Department of Anesthesiology
Medical Subject Headings
Obesity, Morbid; Spondylitis, Ankylosing; Airway Management; Shock; Spinal Cord Injuries
A 67 year old morbidly obese male presented to the ER with weakness in both lower extremities after a fall at home. The patient sustained a T12/ L1 unstable vertebral fractures and cord compression at the thoracolumbar junction with acute traumatic paraplegia.
The patient arrived in the PACU on a backboard and with a cervical collar in place directly from the ER. The review of the patient’s chart revealed that he had a history of hypertension, PE / DVT on coumadin, hypothyroidism, NIDDM, bipolar disorder and cervical spine ankylosing spondylitis of his neck. On physical exam the patient was sleepy, but arousable and unable to move his lower extremities, with loss of bladder and bowel control. There was one 20 G IV in place. The airway exam revealed Mallampati Class 4. The patient was hemodynamically unstable with BP ~80/~40 mm HG; HR ~70’s/min; SpO2 ~86-88%. Resuscitation commenced immediately. The patient was started on face mask @ 10 l/m O2. One liter of normal saline was administered with minimal effect. A phenylephrine infusion was started. The blood pressure improved to SBP of 120’s mm Hg. The O2 saturation increased to 95%. A methylprednisone drip (30mg/kg iv bolus) was started for treatment of his spinal cord injury.
For additional IV access, another 20G IV was placed. Two units of FFP were given to normalize the INR of 2.4. After multiple attempts, a right radial arterial catheter was successfully placed. A right internal jugular (RIJ) central venous catheter was inserted under ultrasound guidance