A 28-year-old primigravida presented in prolonged labour. She underwent a lower-segment Caesarean section (LSCS) 7 hours ago. She is now anxious, has a heart rate of 140 bpm, with no palpable peripheral pulse, but a detectable carotid pulse. There were some clots in the vagina, which were removed by the obstetrician. The patient is scheduled for emergency laparotomy. There have been two sets of blood results. The first, pre-LSCS, were normal. The second, post-LSCS, showed a haemoglobin (Hb) level of 2.8 g/100 ml, low platelets, deranged coagulation, raised fibrinogen degradation product (6), and low albumin and total protein.
1. How are you going to assess the patient clinically?
2. Discuss the classification of shock.
3. How will you proceed?
4. What resuscitation fluid would you use?
5. How will you optimise her, and when (in terms of her BP, Hb etc) will you take her to the operating theatre?
6. How would you correct clotting abnormalities?
7. How would you anaesthetise her?
- Would you consider ketamine for rapid sequence induction?
8. What parameters would you monitor prior to surgery?
- Pros and cons?
- What level of central venous pressure would you aim for?
9. When would you consider giving inotropes/vasopressor?
- Which one would you use first, and why?
10. Where will you send the patient after surgery, and why?
11. Would you consider ventilating her?
12. Her chest X-ray shows pulmonary oedema.
- What might be the cause of this?
- How would you treat it?
- Would you use a vasodilator? Why/why not?
- Would you use albumin? Why?