Ruptured AAA:

 

Pre-op issues:

Assessment

Diagnosis:

·      Unstable: abdo ultrasound

·      Stable: CT AAA

Volume status:

·      End-of-bed: GCS, WOB, colour, warmth

·      Vital signs: RR, HR, BP

·      VBG: Hb, lactate

Prioritisation

Timing of surgery:

·      Uncontained rupture: surgical control before resus

·      Contained rupture: resus before surgical control

Blood pressure control:

·      Uncontained rupture: avoid sympatholysis to prevent death

·      Contained rupture: ensure sympatholysis to prevent pop

Induction risks:

·      Risk of CVS collapse > risk of aspiration

·      Mitigate with mRSI (1.2mg/kg rocuronium + apnoea)

 

Intra-op issues:

Induction collapse

Problems:

·      Cardiac depressant

·      Sympatholytic

·      Relaxant -> release of tamponade

·      IPPV -> impedance to venous return

Solution:

·      CSL 1L

·      Ketamine 10-50mg until dissociated

·      Suxamethonium 1.5mg/kg when dissociated

·      Adrenaline 10mcg/mL

·      Sevoflurane 0.5% + N2O 50%

Bleeding to death

Problems:

·      Uncontrolled bleeding

·      Lots of jobs

Solution:

·      Cross-clamp ASAP

·      Someone for anaesthetic

·      Someone for access

·      Someone for transfusion

 

Plan:

Access

·      Large PIVC x 2

·      Pump set + rapid fluid warmer

Monitoring

·      Standard

Blood

·      O negative

·      Cross-matched

·      Cell saver

Drugs

·      CSL 1L

·      Ketamine 10-50mg until dissociated

·      Suxamethonium 1.5mg/kg when dissociated

·      Adrenaline 10mcg/mL

·      Sevoflurane 0.5% + N2O 50%

 

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