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%

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  Large PIVC x 2

o  A-line

o  Pump sets

o  Rapid fluid warmer

o  Cell saver

 

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