Tough Case

[camkiss]

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Had a rought call yesterday. Worst case of the day:
10am- incoming ruptures AAA from OSH. No other details
1045: pt rolls in intubated BP on transport machine says 117/60. Last BP measured was 30 min ago!!! Pt diaphoretic. Hook up to our monitors...BP 86/40...76/30...pushing phenylephrine...68/28...tell surgeons to quick prep and cut. Work on a-line no palpable radial pulse (of course) try blind unsuccessful. Ultimately get one in brachial artery. Other resident gets in two IJ cordis. Fluid and blood started through rapid infuser. BP coming up to MAP 50s. Drapes...incision. Happen to be looking over drapes as surgeon opens peritoneum...gush of about 1 liter blood spills out. He thrusts his hand onto the aorta to "clamp". Hang more blood and crank up infuser. Pt somehow remains "stable". Cell saver started. Surgeon uses hand for clamp for 30 minutes as fellow dissects. Over the course of the next six hours we give tons of calcium, bicarb, and phenylephrine with decent blood gases with exception large base defecits. The patient ultimately receives 28 liters of fluid and blood products through the rapid infuser. At one point I had the cell saver pumping as fast as it could cycle while watching the reservoir fill and fill and fill. Finally transport patient to ICU. Hb in OR upon leaving is 8. Hb one hour later in ICU is 5. Hb an hour after that is 1.2. Pt expires at 2000 hrs. 6 hours of fighting to keep him alive and he still dies.

Rest for three hours, then up all the rest of the night with ortho trauma.

camkiss

 

[VolatileAgent]

you win some, you lose some. but, no matter how you may have felt about that situation afterwards, dude, just remeber that you are a stud. you gave that guy a fighting chance. you can't always fix a problem that's been brewing for forty years in a few hours. think about all you did for that patient. that should give you solace. you rock, man.

 

[Gimlet]

Had a rought call yesterday. Worst case of the day:
10am- incoming ruptures AAA from OSH. No other details
1045: pt rolls in intubated BP on transport machine says 117/60. Last BP measured was 30 min ago!!! Pt diaphoretic. Hook up to our monitors...BP 86/40...76/30...pushing phenylephrine...68/28...tell surgeons to quick prep and cut. Work on a-line no palpable radial pulse (of course) try blind unsuccessful. Ultimately get one in brachial artery. Other resident gets in two IJ cordis. Fluid and blood started through rapid infuser. BP coming up to MAP 50s. Drapes...incision. Happen to be looking over drapes as surgeon opens peritoneum...gush of about 1 liter blood spills out. He thrusts his hand onto the aorta to "clamp". Hang more blood and crank up infuser. Pt somehow remains "stable". Cell saver started. Surgeon uses hand for clamp for 30 minutes as fellow dissects. Over the course of the next six hours we give tons of calcium, bicarb, and phenylephrine with decent blood gases with exception large base defecits. The patient ultimately receives 28 liters of fluid and blood products through the rapid infuser. At one point I had the cell saver pumping as fast as it could cycle while watching the reservoir fill and fill and fill. Finally transport patient to ICU. Hb in OR upon leaving is 8. Hb one hour later in ICU is 5. Hb an hour after that is 1.2. Pt expires at 2000 hrs. 6 hours of fighting to keep him alive and he still dies.

Rest for three hours, then up all the rest of the night with ortho trauma.

camkiss

We just learned about hemorrhagic shock in physiology...this sounds like he lost enough blood to enter the irreversible stage of shock where no matter what interventions are taken or how much you are able to temporarily stabilize him, he will still die. Is that what happened here?

 

[jetproppilot]

Had a rought call yesterday. Worst case of the day:
10am- incoming ruptures AAA from OSH. No other details
1045: pt rolls in intubated BP on transport machine says 117/60. Last BP measured was 30 min ago!!! Pt diaphoretic. Hook up to our monitors...BP 86/40...76/30...pushing phenylephrine...68/28...tell surgeons to quick prep and cut. Work on a-line no palpable radial pulse (of course) try blind unsuccessful. Ultimately get one in brachial artery. Other resident gets in two IJ cordis. Fluid and blood started through rapid infuser. BP coming up to MAP 50s. Drapes...incision. Happen to be looking over drapes as surgeon opens peritoneum...gush of about 1 liter blood spills out. He thrusts his hand onto the aorta to "clamp". Hang more blood and crank up infuser. Pt somehow remains "stable". Cell saver started. Surgeon uses hand for clamp for 30 minutes as fellow dissects. Over the course of the next six hours we give tons of calcium, bicarb, and phenylephrine with decent blood gases with exception large base defecits. The patient ultimately receives 28 liters of fluid and blood products through the rapid infuser. At one point I had the cell saver pumping as fast as it could cycle while watching the reservoir fill and fill and fill. Finally transport patient to ICU. Hb in OR upon leaving is 8. Hb one hour later in ICU is 5. Hb an hour after that is 1.2. Pt expires at 2000 hrs. 6 hours of fighting to keep him alive and he still dies.

Rest for three hours, then up all the rest of the night with ortho trauma.

camkiss

Nice job, bro.

You did your job.

And the patient wouldda probably died anyway, but mortality in this critical patient is directly linked to surgeon prowess. And dissecting for thirty minutes while another surgeon clamps the aorta shut with his hand is as good as a tombstone. 👎