You are asked to help manage a 6-year-old boy involved in a bicycle accident. He was thrown into and over his handlebars. He was brought to the ER with the following vital signs: HR 140, BP 70/40, RR 28, SpO2 92% on 100%. How will you assess and manage this patient?
Potentially life-threatening situation, risk of intra-abdominal injury and occult injuries of trauma. Follow ATLS approach (ABC’s and AMPLE).
Initial considerations of hypotension (DDx hypovolemia, Tension PT, Hemothorax, etc), paediatric pt (coop, altered physio/pharm etc), trauma (blood loss, abd injury, thoracic injury, c-spine).
Mx: appropriately begin resuscitation (2 Lrg bore IV’s, fluid bolus 20cc/kg), specifically address assessment of abdomen (mechanism of injury: handlebars into belly). C-spine precautions required. Should address possible thoracic injury as SaO2 is low.
The patient has bruises to his Lt upper quadrant. There was no loss on consciousness, no obvious chest trauma, and no obvious orthopedic injury. PMHx reveals homozygotic sickle cell anemia with previous admission for acute chest syndrome requiring transfusion. Otherwise, he is healthy with no allergies or medication. Physical exam is unremarkable aside from abdominal tenderness/guarding. A FAST scan demonstrates free fluid in the Lt subphrenic space. His HgB is 80 and platelets of 160. His cross-match reveals antibodies causing a difficult cross-match and remains pending. Following a 40cc/kg fluid challenge, his BP and HR are unchanged. The surgeon feels he needs an urgent laparotomy, possible splenectomy. How will you provide anesthesia?
Emergent situation requiring source control of blood loss. Minimal time to optimize, should proceed to OR despite challenge to optimize. Recognize need for type-specific blood resuscitation and possible massive transfusion protocol (failure to give blood critical lapse). Must also minimize risk of sickling (hypoxia, anemia, cold, acidosis, euvolemia & pain control). Induction should be timely (ie-recognize goal directed fluid management will likely fail) and should address hemodynamics, c-spine and full stomach.
Following the induction in the described manner, the surgeon proceeds with the laparotomy. During the procedure, tea coloured urine is noted in the foley bag with increasing patient temperature. What is your differential diagnosis and how would you manage?
DDx: Acute hemolytic transfusion reaction, Rhabdomyolysis from compartment syndrome, Malignant hyperthermia, Renal/bladder injury from the trauma, Vaso-occlusive crisis causing kidney injury.
Mx: Stop the transfusion, Inform the blood bank – difficult cross match – need blood ASAP, 100% O2 – optimize PaO2 to minimize sickling, Recheck ABO status, Confirm patient identity and identity of the blood, Maintain urine output, Alkalinize the urine, Check electrolytes, calcium, coagulation profile, Supportive care, Check urine for hemoglobin as opposed to myoglobin