Clinical case 039: Ectopic ectopic – a Gedankenexperiment

This case starts with a bad gas.  This patient arrived ‘in extremis’.  Suspected ectopic transferred in by plane with the following data:

  • Urinary HCG positive
  • Abdominal pain for a few days
  • No urine output for the last 24 hours
  • Hb in the remote clinic was 130 g/l yesterday
  • A 14 second US in ED showed a lot of free fluid, black with swirling clots in it….

She got an arterial line at the door and here is her opening ABG:

pH = 6.90

pCO2 = 58

 pO2 = 255 (on rebreather 10L)

 HCO3 = 10

BE = – 15

 Na = 140

K = 8.9

Ca = 0.76

Glucose = 21  (~ 380 in the US)

Lactate = 10.5

Hb = 58 g/l (was 130 a few hours ago, and she has had 4 units PRBCs in transit)

The Obstetrician and Surgeon are there, keen to get in and control the bleeding ASAP.  But I am a bit nervous about “whizzing her off to sleep” without a little more resus and think time. 

So here are a few random questions about this case that I would like to hear your answers to.

  1. What drugs / agents would you want to give this patient before induction / intubation?
  2. What is you plan A for induction and intubation, including ventilator settings?
  3. What blood products / factors do you want to give in the next 30 minutes or so…?

Ok, those are the questions to ponder.  Tough case.  And that is all the info that was available at the time.  Clearly not one where we can wait too long before jumping in and getting control.  So what are you going to do?

Casey

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