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)

 

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%

     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

 

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