A 23-yr-old man (75 kg and 6′0″) is admitted with a single stab wound just below his umbilicus. There are no other injuries as per the emergency physician. The patient is conscious, orientated for time and place, and vital signs are stable. He states he has not eaten anything for 6 h, but he smells of alcohol. Blood is taken for hematocrit and chemical analysis, and it is cross-matched for blood. His history is noncontributory. He has no allergies, and a previous general anesthetic for a right inguinal hernia repair is reportedly uneventful. The surgeon wants to do an emergency laparotomy and the patient is taken to the operating room at 9 pm, where you meet him for the first time. You review the chart and confirm his history. On examination, the patient has one stab wound, as described, and no other injuries as far as you can see. A 16-gauge IV in his left hand is working well. Examination of the anterior part of his chest and heart reveal nothing abnormal. You elect to do a rapid sequence technique, using thiopental and succinylcholine. Before induction, the blood results become available and his electrolytes, creatinine, and blood glucose are all within normal limits. His hematocrit is 36%. Normal routine monitors are placed, including a three-lead electrocardiogram, a noninvasive blood pressure monitor on his right arm, and an oximeter on his left ring finger. You give the patient 1 g of Keflex slowly (over 2–3 min) IV, as ordered by the surgeon. The test dose of Keflex is negative, as there is no change in hemodynamic parameters. You note the vital signs and start to preoxygenate the patient. General anesthesia is induced with thiopental 200mg, succinylcholine 100mg, and an endotracheal tube (ETT) is placed uneventfully in the trachea. You hear bilateral air entry and end-tidal CO2 is present. The ETT is taped at 22 cm and the surgery begins. Anesthesia is maintained with fentanyl 250mg and isoflurane 0.8%, with 50% oxygen in air. Shortly after the incision is made, there is a rapid decrease in this systolic blood pressure to 40mmHg. His heart rate goes to 150 beats/min and the saturation falls to below 82%. You ask the surgeon to check for bleeding, but he states that there is no bleeding in the abdomen. He also feels the diaphragm and states that it is intact. By now, the end-tidal CO2 is nearly at zero, despite the fact that you can hear bilateral air entry over the anterior part of his chest. You tell the surgeon to do a thoracotomy, but the surgeon feels this must be an allergic reaction or an anesthetic mishap. Large doses of epinephrine are given IV, with no improvement. Despite heroic attempts on your part and those of your colleagues who come to help, the patient is pronounced dead 30 min later. If the patient did not die from an allergic response to drugs, from an anesthetic mishap, or from an undiagnosed surgical bleed in the abdomen, why did the he die?
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