#Case_14 Acute Abdomen and collapsed after induction.

[nimbus]

News Flash. EVERYONE is smaller than Americans. Except maybe Mexico. You can always tell when you board a plane headed here from Europe or wherever that “Yup, this plane is definitely heading to America” because of the size of the people.
I connect in Europe each time I go to the motherland.

Mexicans in Mexico are smaller too, especially the indigenous Mexicans.

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[Radetzky]

You need to tell your surgeons that he’s only going to get sicker if they wait to operate- they haven’t fixed the underlying problem!

The hemodynamic profile of wide PP warm sepsis only occurs after fluid resuscitation. The unresuscitated pt is indistinguishable from cardiogenic shock.

 

[shepardsun]

Hypnotics are incredibly overrated in the patient in extremis. I always tell my residents that if a patient comes up to me and complains of awareness during a previous massive trauma or periarrest intubation or shock induction, I provide them my address for them to send me a Christmas card for saving their life and not killing them on induction. Obviously a little facetious, but only slightly.

 

[chessknt]

Thanks for the advice Dr. Planktonmd; pneumothorax was not suspected because of peak airway pressure, regardless of the no breathing sounds. So, let us say say to rule out pneumothorax; what shall we do "a decompression of the chest wall by inserting cannula at 2nd intercostal space, right?"; this would be disaster if it happened and not to mention the surgery team was requesting for the relative to come inside the OR room to see their guy alive; I was very curious as he asked twice. I would imagine if we punctured his chest and Inadvertently lead to pneumothorax? Honesty, I am glad to his Peak pressure wasn't elevated and ruled out pneumothorax and if even bronchospasm was treated. The lesson is that PPV would decrease both preload and afterload and to increase cardiac out in healthy individual, and this guy had an empty heart (the one thing I did which was unusual as I love it, I stopped the Peep respecting the physiology I have).

He was old guy, skinny and unknown goiter. We don't know his hypovolemia was for how long? We can't rule out his goiter and to be honest if this guy if he had SBO, I would go aggressively with fluids; it is not the first time to deal with DU acute abdomen, but not in the setting of sepsis to be honest, all were young with stable BP or upper border, not an old guy with 240/130 like on presentation and got a goiter; I am still blaming myself for that and thinking about how wild and tricky the presentation could be.

Thanks Dr. Planktonmd for your insight again.

To fix a tension pneumo you finger/blunt dissect down to the ribs as fast as possible and feel inside the chest, then put a tube in. Any other method has a failure rate which is unacceptable in a life threatening reversible situation. If you're waiting for equipment you can stab a 14g iv anteriorly but even if you're wrong you need to commit to putting a tube in if this is something you'd be going to act on.

 

[chessknt]

Hypnotics are incredibly overrated in the patient in extremis. I always tell my residents that if a patient comes up to me and complains of awareness during a previous massive trauma or periarrest intubation or shock induction, I provide them my address for them to send me a Christmas card for saving their life and not killing them on induction. Obviously a little facetious, but only slightly.

Completely agree someone on the verge of death has different goals than a healthy outpatient.

 

[pro-propofol]

Possibly abdominal compartment syndrome.
Without the negative pressure of spontaneous ventilation venous return drops precipitously.
Stat laparotomy decreases abdominal pressure resulting in amazing recovery.
Seen it happen once.

 

[Arch Guillotti]

To fix a tension pneumo you finger/blunt dissect down to the ribs as fast as possible and feel inside the chest, then put a tube in. Any other method has a failure rate which is unacceptable in a life threatening reversible situation. If you're waiting for equipment you can stab a 14g iv anteriorly but even if you're wrong you need to commit to putting a tube in if this is something you'd be going to act on.

Disagree. Stick a needle in there. Takes 2 seconds. A true tension pneumo will loudly audibly release immediately.

 

[chocomorsel]

Disagree. Stick a needle in there. Takes 2 seconds. A true tension pneumo will loudly audibly release immediately.

Had a few of these during Covid. Tube after tube. Didn’t use needless though. Just fast chest tubes. Totally cool to see them recover from the verge of death. Until they try the next round that is.

 

[Twiggidy]

Hypnotics are incredibly overrated in the patient in extremis. I always tell my residents that if a patient comes up to me and complains of awareness during a previous massive trauma or periarrest intubation or shock induction, I provide them my address for them to send me a Christmas card for saving their life and not killing them on induction. Obviously a little facetious, but only slightly.

Agree.

I believe I gave this same input on the last case posted. When a patient is this sick and needs an induction, there's no need for ketamine AND propofol. It's too much.

 

[chessknt]

What if they're big? What if you put a needle in and don't hear air? How can you know where you are?

 

[coffeebythelake]

What if they're big? What if you put a needle in and don't hear air? How can you know where you are?

how big we talking about here? u just need to reach from skin to pleural space, at the 2nd midclavicular line. that shouldn't be that much thickness there even for some morbidly obese dude.