Another Case

[Noyac]

I just can't get into the current topics on this forum but thats b/c I have a job. For those of you awaiting your residency position, good luck.

Here is a case I did the other night. 57 y.o. male on the floor was being watched by gen.surg. after he broke some ribs and had splenic lac. He was 2 days out and was doing fine when all of a sudden he drops his pressure. I get a call from the surgeon stating that he needs to go to the OR pronto. I go to the floor to help with transport ( had a feeling I may be needed) with a stick of neo. When I see him, he is in steep T-berg and has a pressure of 70/30 - 50/20, diaphoretic and dry heaving. His normal BP is 130/80. So b/w dry heaves I get some H&P from him which I couldn't get from the chart due to the urgency. His belly is tight and distended. He tells me that he has pulm HTN and ankylosing spondylitis. I ask how bad is his PHTN (can he exercise, need O2, and meds) and he says that the Dr. that found it stated that it was about as high as he has seen in someone walking around without O2. I don't really know how to take that info but, Oh well. He says he is on norvasc for it and something else that he can't remember the name of. We run down to the OR and get started.

How would you do this case?

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[militarymd]

The dude is bleeding to death. I would ignore the pulmonary hypertension for right now. I would worry about what his neck looks like with his ankylosing spondylitis....ie..is it going to be hard to tube the guy.

I would assume he is NPO??? if they are watching his splenic lac? I took an anesthesiologist who had a splenic lac (from a motorbike crash) that bled during his observation period when I was a fellow.

 

[jetproppilot]

The dude is bleeding to death. I would ignore the pulmonary hypertension for right now. I would worry about what his neck looks like with his ankylosing spondylitis....ie..is it going to be hard to tube the guy.

I would assume he is NPO??? if they are watching his splenic lac? I took an anesthesiologist who had a splenic lac (from a motorbike crash) that bled during his observation period when I was a fellow.

Yep- I concur. All rules are outta the window with someone who is about to die. Most likely you can intubate him....but if you have difficulty, of course you'd try all our tricks...bougie, fast-track lma, etc etc....cant spend alotta time with a fiberoptic...if its all ready for you, you could try it...but if all else fails, do whatever you have to...break teeth, whatever... I'd rather have a dude with broken teeth who is alive than a dead dude with perfect teeth in a casket.

One of our ENT surgeons marketed a cylindrical, about 3" long, metal, die cast trach setup that attaches to your keyring that you can unscrew, assemble, stick the crichothryroid membrane, and ventilate with a ambu bag or circuit. I'd even consider getting mine dirty for this dude.

This is a true "WE'RE LOSING HIM!!!" scene right outta ER.

This is where having more than one anesthesia provider is helpful...while you're working on the tube, your CRNA/AA/MD/whatever colleague is getting a 14" peripheral, or two, calling for O- blood if the guy isnt crossmatched, and grabbing the Unit-1 if you've got it.

Bottom line though is 9 times outta 10 you wheel him into the OR, put on your monitors, pick your martini of choice....I'd go with etomidate 10 mg, maybe add a little more, sux 100 mg, tube (if unsuccessful resort to above), then nondepolarizer, some fentanyl if he'll tolerate it, consider scopolamine .2mg if unable to sustain adequate volatile agent level secondary to hemodynamic instability, pour in blood, advise blood bank to stay 4 ahead, make sure FFP/platelets are being worked on as well, add more amnestics/analgetics as able, 1 g ca++ after the fourth/eighth/12th units, keep him warm and peeing, start an A line if you get comfortable enough and have some time since serial (q30-60 minutes) H&H will keep your blood administration more scientific, and if you get real comfortable, ABG so you can appropriately treat the (probable) acidosis (secondary to initial hypoperfusion) if necessary, coags, fibrinogen level, platelet count, watch for dilutional thrombocytopenia.

 

[jetproppilot]

Yep- I concur. All rules are outta the window with someone who is about to die. Most likely you can intubate him....but if you have difficulty, of course you'd try all our tricks...bougie, fast-track lma, etc etc....cant spend alotta time with a fiberoptic...if its all ready for you, you could try it...but if all else fails, do whatever you have to...break teeth, whatever... I'd rather have a dude with broken teeth who is alive than a dead dude with perfect teeth in a casket.

One of our ENT surgeons marketed a cylindrical, about 3" long, metal, die cast trach setup that attaches to your keyring that you can unscrew, assemble, stick the crichothryroid membrane, and ventilate with a ambu bag or circuit. I'd even consider getting mine dirty for this dude.

This is a true "WE'RE LOSING HIM!!!" scene right outta ER.

This is where having more than one anesthesia provider is helpful...while you're working on the tube, your CRNA/AA/MD/whatever colleague is getting a 14" peripheral, or two, calling for O- blood if the guy isnt crossmatched, and grabbing the Unit-1 if you've got it.

Bottom line though is 9 times outta 10 you wheel him into the OR, put on your monitors, pick your martini of choice....I'd go with etomidate 10 mg, maybe add a little more, sux 100 mg, tube (if unsuccessful resort to above), then nondepolarizer, some fentanyl if he'll tolerate it, consider scopolamine .2mg if unable to sustain adequate volatile agent level secondary to hemodynamic instability, pour in blood, advise blood bank to stay 4 ahead, make sure FFP/platelets are being worked on as well, add more amnestics/analgetics as able, 1 g ca++ after the fourth/eighth/12th units, keep him warm and peeing, start an A line if you get comfortable enough and have some time since serial (q30-60 minutes) H&H will keep your blood administration more scientific, and if you get real comfortable, ABG so you can appropriately treat the (probable) acidosis (secondary to initial hypoperfusion) if necessary, coags, fibrinogen level, platelet count, watch for dilutional thrombocytopenia.

AND dilutional hypofibrinogenemia (cryo best, ffp second best).

 

[Noyac]

I didn't expect anything different from you 2. Mostly trying to change the current thread topics. I'll bet you scared off a few as well but no worries.

PS: He just ate not long b/4 the spleen finally ruptured since he was being watched on the floor for 2 days.

You are right, he is bleeding to death. Would anybody do anything different. These are the easiest cases sometimes, IMHO.

 

[jetproppilot]

I didn't expect anything different from you 2. Mostly trying to change the current thread topics. I'll bet you scared off a few as well but no worries.

PS: He just ate not long b/4 the spleen finally ruptured since he was being watched on the floor for 2 days.

You are right, he is bleeding to death. Would anybody do anything different. These are the easiest cases sometimes, IMHO.

THINK, NOY, THINK!!! MIL AND I ARE JUST AS BORED AS YOU WITH.....

1) what color pants to the repeat interview, blue or navy blue?

2)The Chair from University of Guadalajara called me, coughed twice, and had mexican music playing in the background. What does this mean?

3) One of the residents at U of Columbia seemed cocky....should I just smile, or pull out my glock and put a cap in his a ss?

4)The Vice-Chair at VSU is currently on American Idol...what does that say about their didactics?

5) I interviewed at 57 programs. Here they are:
Joes Anesthesia University, Nacho Mama's U in Acapulco, Needa Lobster U in Maine, Skoals R Us U in Florida, Putta Raft In Your House University in New Orleans, Hotchiks With Snotrockets U in Snowmass CO, CrotchrokkitAsian U in Gruntsville Alabama, etc etc.
HOW DO I RANK THEM???

ok sorry matching dudes but i'm very bored with reading about matching...sorry...thanks noy for the case...

 

[jetproppilot]

I didn't expect anything different from you 2. Mostly trying to change the current thread topics. I'll bet you scared off a few as well but no worries.

PS: He just ate not long b/4 the spleen finally ruptured since he was being watched on the floor for 2 days.

You are right, he is bleeding to death. Would anybody do anything different. These are the easiest cases sometimes, IMHO.

He could be mauling a Whopper on the stretcher-ride to the OR...doesnt matter...try an RSI, if you run into problems, you gotta ventilate him...and superstud-Noyac ventilating will more-often-than-not keep the Whopper in his stomach.

His NPO status is number ninety-five on this dude's list of ninety-six problems.

 

[ThinkFast007]

Yep- I concur. All rules are outta the window with someone who is about to die. Most likely you can intubate him....but if you have difficulty, of course you'd try all our tricks...bougie, fast-track lma, etc etc....cant spend alotta time with a fiberoptic...if its all ready for you, you could try it...but if all else fails, do whatever you have to...break teeth, whatever... I'd rather have a dude with broken teeth who is alive than a dead dude with perfect teeth in a casket.

One of our ENT surgeons marketed a cylindrical, about 3" long, metal, die cast trach setup that attaches to your keyring that you can unscrew, assemble, stick the crichothryroid membrane, and ventilate with a ambu bag or circuit. I'd even consider getting mine dirty for this dude.

This is a true "WE'RE LOSING HIM!!!" scene right outta ER.

This is where having more than one anesthesia provider is helpful...while you're working on the tube, your CRNA/AA/MD/whatever colleague is getting a 14" peripheral, or two, calling for O- blood if the guy isnt crossmatched, and grabbing the Unit-1 if you've got it.

Bottom line though is 9 times outta 10 you wheel him into the OR, put on your monitors, pick your martini of choice....I'd go with etomidate 10 mg, maybe add a little more, sux 100 mg, tube (if unsuccessful resort to above), then nondepolarizer, some fentanyl if he'll tolerate it, consider scopolamine .2mg if unable to sustain adequate volatile agent level secondary to hemodynamic instability, pour in blood, advise blood bank to stay 4 ahead, make sure FFP/platelets are being worked on as well, add more amnestics/analgetics as able, 1 g ca++ after the fourth/eighth/12th units, keep him warm and peeing, start an A line if you get comfortable enough and have some time since serial (q30-60 minutes) H&H will keep your blood administration more scientific, and if you get real comfortable, ABG so you can appropriately treat the (probable) acidosis (secondary to initial hypoperfusion) if necessary, coags, fibrinogen level, platelet count, watch for dilutional thrombocytopenia.

WOW...i cant wait to be able to rattle it off like this

 

[Gimlet]

One of our ENT surgeons marketed a cylindrical, about 3" long, metal, die cast trach setup that attaches to your keyring that you can unscrew, assemble, stick the crichothryroid membrane, and ventilate with a ambu bag or circuit. I'd even consider getting mine dirty for this dude.

Sweet...I will definitely be needing one of those someday, if only to impress people in bars when they ask "what's that" and point at my keyring.

 

[Frank Rizzo]

Thanks for the case. Definitely a nice change from the flame wars that have been going on lately. Only five more months... I'm over the hump as far as my intern year goes. Can't wait for CA-1 in July.

 

[Noyac]

So here's my approach.

Went to the floor as I said with a stick of neo. Brought him to the OR and moved to the table. He needed about 500mcg of neo to get to the OR. I had the surgeons prep him as I was placing monitors (like a stat C/S). I gave him 200mcg neo, etomidate 14 mg, sux 120mg. Mac 4 (my favorite) and 8.5 OETT no problem.

Just tired of the recent threads so there you go.

Ankylosing Spondylitis was real but as Jet mentioned WHO CARES, he's dying. Sorry I didn't have a better case for you guys.

By the way extubated at the end of the case after 4 units PRBC's, 2.5L crystal and he did great.

 

[Noyac]

So here's my approach.

Went to the floor as I said with a stick of neo. Brought him to the OR and moved to the table. He needed about 500mcg of neo to get to the OR. I had the surgeons prep him as I was placing monitors (like a stat C/S). I gave him 200mcg neo, etomidate 14 mg, sux 120mg. Mac 4 (my favorite) and 8.5 OETT no problem.

Just tired of the recent threads so there you go.

Ankylosing Spondylitis was real but as Jet mentioned WHO CARES, he's dying. Sorry I didn't have a better case for you guys.

By the way extubated at the end of the case after 4 units PRBC's, 2.5L crystal and he did great. Better to be lucky than good.

 

[jetproppilot]

Sorry I didn't have a better case for you guys.

No, bro. Nice case. Thanks.

 

[Idiopathic]

THINK, NOY, THINK!!! MIL AND I ARE JUST AS BORED AS YOU WITH.....

1) what color pants to the repeat interview, blue or navy blue?

2)The Chair from University of Guadalajara called me, coughed twice, and had mexican music playing in the background. What does this mean?

3) One of the residents at U of Columbia seemed cocky....should I just smile, or pull out my glock and put a cap in his a ss?

4)The Vice-Chair at VSU is currently on American Idol...what does that say about their didactics?

5) I interviewed at 57 programs. Here they are:
Joes Anesthesia University, Nacho Mama's U in Acapulco, Needa Lobster U in Maine, Skoals R Us U in Florida, Putta Raft In Your House University in New Orleans, Hotchiks With Snotrockets U in Snowmass CO, CrotchrokkitAsian U in Gruntsville Alabama, etc etc.
HOW DO I RANK THEM???

ok sorry matching dudes but i'm very bored with reading about matching...sorry...thanks noy for the case...

oh, never mind.

 

[SilverStreak]

I know this is an old thread, but I have a couple of questions after reading it.

1. I thought T berg was considered to be bad practice now days, that it can cause worsening hypotension because of the effect on the barorecptors. Don't get me wrong, I know in this guys case you do what you have to do and he wasn't going to the OR stat to get fixed up. But, in a scenario outside of this, I've been told we don't use T berg anymore to elevate the legs above the heart for increased venous return.

2. why the calcium after the blood products?

 

[Noyac]

I know this is an old thread, but I have a couple of questions after reading it.

1. I thought T berg was considered to be bad practice now days, that it can cause worsening hypotension because of the effect on the barorecptors. Don't get me wrong, I know in this guys case you do what you have to do and he wasn't going to the OR stat to get fixed up. But, in a scenario outside of this, I've been told we don't use T berg anymore to elevate the legs above the heart for increased venous return.

2. why the calcium after the blood products?

I can understand the T-berg question but I have not heard that it had fallen out of favor. I would doubt it as well b/c you do see it improve hemodynamics when used. I used it from time to time in the heart room when I didn't want to pharmacologically treat BP cause it was due to what the surgeon was doing at the time (pushing on the heart) and as soon as he was done it would resolve. You get the idea?

Ca++ is to replace the chelated Ca++ that occurs from the citrate in the PRBC's.

 

[SilverStreak]

I can understand the T-berg question but I have not heard that it had fallen out of favor. I would doubt it as well b/c you do see it improve hemodynamics when used. I used it from time to time in the heart room when I didn't want to pharmacologically treat BP cause it was due to what the surgeon was doing at the time (pushing on the heart) and as soon as he was done it would resolve. You get the idea?

Ca++ is to replace the chelated Ca++ that occurs from the citrate in the PRBC's.

You see improvement in hemodynamics to a point, then it can work against you, or so I've been told. I know it works, I've seen it myself, but I've been told now days that it's not the best option. Short term with the hearts, I would see it benefit more because in a couple of minutes, the cause of your problem is gonna be resolved anyhow.

I know calcium binds to citrate, but I didn't realize PRBCs had citrate.

 

[Idiopathic]

You see improvement in hemodynamics to a point, then it can work against you, or so I've been told. I know it works, I've seen it myself, but I've been told now days that it's not the best option. Short term with the hearts, I would see it benefit more because in a couple of minutes, the cause of your problem is gonna be resolved anyhow.

I know calcium binds to citrate, but I didn't realize PRBCs had citrate.

The effects of gravity take precedence over the baroreceptor effects initially. Obviously given enough time to compensate, then the effects will diminish.

 

[dogbone65]

You see improvement in hemodynamics to a point, then it can work against you, or so I've been told. I know it works, I've seen it myself, but I've been told now days that it's not the best option. Short term with the hearts, I would see it benefit more because in a couple of minutes, the cause of your problem is gonna be resolved anyhow.

I know calcium binds to citrate, but I didn't realize PRBCs had citrate.

Yep, it keeps the cells from clotting...it's on the bag...check it out. After giving several bags O'cells it can drop you ICa.

 

[cdql]

WOW...i cant wait to be able to rattle it off like this

haha...out of curiousity, is this something that all anesthesiologists pick up over time?

Or is this something that only the better docs are able to do? (e.g. thinking so quickly and clearly under pressure?)

 

[Noyac]

haha...out of curiousity, is this something that all anesthesiologists pick up over time?

Or is this something that only the better docs are able to do? (e.g. thinking so quickly and clearly under pressure?)

Its the sign of someone who knows their Shizzle. Absolutely all of the good ones can think quickly and more importantly clearly under pressure. Jet just happens to have an exceptional talent for expressing himself.