Home > Anaesthesia, Critical Care > Term 4 Week 6 (w/c 8/10/12)

Term 4 Week 6 (w/c 8/10/12)

Thanks to everyone who contributed to last weeks discussion. We hope that you learnt something about pre-hospital anaesthesia. This weeks case moves back into the hospital environment.

You have been called to see a 55 year old surgical inpatient who has collapsed in the toilet.

As you go to the ward to see the patient what are your intial thoughts?

When you arrive on the ward you find the patient on the floor outside the toilet.

He looks pale and sweaty, is tachycardic HR 120 and BP 90/40. The nursing staff tell you that he was admitted 4 hours ago with generalised abdominal pain. He pulled the emergency buzzer in the toilet and as they got to him he collapsed. He has never stopped breathing or lost a palpable pulse. His past medical history includes an MI 4 years ago following which he underwent CABG. He is hypertensive and smokes 40 cigarettes a day.

What are your thoughts now? What are you going to do next?

Thanks for the comments so far. Most people yesterday wanted to do an ABCDE assessment with regards to working out a potential cause for his collapse.

Your assessment reveals a patent airway, a respiratory rate of 25, SpO2 96% on 15L with a few basal crackles. HR 130 irregularly irregular BP is now 80/40 CRT 4s. His abdomen is distended and generally tender. He responds to pain. He has a mottled appearance in both legs.

What are you going to do now?

There have been several ideas as to the next plan of action. Which of these listed in the poll would you do or do you have another idea?

The surgeons would like a CT but the patient deteriorates further with further abdominal distension and hypotension BP 70/30 so agree with that he should go to theatre.

What is your anaesthetic plan?

You induce anaesthesia and he becomes profoundly hypotensive. The surgical team discover a ruptured AAA and some ischaemic looking small bowel. They quickly clamp the aorta. His BP is currently 60/20 HR 153

What do you do now? What is your plan for intra-operative fluid management?

There are no trick questions in #gasclass. It is an educational tool only. Everyone’s opinion is as valid as the next person. Follow the conversation by using (or searching for) the hashtag #gasclass on twitter. We welcome input from all specialties and you can send us a direct message if you would prefer to remain anonymous.

@gasclass

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Categories: Anaesthesia, Critical Care
  1. Janet Evans
    October 8, 2012 at 8:25 pm

    Low blood pressure post op.

  2. SuBo
    October 8, 2012 at 8:45 pm

    You might think initially its was a PTE, but it could equally be anaphylaxis to the diclofenac that was mistakenly given for post op pain ( It was 10 years since his last allergic reaction and the FY1 thought it would be OK) or that crab curry that was on the menu tonight.

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