ectopic

Question 1

34 year old is scheduled for ex lap for suspected tubal.
PMH: tobacco.

20 minutes into the procedure the BP drops to 44 mmHg and her peak airway pressures increase to 52 cm H20. what is your ddx?

Answer 1

1. upward pressure of diaphragm and reflex vagal tone during formation of pneumoperitoneum
2. mainstem intubation
3. tension ptx (smoking)
4. capnothorax
5. CO2 embolism with gas “lock”
6. anaphylaxis
7. bronchospasm
8. stiff chest syndrome

Question 2

what is the difference in anaphylaxis and anaphylactoid reaction?

Answer 2

anaphylaxis is type I hypersensitivity with second exposure to antigen that previously evoked production of antigen-specific IgE antibodies. degranulation of mast cells and basophils results in release of histamine, leukotrienes, prostaglandins, TNF and cytokines. increase capillary permeability, vasodilation, bronchoconstriction, negative isotropy, coronary artery vasoconstriction. usually occurs within 10 minutes of exposure.

anaphylactoid reaction is indistinguishable but the mast cell and basophil degranulation is triggered by direct interaction with certain allergens, rather than by IgE antibodies. it does not require prior sensitization and produce anaphylaxis-like symptoms in a dose-dependent manner.

Question 3

assuming she is having a type I hypersensitivity reaction, what is the treatment?

Answer 3

1. inform surgeon, call for help
2. discontinue all infusions, inhalation agents
3. ventilate with 100% FiO2
4. 1-2 L fluid bolus (to replace intravascular volume)
5. IV epi since hypotensive (if normotensive, admin subQ)’
6. corticosteroids (enhances b-agonist effects and inhibits leukotriene, prostaglandin production - effects delayed for 4-6 hours)
7. H2 blocker
8. inhaled b2 agonist
9. supportive care

double dose of epic every 1-2 minutes until a satisfactory systemic response is achieved.

refractory hypotension - consider bicarb, vasopressin, echo

Question 4

how does epi work?

Answer 4

alpha-agonist activity leads to vasoconstriction and reversal of hypotension.
beta-agonist activity relaxes bronchia smooth muscles and increases intracellular cAMP (restores membrane permeability and decreases release of vasoactive mediators).

depending on severity of condition, start with 10-100 mpg IV. if normotensive, 0.3-0.5 mg subQ

Question 5

what are the risk factors for latex allergy?

Answer 5

1. spina bifida (repeated latex exposure)
2. congenital urinary tract abnormalities
3. multiple surgeries
4. health care workers
5. rubber industry workers
6. avocado, banana, chestnut, kiwi, passion fruit allergy

Question 6

can healthcare workers decrease their risk of latex allergy?

Answer 6

reduce exposure by using non-powdered latex gloves or latex-free gloves.