orthopedic, thoracic, urologic, or otolaryngologic procedures.Answer: EHolt NF. Perioperative cardiac risk reduction. Am Fam Physician. 2012; 85(3):239–246. PMID: 22335263.London MJ, Schwartz GG, Hur K, Henderson WG. Association of perioperative statin use with mortality and morbidity after major noncardiac surgery. JAMA Intern Med. 2017; 177(2):231–242. doi: 10.1001/jamainternmed.2016.8005. PMID: 27992624.6 A 34‐year‐old woman arrives in your trauma bay following an MVC in which she was the ejected driver. She was unresponsive at the scene, with hypotension and tachycardia noted by EMS. Upon arrival to the trauma bay, she has a GCS of 6 with a HR of 130, BP 106/89, SpO2 of 91% on facemask, and has a respiratory rate of 28. She has scattered abrasions on her trunk, and FAST exam demonstrates fluid in the RUQ, as well as a gravid uterus. Which of the following is true in regard to this patient's pregnancy?Her pulmonary status and likelihood of first attempt success at intubation are unchanged compared to a nonpregnant counterpart.A chest tube should be placed approximately 3–4 rib spaces higher than in the nonpregnant patient.She is more susceptible to metabolic acidosis than a nonpregnant counterpart.This patient likely has a higher end‐tidal CO2 than a nonpregnant patient.Her risk of intra or retroperitoneal hemorrhage is lower than in a nonpregnant patient.The physiologic changes of pregnancy are important to know, especially in the trauma patient, and are summarized below:Pulmonary: Pregnancy is associated with increased airway edema, O2 consumption, and decreased RV and FRC. Therefore, intubation is technically more difficult and a patient may require a smaller endotracheal tube and additional airway adjuncts for successful airway management. It is important to properly preoxygenate prior to intubation. Increased tidal volume and minute ventilation lead to a compensated respiratory alkalosis, and elevation of the diaphragm in a gravid uterus requires chest tubes to be placed 1–2 rib spaces higher than in the nonpregnant patient.GI: Decreased gastric emptying and LES tone lead to increased risk of aspiration.CV: Increased plasma volume can delay recognition of hemorrhagic shock. Increased HR and decreased BP can alter the clinical picture in evaluating hypovolemic shock. Increased uterine and bladder blood flow, as well as increased vascular congestion, increased the risk of maternal hemorrhage with direct abdominal injury or retroperitoneal bleeding.Renal: To compensate for pregnancy‐associated respiratory alkalosis, the kidneys increase bicarbonate excretion. This leads to a decreased HCO3, effectively reducing the capacity to buffer against a metabolic acidosis.Answer: CSakamoto J, Michels C, Eisfelder B, Joshi N. Trauma in pregnancy. Emerg Med Clin North Am. 2019; 37(2):317–338. doi: 10.1016/j.emc.2019.01.009. Epub 2019 Mar 8. PMID: 30940375.Mendez‐Figueroa H, Dahlke JD, Vrees RA, Rouse DJ. Trauma in pregnancy: an updated systematic review. Am J Obstet Gynecol. 2013; 209(1):1–10. doi: 10.1016/j.ajog.2013.01.021. Epub 2013 Jan 17. PMID: 23333541.Carroll MA, Yeomans ER. Diabetic ketoacidosis in pregnancy. Crit Care Med. 2005; 33(10 Suppl):S347–S353. doi: 10.1097/01.ccm.0000183164.69315.13. PMID: 16215358.
7 A 28‐year‐old man presents to the trauma bay following a motorcycle crash in which he sustained significant head trauma. A CT brain from the referring facility demonstrates a large left‐sided subdural hemorrhage with midline shift, and the patient has a GCS of 7, with a laryngeal‐mask airway in place due to EMS being unable to perform endotracheal intubation. You prepare to establish a definitive airway in the trauma bay. Regarding induction medication selection in patients with traumatic brain injury (TBI), the optimal agents are:MidazolamPropofolEtomidateKetamineBoth C and DWhile there are no absolute contraindications to any of the above medications for RSI in patients with TBI, the practitioner should be very aware of the consequences of each agent. Midazolam and propofol are both associated with a significant incidence of post‐induction hypotension, subsequently worsening CPP and possibly increasing secondary brain injury. In fact, episodes of hypotension as short as 10 minutes have been shown to increase mortality in patients with TBI. However, administration of adequate oxygenation is also key – SpO2 of less than 90% is also associated with increased mortality. Etomidate and ketamine, on the other hand, have a significantly decreased incidence of post‐administration hypotension and would be preferred for induction.Answer: EShriki J, Galvagno SM Jr. Sedation for rapid sequence induction and intubation of neurologically injured patients. Emerg Med Clin North Am. 2021; 39(1):203–216. doi: 10.1016/j.emc.2020.09.012. Epub 2020 Oct 31. PMID: 33218658.
8 A 32‐year‐old man with a 4 year smoking history (without COPD), hypertension controlled with losartan, and well‐controlled type I diabetes mellitus is about to undergo emergent exploratory laparotomy for perforated appendicitis. Prior to making incision, the circulating nurse asks you to declare an American Society of Anesthesiologists (ASA) classification for this operation. The correct answer is:22E33E4The American Society of Anesthesiologists developed this simple scale to describe the degree of a patient's medical illness. The numeric system was designed to ease communication between providers, provide a common language for documentation, and ease data abstraction for research. Because of variation among providers, it should not be used as the sole determinant of patient status and is not meant to act as an evaluation of perioperative risk.ASA 1: Healthy patient; good exercise tolerance, excludes extremes of age.ASA 2: Mild systemic disease, Mild diseases only without substantive functional limitations. Current smoker, social alcohol drinker, pregnancy, obesity (30 < BMI < 40), well‐controlled DM/HTN, mild lung disease.ASA 3: Severe systemic disease, Substantive functional limitations; one or more moderate to severe diseases. Poorly controlled DM or HTN, COPD, morbid obesity (BMI ≥40), active hepatitis, alcohol dependence or abuse, implanted pacemaker, moderate reduction of ejection fraction, ESRD undergoing regularly scheduled dialysis, history (>3 months) of MI, CVA, TIA, or CAD/stents.ASA 4: Severe systemic disease, at least one severe disease that is poorly controlled or at end stage; possible risk of death; Recent (<3 months) MI, CVA, TIA or CAD/stents, ongoing cardiac ischemia or severe valve dysfunction, severe reduction of ejection fraction, shock, sepsis, DIC, ARD or ESRD not undergoing regularly scheduled dialysis.ASA 5: Moribund patients not expected to survive more than 24 hours without surgery; ruptured abdominal/thoracic aneurysm, massive trauma, intracranial bleed with mass effect, ischemic bowel in the face of significant cardiac pathology or multiple organ/system dysfunction.ASA 6: Brain‐dead patients undergoing organ or tissue procurement procedures for transplantation.An “E” is added to any case designated emergent.The patient above has well‐controlled disease of more than one body system, and requires emergent surgery, earning the designation ASA 2E.Answer: BHurwitz EE, Simon M, Vinta SR, Zehm CF, Shabot SM, Minhajuddin A, Abouleish AE. Adding examples to the ASA‐physical status classification improves correct assignments to patients. Anesthesiology. 2017; 126:614–622.Mayhew D, Mendonca V, Murthy BVS. A review of ASA physical status – historical perspectives and modern developments. Anaesthesia 2019; 74:373–379.
9 You are waiting for your patient to arrive in the OR for a planned right inguinal hernia repair when anesthesia alerts you that they think you should reschedule your elective procedure due to uncontrolled hypertension. The patient currently has a BP of 178/100, and his only significant medical history is obesity, HTN, and HLD. He states that he has known about his hypertension for several months, but has not yet started his losartan that his PCP prescribed for him. He initially presented to the ED 3 days ago due to significant pain with his hernia and not being able to reduce it himself. Eventually, the surgical intern on call was able to reduce the hernia and the patient was discharged home. What is the appropriate course of action in this situation?Cancel the case and reschedule for after he achieves better control with his prescribed regimen.Admit the patient overnight for control of his blood pressure, with plans to operate the following day if he has responded to IV therapy.Have a thorough discussion with the patient regarding risks and benefits, and proceed with the operation.Administer high‐dose beta blockade and, if successful, proceed with the operation.This acute hypertension is likely due to pain and will likely resolve with sedation. Therefore, no intervention is needed.While broadly encountered in the surgical population, there are no universal guidelines for case cancelation with hypertension in noncardiac cases. Based on risk stratification for
