Update

DTOR
Domoyong 40/M
Asa 4e (hypovolemic shock) – systemic dse constant threat to life
MC 2
Hypovolemic Shock Grade 3 sec to Penetrating stab wound R upper quadrant with 1) Grade 3 Liver Injury segment 4A through and through, 2) Grade 3 Diaphragmatic Injury, 3) Suprarenal Inferior Vena Cava Injury
s/p Exploratory Laparotomy, Hepatorrhaphy, Phrenorrhaphy, Lateral Venorrhaphy; Perihepatic Packing; JP drain
under GETA
60 kg

2 hrs post-injury
Rcvd px Awake, intoxicated, GCS 14 (e4v4m6), (+) pallor, sce cbs, (+) ctt in situ (400cc initially drained), soft abd, fp

INDUCTION: GETA-RSI
Preox
Sellick’s done on cricoid
Midazolam 2mg IV (0.1-0.3 mg/kg) – onset 2 mins – GABA-A receptor/chloride channel hyperpolarization
Ketamine 50mg IV (0.5-2 mg/kg) – onset 30-60 sec – NDMA receptor antagonist
Pretx with Atrac (10% of ED95 (0.25 mg/kg))
Succinylcholine 90mg IV (1.0-1.5mg/kg)
VL done, CL grade 1
ETT 8.0

Pre-induction goals:
- Avoid hypothermia
- Establish IV access and monitoring
- Secure blood, establish MTP (if ever)

Induction goals:
- Volume resuscitation
- Maintain adeq vascular access
- Immed secure airway

Intraop:
- Maintain MAP >60mm Hg (70 baseline)
- Baseline labs
- Initial management of hemodynamic instability
- Treat hemorrhagic shock

baseline 90/60, 95, 20, 100%

intraop 100-130/60-80, 90-120, 100%
fluids: 500cc voluven, 2L gelofusine,
PLR 4L
inotropes: on 0.12 mcg/kg/hr Norepi
BL 5L
s/p BT 2 U pRBC, ongoing 3nd BT
ABG correction started with 60 meqs Sodium bicarb

90/60, 102, VR, 100%

Calcium gluc 1 g IV given Norepi at 0.18 mcg/kg/min
UO: 5cc/kg/hr
Delayed extubation GCS 8 (e2vtm5)
On Mech vent w/ ff setup
Px Currently at PACU AC mode, FiO2 100%, BUR 18, PEEP 5
CPOT 0 (+) pallor, sce cbs, soft abd, fp, (+) CTT in situ
with 6 U FFP, 6 U PC, 5 U pRBC, 1 U WB

Plan:
1) Rpt ABG at PACU
2) Rpt CBC APC 6 hrs post BT
3) Rpt S.Na, K, Mg, Crea, Ca
4) Transfuse available blood products

Post-op Meds:
1) Tramadol + Paracetamol Drip (Tramadol 100mg + Paracetamol 900mg + 92cc PNSS) to run for 8H via
soluset x 3 days
2) Tramadol 25mg slow IVTT Q4H as PRN for BTP (max of 4 doses in 24 hours)
3) Omeprazole 40mg IVTT OD while on NPO
4) Tranexamic 500mg IV Q8H x 4doses
5) Midazolam 1-2mg IV Q15 mins as PRN for restlessness

Thank you