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 collapse

· Contained rupture: ensure sympatholysis to prevent pop

Induction risks:

· Risk of CVS collapse > risk of aspiration

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

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%

· Surgeons prepped, patient scrubbed

Bleeding to death

· If uncontained: uncontrolled bleeding

o Cross clamp first

o Resuscitation second

· If contained: risk of complete rupture

o Preserve transmural pressure (SBP <120)

o Laryngoscopy: opioid, topicalization

o Incision: more opioid

· Anticipation:

o Access

o Warming

o Products