2024.1 Day 1 VIVA 4

Resuscitation and Trauma

You have been called by the on-shift Emergency Department (ED) Medical Officer to attend the ED to assist with the resuscitation of a 50-year with known alcoholic liver cirrhosis and bleeding oesophageal varices.

He had presented with coffee ground vomitus but is now vomiting frank fresh blood.

His heart rate is 130 beats per minute, blood pressure 75/40 mmHg and oxygen saturations of 92% on room air. He is cool, clammy and peripherally shut down. He weighs 70 kilograms.

You have been tasked with gaining vascular access by the Emergency Department Medical Officer, what do you do?

Immediate vascular access strategy:

• First attempt two 14-16G peripheral IVs in antecubital fossa

• Rationale: Fastest way to achieve high-flow resuscitation (gravity flow ~100-150ml/min per 14G IV)

• If unsuccessful after 2 attempts by experienced operator → proceed to IO

Intraosseous access as backup:

• Preferred site: Proximal tibia (2cm below tibial tuberosity, medial flat surface)

• Alternative: Proximal humerus (greater tubercle, avoids long bone fractures)

• IO flow rates: Up to 100ml/min with pressure bag, equivalent to central access

• Special considerations:

  • Painful insertion → give lidocaine 40mg IO after placement

  • Temporary measure (max 24hrs) → arrange definitive access

Central venous access if needed:

• Femoral vein preferred in this scenario due to:

  • Easier compression if bleeding occurs (vs subclavian/IJ)

  • Preserved landmarks in hypotensive patient

  • Lower pneumothorax risk vs thoracic approaches

• Ultrasound guidance mandatory:

  • Identify vein/artery relationship (vein medial to artery in femoral triangle)

  • Use dynamic needle tip tracking to avoid arterial puncture

• Avoid subclavian: High risk of pneumothorax/bleeding in coagulopathic patient

The patient remains hypotensive after 2L crystalloid. What next?

Activate major haemorrhage protocol as MTP unavailable in Scenarioville:

• Call laboratory immediately

• Initial ratio: 4 units PRBC : 4 units FFP : 2 pools cryoprecipitate if available

• Rationale: Balanced resuscitation addresses coagulopathy of trauma/liver disease

Vasopressor support:

• Noradrenaline infusion starting at 0.05mcg/kg/min via central line

• Titrate to MAP >65mmHg

• Rationale: Cirrhotic patients often have relative vasodilation

Adjuncts:

• Tranexamic acid 1g IV over 10min (CRASH-2 evidence in bleeding)

• Vitamin K 10mg IV (corrects nutritional deficiency in alcoholics)

What lab tests would you prioritise?

Immediate priority tests (first 5 mins):

• Venous blood gas: Lactate (prognostic), pH, hemoglobin (point-of-care)

• Coagulation: INR, fibrinogen (critical in liver disease)

Secondary tests (next 15 mins):

• Full blood count: Baseline Hb (may be normal initially in acute bleed)

• U&E: Creatinine (HRS risk), Na+ (dilutional hyponatremia common)

• LFTs: Bilirubin (Child-Pugh staging), ALT/AST

• Group & Hold: 4 units minimum (crossmatch if time permits)

Special considerations:

• No ROTEM in Scenarioville → rely on clinical bleeding + fibrinogen level

• Thrombocytopenia likely → but no platelets available locally

How would you monitor response to resuscitation?

Clinical parameters (q5min initially):

• Mental state (improving encephalopathy = good sign)

• Urine output (aim >0.5ml/kg/hr via catheter)

• Skin perfusion (capillary refill, temperature gradient)

Hemodynamic (continuous):

• Arterial line preferred once stable enough for placement

• Dynamic parameters: PP variation >13% suggests fluid responsiveness

Laboratory trends:

• Lactate clearance (>30% reduction in 2hrs = good prognosis)

• Serial Hb (expect 1g/dL rise per unit PRBC if no ongoing bleed)

• Fibrinogen >1.5g/L target (critical for clot stability)

The INR is 2.5. How does this alter your transfusion strategy?

FFP administration:

• Initial dose 15ml/kg (≈1000ml for 70kg)

• Recheck INR after 30min

• Target INR <1.5 for procedural hemostasis

Cryoprecipitate if fibrinogen low:

• 2 pools (≈10 units) raises fibrinogen by ~1g/L

• Preferred over FFP for isolated hypofibrinogenemia

Vitamin K adjunct:

• 10mg IV slow push (works over 6-12hrs)

Special considerations:

• FFP has marginal effect when INR >2.0 in cirrhosis

• May accept higher INR (1.8-2.0) if volume overload concern

What are the risks of over-resuscitation in cirrhosis?

Portal hypertension exacerbation:

• Increased intravascular volume → elevated portal pressures → rebleeding risk

• Target CVP 6-8mmHg (avoid >10)

Volume overload complications:

• Acute pulmonary edema (reduced cardiac reserve in cirrhosis)

• Worsening ascites (increases intra-abdominal pressure)

Coagulation dilution:

• Excessive crystalloid dilutes remaining clotting factors

Management strategy:

• Early vasopressor use rather than excessive fluids

• Target MAP 65-75mmHg (not normal BP)

The team plans balloon tamponade. How would you secure the airway?

Pre-RSI Preparation:

• Positioning:

  • 30° head-up tilt to reduce aspiration risk

  • Left lateral tilt if active hematemesis (rarely practical)

• Pre-oxygenation:

  • HFNC at 60L/min, FiO₂ 1.0 for 3-5 mins (apneic oxygenation during laryngoscopy)

  • NIV contraindicated (risk of gastric insufflation → more vomiting)

• Equipment:

  • Video laryngoscope (hyperangulated blade) + bougie immediately available

  • Dual suction (Yankauer + catheter) with wide-bore tubing

  • Cricothyroidotomy kit opened and ready

Drug Selection:

• Induction:

  • Ketamine 1-1.5mg/kg (50-100mg) – maintains BP better than propofol

  • Avoid etomidate (adrenal suppression in sepsis)

• Muscle Relaxant:

  • Rocuronium 1mg/kg (70mg) – fast onset, no K⁺ release like suxamethonium

  • Sugammadex available for reversal if needed

Intubation Technique:

• Modified RSI:

  • Apply cricoid pressure only if trained assistant available

  • Quick-look with blade to assess for blood in airway

  • Suction under direct vision before tube passage

• Tube Selection:

  • 7.0-7.5mm ETT (smaller may impede scope passage)

  • Consider pre-loading Sengstaken tube over ETT before intubation

Post-Intubation Management:

• Ventilation:

  • Start with VC-VG mode: TV 6-8ml/kg, PEEP 5-8cmH₂O

  • Permissive hypercapnia (pH >7.2) to avoid excessive PEEP

• NG Tube Controversy:

  • Only insert after ETT placement confirmed

  • Soft silicone tube preferred, avoid suction initially

Why avoid succinylcholine in this patient?

Hyperkalemia risk:

• Chronic liver disease → upregulated extrajunctional ACh receptors

• Potential for life-threatening K⁺ rise (even without overt renal failure)

Prolonged paralysis:

• Reduced pseudocholinesterase production in cirrhosis

• 2-3x longer duration of action expected

The saturations drop to 85% during laryngoscopy. What now?

Immediate actions:

• Withdraw blade, resume facemask ventilation with 100% O₂

• Have assistant perform vigorous suction while ventilating

Second attempt modifications:

• Switch to video laryngoscope if not already using

• Apply optimal external laryngeal manipulation

• Limit attempt to <30 seconds

If fails:

• Insert supraglottic airway (e.g., i-gel) as bridge

• Prepare for front-of-neck access if SGA fails

How would you modify ventilation for variceal bleeding?

PEEP strategy:

• Start with 5cmH₂O, increase only if hypoxia persists

• Avoid >10cmH₂O → increases right atrial pressure → ↑ portal hypertension

• Tidal volume:

  • Lower range (6ml/kg) to reduce risk of gastric insufflation

Monitoring:

• Watch for rising airway pressures → may indicate gastric distension

The surgeon requests gastroscopy now. Your concerns?

Hemodynamic stability:

• Must have MAP >65mmHg and lactate trending down

Airway protection:

• ETT cuff pressure checked (20-30cmH₂O) to prevent aspiration

Team preparation:

• Surgeon must be skilled in variceal banding

• Anesthetist should remain at head for airway management

Blood products:

• At least 4 units PRBC and 2 FFP immediately available

Would you transfer without endoscopy?

Indications for transfer:

• Failed endoscopic control after 2 attempts

• Unavailable specialist (e.g., no GI surgeon onsite)

Logistics:

• Retrieval team ETA 2hrs → balloon tamponade as bridge

• Minnesota tube preferred if transfer delayed

Risks:

• 30% rebleed rate during transfer

• Must have secured airway + 2 large-bore IVs

The surgeon insists on gastroscopy despite instability. How do you proceed?

Graded Assertiveness Framework (ANZCA PG07):

1. Advise:

   • "His lactate is still 5.2 - I recommend correcting his acidosis first"

2. Suggest:

   • "Perhaps we could start terlipressin while preparing?"

3. Assert:

   • "I cannot safely anesthetize him with his current Hb of 65"

4. Escalate:

   • "Let's call the ICU consultant for a second opinion"

Risk-Benefit Analysis:

• Procedural risks:

  • 40% mortality if scope performed in shock

  • High aspiration risk despite intubation

• Benefits:

  • 80% success rate if banding achieved

Scenarioville limitations:

• No interventional radiology for salvage TIPS

• Blood product limitations (no platelets)

Alternative Strategies:

• Pharmacologic bridge:

  • Terlipressin 2mg q4h (reduces portal pressure by 20%)

  • Octreotide infusion 50mcg/hr

• Mechanical tamponade:

  • Minnesota tube placement (requires ETT size ≥7.5mm)

  • 500ml gastric balloon inflation + 0.5kg traction

What are the anaesthetic risks during gastroscopy?

Aspiration:

• Blood clots may occlude suction

• Requires two working suctions

• Hemodynamic swings:

  • Stimulation may cause vagal Bradycardia

  • CO₂ insufflation → reduced venous return

Airway compromise:

• Scope may dislodge ETT

• Requires 2-person technique (one for airway, one for scope)

How would you prepare for intra-procedural arrest?

Pre-assign roles:

• Airway: Anaesthetist

• Chest compressions: Surgeon

• Drugs: Nurse

Equipment check:

• Defibrillator pads applied pre-procedure

• Emergency O-negative blood in room

Drug preparation:

• Adrenaline 1:10,000 drawn up

• Calcium chloride ready (for citrate toxicity)

The retrieval team is delayed. Would you give vasopressin?

Terlipressin preferred:

• 2mg IV stat then 1mg q4h

• Selective V1 receptor action → fewer cardiac side effects

Vasopressin alternative:

• 0.01-0.04 units/min infusion

• Requires arterial line for BP monitoring

Monitoring:

• Watch for hyponatremia (SIADH effect)

• Limb ischemia risk in peripheral administration

What are the CVC insertion risks in this patient?

Bleeding (most significant):

• Femoral site allows direct compression

• IJ approach risks carotid puncture

Infection:

• Cirrhotic patients have 5x higher CLABSI risk

Technical:

• Ultrasound guidance reduces complications by 60%

• Avoid subclavian (high pneumothorax risk)

How would you hand over to retrieval?

ISBAR format:

• I: "This is Dr Smith from Scenarioville ED"

• S: "50M cirrhotic with uncontrolled variceal bleed"

• B: "6U PRBC, 4FFP given, ETT in situ"

• A: "Currently MAP 70 on noradrenaline 0.1mcg/kg/min"

• R: "Urgent transfer for possible TIPS"

Critical Phrases:

• "Peripheral IV first, IO if delayed, femoral CVC if needed"

• "MTP with 1:1:1 ratio, but no platelets in Scenarioville"

• "Monitor lactate clearance and fibrinogen trends"

• "RSI with ketamine + rocuronium, not propofol/sux"

• "Video laryngoscopy + bougie as first choice"

• "Limit PEEP to <10cmH₂O in portal hypertension"

• "Graded assertiveness: advise → suggest → assert → escalate"

• "Terlipressin as pharmacologic bridge"

• "ISBAR handover with transfusion totals"

Key Concepts Covered:

1. Cirrhosis-specific resuscitation:

   • Avoid over-transfusion (target Hb 70-80)

   • Early FFP/cryoprecipitate for coagulopathy

2. Airway in GI bleed:

   • RSI with hemodynamically stable induction

   • Video laryngoscopy first-line

3. Resource-limited practice:

   • No platelets in Scenarioville

   • 2hr retrieval time impacts decision-making