SHOCK

1. A Case of Ruptured Ectopic
Pregnancy in Shock
Speaker - Razi Shahid
Moderater - Dr Aftab sir

2. • Patient - Mrs Sunita kumari 24 years , Female
• Resident of Pakbara , Moradabad
• Chief Complaints
• Pain in Abdomen since morning

3. History of Presenting illness
• As stated by the patient she was apparently well 1 day back when she
developed sudden pain in abdomen. The pain was severe in intensity.
Pain started in morning and then gradually increased,no elevating and
reliveing factors, non radiating, no medication taken.
• For this complaint she came to the emergency department of TMU
• Patient had H/o amenhorea since 1 and half months
• Patient had not done any pregnancy test and was unaware of
pregnancy.

4. • No H/o Dm, HTN, Jaundice, T.B., Thyroid disorder.
• No H/o suggestive of fever, cough, snoring, difficulty in breathing,
and allergies.
• No H/o food intake last night and water intake since morning
• No H/o any previous pregnancy , Surgery
• Bladder - no urine output since morning.

5. General Examination
• General condition- Conscious but agitated
• Average Built
• Pallor- Marked
• Icterus - Not Present
• Cyanosis- Not Present
• Oral cavity - Dry
• No jvp engorgement
• Carotids Palpable
• No Palpable Lymphadenopathy
• Neck no abnormality seen

6. • No Clubbing
• Pulse - 130 per minute, regular, low volume , peripheral pulse feeble
• Peripheral extremities as cold
• Respiraton- 25 per minute, SpO2- 96% at room air
• A febrile
• Blood Pressure- 70/32mm Hg
• No Pedal edema

7. Systemic Examination
• Cardiovascular System
• Auscultation S1 S2 Audible.
• No added sounds/murmurs.

8. • Respiratory System
• Auscultation normal vesicular breath sounds present.
• No added sounds.

9. • Abdominal Examination
• Tender on palpation
• Guarding present.
• No palpable organomegaly present.

10. • CNS
• Conscious oriented. EMV 15/15, agitated
• All cranial nerves intact.
• Superficial and deep reflexes normal.

11. Airway examination
• Mouth opening adequate
• MP grade 2 ,supine position
• Neck movement normal
• No loose teeth

12. INVESTIGATIONS
• Urinary pregnancy test positive
• Complete Blood Count
• Hb- 5 gm%
• TLC- 11420
• Platelets- 3.8 lakhs
• Diagnostic Peritoneal Lavage 10 ml blood
• RBS- 220mg/dl

13. Investigations Sent
• ABG and Blood grouping
• LFT & KFT
• PT/INR

14. Anaesthetic Consideration
• Consent for Anaesthesia and Surgery taken from Husband.
• Patient taken under ASA grade 3E.

15. Anaesthetic Management
• Improve Oxygenation
• Resuscitate with Intravenous fluids
• Correct Haemostatic disorders

16. Patient Optimisation
• Moist O2 inhalation
• 16 gauge IV cannula secured in External jugular vein
• 18 gauge IV cannula secured in median cubital vein Left hand
• 500ml warm normal saline fast and 500ml colloid given started
• IV Infusion Noradrenaline 6ml/hr (8mcg/min) started through external
jugular cannula.
• Patient covered with blankets
• Nasogastric Tube inserted
• Foley's catheter inserted, 50ml U/O
• Expedite arrangement of blood products.

17. • Pre medication was given.
• Antacid, H2 Blockers
• Injection Metaclopramide 10mg IV
• Inj Glycopyrolate 0.2mg IV
• Inj Ceftriaxone 1 gram IV
• Patient shifted to theatre.

18. Monitoring
• ECG
• BP
• ET CO2
• Pulse oximetry
• Temperature
• Monitor urine output
• Peri-op Blood Loss

19. Intraoperative phase
• Patient in supine position
• Pre oxygenate patient with 100% Oxygen
• Inj Dexamethasone 8mg IV
• Induction agent - Ketamine 50mg IV
• Muscle relaxation with Inj Suxycinlicholine 100mg IV
• Intubated with no 7 CETT , and fixed after confirmation of tube
position.

20. Maintenance and Intra operative Phase
• O2 + N 2 0 + Inj Atracil 25mg
• Inj Fentanyl 50mcg IV
• Inj Tranexamic acid 1 gm IV
• Administered warm IVF Ringer Lactate
• Transfused 2 units of PRBC intra-op

21. • Transfused 3 units of FFP
• Inj Hydrocortisone 100mg IV
• Inj Calcium gluconate 1gm IV
• Inj Paracetamol 1 gm IV
• After source of bleeding is controlled
• Dose of noradrenaline tapered accordingly
• Intra operative haemodynamic stability achieved

22. INTRAOPERATIVE CHART
Pre
intubation
Post
Intubatio
n
5
m
in
10
mi
n
15
mi
n
20
mi
n
25
mi
n
30
mi
n
35
mi
n
40
mi
n
45
mi
n
50
mi
n
55
mi
n
60
mi
n
65
mi
n
70
mi
n
75
mi
n
80
mi
n
85
mi
n
90
mi
n
95
mi
n
100 min
BP mmHg-
92/60@7
ml/kg
(9mcg/min)
96/62
99
/6
4
10
1/6
9
10
0/6
5
10
6/7
0
99/
71
10
0/7
3
11
0/6
8
10
8/7
0
12
0/7
2@
6m
l/hr
(8
mc
g/
mi
n)
13
0/7
5
12
4/7
0
12
8/7
6@
5m
l/hr
(6.
6m
cg/
mi
n)
12
6/7
2
12
8/8
0@
4m
l/hr
(5
mc
g/
mi
n)
12
5/7
5
12
6/7
7
12
5/7
6@
3m
l/hr
(4
mc
g/
mi
n)
12
4/7
4
122/73@2
ml/hr
(2.6mcg/
min)
Pulse -
128/min
122
11
9
11
9
11
7
11
0
10
9
111
10
7
99
10
0
98 95 91 92 89 88 86 87 86 89 99
Atracurium
25mg
5m
g
5m
g
2.5
mg
Extubatio
n
IVF 1 RL +
COLLOID
1
PR
BC
FF
P
1
PR
BC
FF
P
FF
P
1
RL
U/O 50ml 10 20 10 20 30 40 180ml

23. • Intra operative Blood loss -
• Suction/Laprotomy pads 1200 ml
• Gauge 20 × 10 = 200ml
• Floor Spilage - 100-200ml
• Approximately Blood loss - 1.5 litres

24. Reversal & Emergence
• Anaesthetic gases and intravenous anesthetic drugs stopped.
• Suctioning done.
• Inj Ondensetron 4mg IV
• Reversal of neuromuscular blocker was done by Inj Neostigmine
2.5mg with Inj Glycopyrrolate 0.5mg IV
• After adequate reversal of neuromuscular strength patient was
extubated.
• Patient shifted to ICU for further monitoring.

25. • Post op vitals
• Patient - awake conscious oriented
• BP- 122/73@2ml/hr (2.6mcg/min)
• Pulse - 99 / minute in radial artery left hand,normovolumic ,
normorythmic ,no special character, all other peripheral pulses
palpable.
• Temperature - normal , all peripheral extremities are warm.
• SpO2 100%, chest bilateral clear.
• Urine output - 180ml

26. Post operative advice
• Monitor airway, breathing , circulation, temperature.
• Moist O2 inhalation
• Inj PCM 1 gm TDS
• Any episode of Nausea and Vomiting
• IVF RL : DNS at 80ml/hr
• Transfuse 1 unit of PRBC

27. • Evaluation of electrolyte , ABG
• Fresh CBC, KFT
• Clotting Profile
• Chest X ray
• Watch for bleeding.
• Rest as per department concerned

28. Post op day 1 in ICU
• Patient Conscious oriented supine in head up position
• 1 unit PRBC trasfused overnight, Pallor moderate present
• Temprature - 98.6F, peripheral extremities warm
• Pulse - 89/min
• BP - 123/72 mmHg
• RR- B/L chest clear , no added sounds 16/min,
• SpO2- 100%
• No Increase in abdominal girth
• U/O - 50ml / hour
• Drain - 30 ml in 24 hours

29. ICU Day 1
• CBC
• HB - 8.2 g/dl
• TLC- 9760
• Platelets - 2.1lakhs
• Prothrombin Time - 16 seconds
• INR - 1.1
• LFT & KFT - WNL

30. ABG day 1 ICU
• pH - 7.3
• pCO2 - 41.5 mmHg
• pO2 - 76 mmHg
• cK+ 3.1
• cNa + 139 mmol/L
• cCa+ 1.09mmol/L
• cHCO3 - 22.3 mmol/L
• cLac - 1.7 mmol/L
• cGlu - 162 mg/dl