table, and let the surgeons do their thing, continue with sevo/fent boluses and pray. Lots of O-neg at the ready, obviously.

US liability isn't a concept I'm overly familiar with, but seeing as this is a chronically ill 82 year old, sometimes maybe live and let die is the more ethically sound way of thinking? In this case,might not be anesthesia's call.

Even if your attending's not around yet, is it conceivable that your anesthetics and not the patient's preexisting and acute condition will kill him? S***show either way I look at it.

So,what did you do, and how did the case go?




(Disclaimer: nurse anesthetist student, Norwegian,not a medical resident. Hope you don't mind)

 

[deleted171991]

Great case. Just a hint for residents: KISS.

 

[anbuitachi]

Call for massive transfusion and Belmont. Vascular needs to be compressing abdomen. Ric one of the 20g IV otherwise Place 14fr rij line as quickly as possible and start dumping in blood. Then art line. The other resident should be supporting w pushing epi and setting up epi infusion and getting ready to tube. Induce w lidocaine and sux or just sux

 

[norski]

Call for massive transfusion and Belmont. Induce w lidocaine and sux or just sux

Good point!

 

[dchz]

Ca-3 here.

What would you do?
Try to keep the procedure somewhat sterile then let them start. Encourage endo vascular control first.
His AAA is ruptured but now it's tamponaded (somewhat). I would verbally verify with vascular so we are on the same page.
This is an emergency, call for all hands on deck. Encourage close-loop communication. Delegate 1 person on Belmont, most experienced person for lines, 1 nurse to get all the drugs you would need (bicarb, epi, calcium).

What lines would you start?
The emphasis here is to do whatever necessary to let vascular start first. Anes can work around them. If this guy is hanging on by a thread, knowing his BP with an a line doesn't do you any good. If it's truly as emergent as you say, i'd start with long 14G cathether in the IJ for blood transfusions. Then A line while waiting for the MAC setup.
Goals: 3x 14g, 1 MAC cath. 1 A line.

Which infusions would you begin?
Blood: we don't need increase in SVR in this case. That's not the problem, even if you titrate the pressor to the BP you want, the amount of blood getting to the organs is too small unless you give the blood for cardiac output first. The name of the game is bleeding control. If i was to start a pressor, i wouldn't titrate it to a map higher than 60. The more you squeeze, the more he bleeds.

Send back to ED or attempt resuscitation in OR?
LOL I can't believe this is a serious question. You keep the patient in the damn OR.

Do you start the case or wait for your attending? What are the liabilities or waiting or proceeding?
Start the Fing case, is this a joke?

 

[getdown]

I'm just flabbergasted that the attending goes home on the weekends. I mean, your hospital sounds like a level 1 trauma center, how do you not have an attending in house with a brand new CA-1.

 

[anbuitachi]

Ca-3 here.

What would you do?
Try to keep the procedure somewhat sterile then let them start. Encourage endo vascular control first.
His AAA is ruptured but now it's tamponaded (somewhat). I would verbally verify with vascular so we are on the same page.
This is an emergency, call for all hands on deck. Encourage close-loop communication. Delegate 1 person on Belmont, most experienced person for lines, 1 nurse to get all the drugs you would need (bicarb, epi, calcium).

What lines would you start?
The emphasis here is to do whatever necessary to let vascular start first. Anes can work around them. If this guy is hanging on by a thread, knowing his BP with an a line doesn't do you any good. If it's truly as emergent as you say, i'd start with long 14G cathether in the IJ for blood transfusions. Then A line while waiting for the MAC setup.
Goals: 3x 14g, 1 MAC cath. 1 A line.

Which infusions would you begin?
Blood: we don't need increase in SVR in this case. That's not the problem, even if you titrate the pressor to the BP you want, the amount of blood getting to the organs is too small unless you give the blood for cardiac output first. The name of the game is bleeding control. If i was to start a pressor, i wouldn't titrate it to a map higher than 60. The more you squeeze, the more he bleeds.

Send back to ED or attempt resuscitation in OR?
LOL I can't believe this is a serious question. You keep the patient in the damn OR.

Do you start the case or wait for your attending? What are the liabilities or waiting or proceeding?
Start the Fing case, is this a joke?

Wow we must be a vastly different culture. A nurse to get you drugs??? By nurse do you mean Crna ? I assumed there only one is ca1 other than ca3. If you mean circulating nurse, they get drugs for you? If I asked them that here they'd laugh at me. Even if they did go try to find drugs by the time they find them the patient will be dead

Also if gonna put long 14 in ij I'd just put a central line. I'm not going to care about full sterility at this point. Just clean and stick. It can be replaced once he's more stable.

 

[Planktonmd]

There is nothing wrong with getting the patient to the OR, starting resuscitation and getting everything ready while the attending is on the way.
Since the plan is endovascular repair then induction of anesthesia can wait until everything is ready and your attending is in the room. If they are so anxious to start they can start under local.
If the plan on the other hand is to open the abdomen and clamp the aorta as a life saving procedure then you have no choice, you give minimal anesthesia and SUX then put the tube in with the surgeon standing there scalpel in hand.
Good IV access should be your only focus until you get help.

 

[Noyac]

This is a good case for scopolamine. Otherwise, don’t give anything but fentanyl and sux. Then pray that he complains about the myalgias (Sorry, but I had to say it).

I’ll chime in with more after others have had a chance. This is trauma 101.

 

[dchz]

Wow we must be a vastly different culture. A nurse to get you drugs??? By nurse do you mean Crna ? I assumed there only one is ca1 other than ca3. If you mean circulating nurse, they get drugs for you? If I asked them that here they'd laugh at me. Even if they did go try to find drugs by the time they find them the patient will be dead

Also if gonna put long 14 in ij I'd just put a central line. I'm not going to care about full sterility at this point. Just clean and stick. It can be replaced once he's more stable.

Yep. circulating nurse will get me non controlled meds like calcium, bicarb, and epi if needed. there i usually 2-3 in a case like this with us at my institution. Get this, if it's the right (80% of them) anes tech, they will start loading the belmont for me too!! (i must be spoiled).

Sounds like OP didn't have a central line ready. Also, i pref long 14 over double or triple lumens. I 100% will not have a MAC catheter ready to go at the scenario described.

I don't care about full sterility either, but if they want to clean the feces off his groin before they stick, i think that's reasonable.

 

[anbuitachi]

Yep. circulating nurse will get me non controlled meds like calcium, bicarb, and epi if needed. there i usually 2-3 in a case like this with us at my institution. Get this, if it's the right (80% of them) anes tech, they will start loading the belmont for me too!! (i must be spoiled).

Sounds like OP didn't have a central line ready. Also, i pref long 14 over double or triple lumens. I 100% will not have a MAC catheter ready to go at the scenario described.

I don't care about full sterility either, but if they want to clean the feces off his groin before they stick, i think that's reasonable.

We have the MAC kits in these ORs so can just open one up and start stabbing.
But that's insane. 2 to 3 nurses? Tech loading Belmont!? What country is this??

Also regarding scopolamine. I've never used it and don't even know where to get IV scopolamine especially in middle of the night

 

[dannyboy1]

Keep it simple. More/better access, tube, resuscitate with blood products/pressers. Art line and CVL when u have the time. More hands in the room the better. The good news is, this case is a freebie, no one will be surprised or blame you if this patient dies on the table ( unless you **** up the airway )

 

[GravelRider]

Send back to ED or attempt resuscitation in OR?
Do you start the case or wait for your attending? What are the liabilities or waiting or proceeding?

Haha. I imagined being a resident and telling the vascular surgeon with a straight face that we have to send this guy back to the ER while we wait for my attending to stroll in (hopefully with a cup of coffee in hand).

Is the death of ASA V even reportable to a malpractice carrier?

 

[Noyac]

Also regarding scopolamine. I've never used it and don't even know where to get IV scopolamine especially in middle of the night

I trained in a Trauma heavy program. We had it stocked in every OR. I admit, it isn’t readily available these days.
If I didn’t have scop then I wou,d just give fent and sux. If he complained later then I consider my care appropriate.

 

[Noyac]

Let me ask a question here. What BP would people aim for at the start of the case?

 

[Gern Blansten]

Keep it simple. More/better access, tube, resuscitate with blood products/pressers. Art line and CVL when u have the time. More hands in the room the better. The good news is, this case is a freebie, no one will be surprised or blame you if this patient dies on the table ( unless you **** up the airway )

As a trainee, there are no freebies. Unfortunately, this is a no win situation for the trainee. They have been set up to fail. There is no scenario where everyone will believe they did the right thing. If you are receiving ruptured AAA's in a large tertiary hospital that has a residency program and your attending anesthesiologist is 30 minutes away at home, your program is multiple standard deviations outside the norm. The patient could die if the resident waits for the attending. The surgeon will be very unhappy if they are told to wait. Proceeding under MAC may be acceptable if it is amenable to an endovascular approach. If the resident induces GETA and the case goes poorly, it could be a game changer for that resident, especially if the reason it goes poorly is related to a challenging intubation or a code following induction (very likely in this patient).
These types of things apparently occurred frequently in the 80's and early 90's. Standard requirements for tertiary hospitals and Level I trauma centers now exist. These are especially important when resident trainees are involved, for the safety of the patients and for the protection of the trainees. No resident should be dealing with that high acuity of patients without an in-house attending immediately available.

It may appear to be a freebie because the patient has a high likelihood of death no matter what happens. However, all actions will be scrutinized tremendously by surgeons, nursing, and anesthesiology colleagues. At least, in a healthy training program, they will be, in my opinion. Hopefully, this scenario, if real, led to a change in practice to in house attending anesthesiologist coverage.

 

[anbuitachi]

Let me ask a question here. What BP would people aim for at the start of the case?

I'd like a bit higher than 50/30

 

[Noyac]

I'd like a bit higher than 50/30

Why?

 

[deleted171991]

Let me ask a question here. What BP would people aim for at the start of the case?

The lowest that maintains some mental status. You don't want to save his life and kill his brain. I would even consider cooling his head.

 

[Noyac]

The lowest that maintains some mental status. You don't want to save his life and fry his brain. I would even consider cooling his head.

That’s better.
Here is my thoughts. He is currently at 50/30. He is opening his eyes to command but his breathing is reported to be agonal. I would think this BP is the basement but it is proving to be somewhat adequate for at least a short period. The only thing that will save this poor guy is a clamp on the aorta. The best chance the surgeons have to get this done quickly is if they can see the anatomy. Therefore, the less blood in the way the better. When they open this belly his BP will be “0”. So what! Get the clamp on and start pumping blood in him. Do chest compressions and see if you can get him back. If they open and somehow the pt maintains some sort of BP count your blessing and get ready to transfuse about 10 units in 5min or less. If you try to get his pressure up before they clamp then it will slow down the process and that will not help.

That’s how I see it anyway.

 

[ethilo]

This might be a good case for REBOA (retrograde endovasc balloon occlusion of the aorta). Surgeon can put it in blind still on the bed or with fluoro if you really want. Good temporizer and you get an A-line transducer at the proximal tip of the balloon. The problem is I don't think it's totally popularized yet amongst trauma centers, though I certainly think it should be. Here's what my plan would be:

As long as things seem "feng shui" in the OR with the patient's own bed just use that but if it's obstructing people from doing their jobs then just move the patient over to the OR table, I don't care how. Nothing slows everything down like extra equipment and loitering people in a room.

1) Betadine splash the whole body with 1 RN including neck and groins for a MAC introducer later. Get another RN to put pads on.
2) My finger on the carotid pulse the whole time while delegating other tasks
3) Tell surgeon to place REBOA ASAP. Tell them to get someone else from surgery on the other groin to put in a femoral introducer.
4) Tell the RN that wants to clean the stool off the bed to go get drugs / crash cart. Remove him/her from the situation to do something useful
5) Start a team on obtaining a Belmont and blood. Massive transfusion protocol, obviously. Delegate people to hang 1:1 and to notify me patient has received 1L
6) Focus the CA-1 on getting access. I'd go for fresh 14g instead of RIC so you can use the existing 20g for pressor instead of losing the line. Place the MAC with ultrasound but no drapes and minimal sterility. I'd emphasize ultrasound as a priority because of all things you want to be sure of is getting this big line in the right place no question.

If patient becomes unresponsive to questions/tapping his forehead, shaking his shoulder THEN put the tube in with +/- sux, otherwise as long as they are still responding in some reasonably meaningful way keep the focus on bleeding/circulation.

 

[dannyboy1]

As a trainee, there are no freebies. Unfortunately, this is a no win situation for the trainee. They have been set up to fail. There is no scenario where everyone will believe they did the right thing. If you are receiving ruptured AAA's in a large tertiary hospital that has a residency program and your attending anesthesiologist is 30 minutes away at home, your program is multiple standard deviations outside the norm. The patient could die if the resident waits for the attending. The surgeon will be very unhappy if they are told to wait. Proceeding under MAC may be acceptable if it is amenable to an endovascular approach. If the resident induces GETA and the case goes poorly, it could be a game changer for that resident, especially if the reason it goes poorly is related to a challenging intubation or a code following induction (very likely in this patient).
These types of things apparently occurred frequently in the 80's and early 90's. Standard requirements for tertiary hospitals and Level I trauma centers now exist. These are especially important when resident trainees are involved, for the safety of the patients and for the protection of the trainees. No resident should be dealing with that high acuity of patients without an in-house attending immediately available.

It may appear to be a freebie because the patient has a high likelihood of death no matter what happens. However, all actions will be scrutinized tremendously by surgeons, nursing, and anesthesiology colleagues. At least, in a healthy training program, they will be, in my opinion. Hopefully, this scenario, if real, led to a change in practice to in house attending anesthesiologist coverage.

Hmm. I have had aorta disasters die on the table both as a resident and as an attending. They were never subject to that much, if any, scrutiny. The deaths were expected.

 

[Arch Guillotti]

The only thing that will save this poor guy is a clamp on the aorta. The best chance the surgeons have to get this done quickly is if they can see the anatomy. Therefore, the less blood in the way the better. When they open this belly his BP will be “0”. So what!

It’s an endovascular case.

 

[T-burglar]

Have the following brought to the room and readied as soon as you hear of the case:

TEE and plain ultrasound
Belmont and first shipment of MTP
Introducers and arterial line kits with some syringes and lab tubes nearby
Underbody bair hugger

Your goal when the patient hits the room is getting the Belmont running through an introducer somewhere , while the vascular team gets the aortic occlusion balloon in place. Try not to induce GA until the aorta is occluded and there is volume running well.

 

[Noyac]

It’s an endovascular case.

What......?

Never mind!

I feel like all the newscasters that jumped to broadcast the Jussie Smollet case.

 

[vector2]

It’s an endovascular case.

Vascular likes to say that but inevitably these guys (with the super tense belly on presentation) end up coming back to the OR a few hrs later for decompression for abd compartment syndrome.

 

[anbuitachi]

Why?

Because the way I read the stem is despite large bolus and pressor his BP is still 50/30. And he's altered and minimally responsive. Im very unimpressed by him opening his eyes. I don't even know if it's him following commands or just opening eyes to pain or something. His brain is poorly perfused and will continue to do so for at least 10 minutes. So I think he needs continued pressure support. Also he is super depleted and hypotensive yet his hr is 70. I'd give some epi to knock it up. Obviously the problem is blood loss so it's just a very temporary thing.

This might be a good case for REBOA (retrograde endovasc balloon occlusion of the aorta). Surgeon can put it in blind still on the bed or with fluoro if you really want. Good temporizer and you get an A-line transducer at the proximal tip of the balloon. The problem is I don't think it's totally popularized yet amongst trauma centers, though I certainly think it should be. Here's what my plan would be:

As long as things seem "feng shui" in the OR with the patient's own bed just use that but if it's obstructing people from doing their jobs then just move the patient over to the OR table, I don't care how. Nothing slows everything down like extra equipment and loitering people in a room.

1) Betadine splash the whole body with 1 RN including neck and groins for a MAC introducer later. Get another RN to put pads on.
2) My finger on the carotid pulse the whole time while delegating other tasks
3) Tell surgeon to place REBOA ASAP. Tell them to get someone else from surgery on the other groin to put in a femoral introducer.
4) Tell the RN that wants to clean the stool off the bed to go get drugs / crash cart. Remove him/her from the situation to do something useful
5) Start a team on obtaining a Belmont and blood. Massive transfusion protocol, obviously. Delegate people to hang 1:1 and to notify me patient has received 1L
6) Focus the CA-1 on getting access. I'd go for fresh 14g instead of RIC so you can use the existing 20g for pressor instead of losing the line. Place the MAC with ultrasound but no drapes and minimal sterility. I'd emphasize ultrasound as a priority because of all things you want to be sure of is getting this big line in the right place no question.

If patient becomes unresponsive to questions/tapping his forehead, shaking his shoulder THEN put the tube in with +/- sux, otherwise as long as they are still responding in some reasonably meaningful way keep the focus on bleeding/circulation.

Agree with delayed tube if possible to focus on other stuff. I mentioned Ric because he has 2 20g iv . If can get a 7 or 8.5 fr ric that would be a huge plus and can immediately start belmonting as soon as blood arrives. Any time saved helps!

Another thing that would be clarifying is what is the staff number? A number of people above said have ppl (usually rn) get XYZ. That would never happen here and we are a major tertiary academic center. There's 1 circulating nurse for the room who's usually pretty slow. Usually at 3am or middle of the night the staff is very short. If it was during the day we'd have many anesthesiologists available to provide help /getting stuff

The impression that I have of the place is they probably don't have that many nurses to help. I mean even the attending goes home. They may have to call in a nurse from home

 

[dchz]

Let me ask a question here. What BP would people aim for at the start of the case?

50/30 sounds good to me...

The lowest that maintains some mental status. You don't want to save his life and kill his brain. I would even consider cooling his head.

The first part is a copout . You have to give a number.

"How are you going to cool his head? With your cold life-less stare??"

-@psai
Probably

 

[Planktonmd]

A good surgeon should know when and how to open the abdomen and clamp the damn aorta! Unfortunately many of the new vascular surgeons today are not quick or good enough to save a patient's life in this old fashion way. And these guys should by all means do everything endovascular.

 

[anbuitachi]

50/30 sounds good to me...



The first part is a copout . You have to give a number.

"How are you going to cool his head? With your cold life-less stare??"

-@psai
Probably

Why not lower? Would you even cycle the cuff anymore with this patient?

Lets say the stem didn't tell you the bp and asked what numbers you want for Bp. What would you say?

 

[pgg]

It surprises me that there's actually a place that has anesthesia residents taking call in-house call without an attending also in-house. Hard to believe risk management office is OK with that.

At my hospital, residents aren't permitted to start cases without an attending. This rule is an explicit written policy; technically attendings aren't even allowed to tell a resident to go ahead and induce a patient without being physically present. I don't agree with this rule all but there it is. About 10 or 12 years back we had some OB disaster crash from triage into an OR in the middle of the night, and for some reason the attending couldn't be found or reached. The obstetrician was doing the usual babybabybabybabybabybabybabybabygonnadie thing and after some minutes of waiting with no attending in sight or answering pages or the phone, eventually the resident just induced and intubated the patient. The case went fine. The resident was almost fired. As a resident myself at the time, I thought the whole thing was ridiculous.

Here, today, if this patient rolled into the OR and for some reason the attending anesthesiologist couldn't be found, the resident would be expected to
- get better access, probably an u/s guided IJ introducer of some sort
- get and give blood, fluids, pressors
And honestly that's really all the patient needs from us at this point. That's doubly true if the surgeon is going to attempt something endovascular. Induction drugs plus opening the belly is a death sentence prior to these two things being in place. If the patient coded the resident could go down the ACLS pathway and intubate the patient.

 

[shepardsun]

Never used a RIC before, not sure we have them at my institution. But they sound pretty great- use existing access to get an infusion catheter without going through the set up/execution (minimal or compressed as it may be in a true emergency like this) of a neck or fem line.

 

[anbuitachi]

It surprises me that there's actually a place that has anesthesia residents taking call in-house call without an attending also in-house. Hard to believe risk management office is OK with that.

At my hospital, residents aren't permitted to start cases without an attending. This rule is an explicit written policy; technically attendings aren't even allowed to tell a resident to go ahead and induce a patient without being physically present. I don't agree with this rule all but there it is. About 10 or 12 years back we had some OB disaster crash from triage into an OR in the middle of the night, and for some reason the attending couldn't be found or reached. The obstetrician was doing the usual babybabybabybabybabybabybabybabygonnadie thing and after some minutes of waiting with no attending in sight or answering pages or the phone, eventually the resident just induced and intubated the patient. The case went fine. The resident was almost fired. As a resident myself at the time, I thought the whole thing was ridiculous.

Here, today, if this patient rolled into the OR and for some reason the attending anesthesiologist couldn't be found, the resident would be expected to
- get better access, probably an u/s guided IJ introducer of some sort
- get and give blood, fluids, pressors
And honestly that's really all the patient needs from us at this point. That's doubly true if the surgeon is going to attempt something endovascular. Induction drugs plus opening the belly is a death sentence prior to these two things being in place. If the patient coded the resident could go down the ACLS pathway and intubate the patient.

They'd rather have a dead baby?

 

[Noyac]

A good surgeon should know when and how to open the abdomen and clamp the damn aorta! Unfortunately many of the new vascular surgeons today are not quick or good enough to save a patient's life in this old fashion way. And these guys should by all means do everything endovascular.

Agreed. This guy is dead if they try to do this endovascularly. But then again he is probably dead either way. I agree that the only way to approach this bad of a scenario is a slash and dive. Get control of the bleeding ASAP.

 

[Noyac]

Lets say the stem didn't tell you the bp and asked what numbers you want for Bp. What would you say?

Whatever allows for the best visualization. Probably gonna shoot for a systolic of 70 and go down from there.

 

[Arch Guillotti]

Vascular likes to say that but inevitably these guys (with the super tense belly on presentation) end up coming back to the OR a few hrs later for decompression for abd compartment syndrome.

That may be the case but there are vascular surgeons out there who will not do an open emergency case.

 

[Iso4ane]

Not to be an angel of death or anything, but this 82yo guy is/was just a hair away of having about as peaceful of a death as one could wish for. Morbidity for this guy is so damn high.

 

[Planktonmd]

That may be the case but there are vascular surgeons out there who will not do an open emergency case.

Isn't that scary???

 

[anbuitachi]

Whatever allows for the best visualization. Probably gonna shoot for a systolic of 70 and go down from there.

What about adenosine lol

 

[deleted171991]

What about adenosine lol

You can do something like that, or NTG, if you have a life-threatening bleed and the surgeon cannot find the source. It takes some serious diapers though.

 

[anbuitachi]

You can do something like that, or NTG, if you have a life-threatening bleed and the surgeon cannot find the source. It takes some serious diapers though.

yea it'd be pretty cool. pushing adenosine in a case like this. i dont know if id want to push NTG, i think id rather push adenosine haha

 

[nimbus]

yea it'd be pretty cool. pushing adenosine in a case like this. i dont know if id want to push NTG, i think id rather push adenosine haha

I’d be afraid they wouldn’t come back from either.

 

[Hork Bajir]

I’ve heard of ppl doing the adenosine thing and it working for a life-threatening bleed from a ruptured intracranial aneurysm... the stuff of legend. The obvious downside, in a dude with CHF and CAD who is starting at a low BP, is that you’re gonna fall below the critical coronary perfusion pressure (below which myocardial contractility will drop exponentially)- need to get back up above the CCPP in order to pop out of that hole, otherwise homeboy is gonna find himself in PEA arrest six seconds later when the adenosine wears off...

 

[abolt18]

I think the good ideas have pretty much been established above. Some of my thoughts I had:

Everyone keeps saying clamp the aorta, but as mentioned they can go endovascular under local and inflate a balloon proximal to the rupture (see REBOA). If this is a big vascular place there's no way these surgeons aren't capable of this. Might only be temporary, but it can hold you over while giving you time to get some blood in him while waiting for the attending. Seems like a much smoother way to occlude the aorta than opening that belly!

RIC one of the 20s and set up a Belmont first while waiting for the attending. Activate MTP. Proceed to neck line if time allows (ultrasound yes, drapes no). Art line when time allows.

This is the kind of patient that a lot of my attendings would just give Ativan + roc for the induction and call it good until we've resuscitated him reasonably well, then turn on some gas.

On the other hand. If I was this 82 year old male I would wish for no such intervention.

 

[anbuitachi]

if this guy coded before blood is up there.. might as well just call it. would there be any point doing cpr without blood

 

[GravelRider]

Does this case meet the definition of futile care? I don’t know the answer to that, but it’s worth thinking about.

This case illustrates the importance for people to have ongoing advanced directives discussed with their primary care physician on a yearly basis. Unfortunately, that fantasy of mine will never be a reality. This 82 year old is going to die. The only variable is the amount of resources we waste on him. Maybe this guy survives the OR, but he likely will not survive the long ICU stay that awaits him.

The academic discussion is fun, though.

 

[deleted171991]

Does this case meet the definition of futile care? I don’t know the answer to that, but it’s worth thinking about.

Does that matter, in the land obsessed with death panels and doing "everything" for the patient?

 

[Modanq]

This might be a good case for REBOA (retrograde endovasc balloon occlusion of the aorta). Surgeon can put it in blind still on the bed or with fluoro if you really want. Good temporizer and you get an A-line transducer at the proximal tip of the balloon. The problem is I don't think it's totally popularized yet amongst trauma centers, though I certainly think it should be. Here's what my plan would be:

As long as things seem "feng shui" in the OR with the patient's own bed just use that but if it's obstructing people from doing their jobs then just move the patient over to the OR table, I don't care how. Nothing slows everything down like extra equipment and loitering people in a room.

1) Betadine splash the whole body with 1 RN including neck and groins for a MAC introducer later. Get another RN to put pads on.
2) My finger on the carotid pulse the whole time while delegating other tasks
3) Tell surgeon to place REBOA ASAP. Tell them to get someone else from surgery on the other groin to put in a femoral introducer.
4) Tell the RN that wants to clean the stool off the bed to go get drugs / crash cart. Remove him/her from the situation to do something useful
5) Start a team on obtaining a Belmont and blood. Massive transfusion protocol, obviously. Delegate people to hang 1:1 and to notify me patient has received 1L
6) Focus the CA-1 on getting access. I'd go for fresh 14g instead of RIC so you can use the existing 20g for pressor instead of losing the line. Place the MAC with ultrasound but no drapes and minimal sterility. I'd emphasize ultrasound as a priority because of all things you want to be sure of is getting this big line in the right place no question.

If patient becomes unresponsive to questions/tapping his forehead, shaking his shoulder THEN put the tube in with +/- sux, otherwise as long as they are still responding in some reasonably meaningful way keep the focus on bleeding/circulation.

Agree. As an anesthesiologist intensivist I have placed 3 REBOAs in the past 12 months. GI bleed, vascular blow out in the unit, and gsw in the bay. Must learn skill. TBH we have equally fast vascular access skills and in dire situations ie REBOA both groins should be stuck simultaneously. One by surgery one by anesthesiology.

Agree with reboa for infrarenal aaa rupture zone 1 deployment. We should also keep it in our back pocket for ob hemorrhaging.

 

[Lecithin5]

Whiff of versed and 100mg roc for your rsi, and get better access for mtp (CA3 can just quickly go for a r ij MAC cordis while CA1 resident follows orders from the ca3 until attending arrives- ie give pressors or blood thru current iv access until cvc is placed; work on aline, etc). I think senior residents are justified in inducing and starting the case in a life-threatening situation. This patient is about to die (and likely will anyway despite best efforts). We used to induce patients in the ICU for codes all the time with no attending present, and I know that a lot of programs do this.

These cases always get your juices flowing, but you gotta be calm and stick with basics.