Airway |
Problems: · Airway: soiled, swollen, shared, remote · Stomach: full of emetogenic blood Assessment of threat: · Hx: prev difficult intubation? · Ex: work of breathing, stridor, drooling? Plan: · Two suckers · Two assistants · Direct laryngoscopy · South RAE ETT · Secure +++ · Decompress stomach with orogastric tube prior to emergence |
Circulation |
Problems: · Blood loss · Dehydration (poor appetite) Assessment of volume status: · Hx: how much bleeding, oral intake, wet nappies · Ex: behaviour + vital signs + CRT · Ix: FBE, VBG, coags, G&H vs XM Plan: · 2 x IVC + pump set · Forced air warmer · 20mL/kg crystalloid pre-induction · Tranexamic acid 15mg/kg · NIBP q2mins |
Induction |
Problems: · Rock: risk of aspiration -> want big dose · Hard place: risk of cardiovascular toxicity -> want little dose · Even worse: intolerance of awake IVC Considerations: · Airway: expect difficulty otherwise? · CVS: quantity and rate of blood loss? Preferred plan: · Discussion + rapport · Amethocaine topicalization · Consider pre-med: midazolam 0.5mg/kg · Awake IVC 22g · Crystalloid 20mL/kg pre-induction if time · Metaraminol 50mcg/kg/h throughout · Propofol 3mg/kg · Rocuronium 1.2mg/kg |
Timing |
· If active and fast bleeding: surgery then resuscitation · If inactive or slow bleeding: resuscitation then surgery |
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