Vascular: Ruptured AAA
Emergency repair of a ruptured abdominal aortic aneurysm. Manage cross-clamp physiology and massive transfusion protocols.
"A 74 y.o. male presents to the ED with sudden onset of excruciating back pain and syncope. BP is 80/40. History of HTN and 50 pack-year smoking. You are called to the OR for immediate surgical repair of a suspected ruptured AAA..."
Cross-clamp hemodynamics, renal protection, and massive transfusion logic.
High-yield for technical management of major vascular emergencies.
How a Board-Certified Consultant answers this scenario.
A ruptured AAA is a surgical and anesthetic emergency requiring immediate control. My primary goal is 'permissive hypotension' (MAP ~55-65 mmHg) until the proximal cross-clamp is applied to avoid worsening the rupture.
I will secure large-bore IV access (14G or Cordis) and have the Level-1 Rapid Infuser ready with uncrossmatched O-negative blood. Induction will be a controlled Rapid Sequence Induction (RSI), likely with etomidate and succinylcholine, only when the surgeon is scrubbed and the patient is prepped and draped to allow for immediate incision if hypotension worsens upon loss of sympathetic tone. I will manage the metabolic fallout of the cross-clamp release (hyperkalemia, acidosis) with bicarbonate, calcium, and hyperventilation, and I will strictly monitor renal function throughout the recovery phase.