Trainwreck #6

[usalsfyre]

I know it's been a few months, but a recent case deserved a posting.

CCT unit, dispatched at 0200 for a transfer from a smallish ICU to Big City Medical Center 20 minutes away. The only info you've got is the patient is "trached and on drips".

On arrival you find a crowd of people with a "deer in the head lights" look standing at bedside of a 46 YOF three hours post-ROSC. The patient was 10 days post-CABG, had been extubated and was scheduled to go home the next day when she suffered a hyperkalemic arrest and required CPR, multiple defibrilations, calcium, bicarb, insulin and D50. The patient had multiple failed airway attempts and had been crich'ed with a 6.0 ETT. You see Levophed and Dopamine hanging, the nurse is telling you she's turning the midazolam drip off now that your here.

The physician is at bedside telling you to "hurry up and get the hell out of here!"

Go....

 

[abckidsmom]

I'm so happy to see a train wreck! Let's start with labs pre and post arrest, vitals and a description of her mental status. Add in anything remarkable from her physical exam and cxr.

And keep the versed running while you type! Omg don't turn that off!

 

[NomadicMedic]

A set of vitals and vent settings too.

 

[Maine iac]

On arrival you find a crowd of people with a "deer in the head lights" look standing at bedside of a 46 YOF three hours post-ROSC.

The patient was 10 days post-CABG, had been extubated and was scheduled to go home the next day when she suffered a hyperkalemic arrest and required CPR, multiple defibrilations, calcium, bicarb, insulin and D50.
Did she have the CABG at this smaller hospital? Was she not extubated fairly soon after the operation? (all the CABGs that I've seen have been extubated within 6 hours of closure.) Just trying to figure out where the 10 days comes from.
The patient had multiple failed airway attempts and had been crich'ed with a 6.0 ETT.
hmm... What's the pt like? Morbidly obese? Horse neck?Does the airway seem to be descent i.e. it is not being tended to every few minutes?

You see Levophed and Dopamine hanging, the nurse is telling you she's turning the midazolam drip off now that your here.
Why is the midazolam coming off? A little pain control/ sedation might be nice.

The physician is at bedside telling you to "hurry up and get the hell out of here!"

Go....

Labs would be nice, blood gasses also. Any other history that we should know about. I assume the worst since it was a 46 yof getting a CABG....

 

[Aidey]

Past history? Smoking status? Drug use? Weight? Family history? Why the heck did a 46yo require a CABG? Why not a stent? How many vessels were involved in the CABG? Did her K+ suddenly spike or had it been creeping up the last 10 days?

Vitals?
Labs - Specifically CBC, metabolic panel and ABGs.

What is her K+ now? Does she have any of hyper K meds hanging? Because Glucose/insulin only help while they are being given. Calcium just masks the problem. Bicarb helps with the acidosis not the actual hyper K. And albuterol only gives you 2-4 hours before the K+ starts going back up again.* Since her arrest was 3 hours ago, her K+ has the potential to be creeping back up again.

Why was she such a hard intubation? Was she that hard to intubate 10 days ago?



*All of that is very simplified for the sake of brevity.

 

[usalsfyre]

I'm so happy to see a train wreck! Let's start with labs pre and post arrest, vitals and a description of her mental status. Add in anything remarkable from her physical exam and cxr.

BMP around the time of arrest was
Na: 128 K+:8.3 CL: 104 HCO3: 30 BUN: 26 Cr: 2.1 BGL:132

Now it’s
NA:132 K:+5.5 CL:108 HCO3:18 BUN:47 Cr: 3.3 BGL:108

Physical exam as follows

HEENT: Intact, pupils are constricted and non-responsive. A clear fluid of unknown orgin is seeping from the nostril, an NG tube putting out some coffee grounds is in place. Airway is “secured” with the ETT in the throat, the physician, RT and nurse all tell you “it’s not really secured very well and if you pull it out she’s dead”, the ETT is full length and appears to have been tied with umbilical tape. There’s dried blood on the neck and a suction canister full of frank blood that came “from the cric (shrug)” at bedside. JVD is noted.

Chest: The whole this feels like mush. Equal rise and fall is noted, breath sounds are diminished, esp on the left, where there is a chest tube hooked to a water seal putting out frank blood (200mls). The CABG scar is present over the sternum, it remains closed (thankfully). A dual lumen subclavian cath was placed during the code, connected to it are dopamine at 20mcg/kg/min, norepinephrine at 20mcg/min. The nurse mentions she was getting vasopressin at one point too, but they D/C’d that an hour ago

Abdomen& pelvis: Soft, but absent of any sounds. A foley is in place, there has been zero output since the arrest. A rectal tube it also present.

Extremities are intact, radial pulses are VERY narrow but absolutely bounding. A 20ga is present in the R wrist. The patient is very pale, cool to the touch.

And keep the versed running while you type! Omg don't turn that off!

Too late, its off and the patient does…..nothing. A couple of twitches, that’s it. The patient was 100% intact prior to the arrest.

A set of vitals and vent settings too.

HR of 136, B/P of 177/112, no resp effort outside the vent at 20, SpO2 of 99%, ETCO2 of 34

A/C at 20, vT of 550, 0 PEEP FiO2 of 80%

Labs would be nice, blood gasses also. Any other history that we should know about. I assume the worst since it was a 46 yof getting a CABG....

The patient was extuabted prior to the code, and scheduled to go home with in the next 36 hours or so.

PaO2 of 204
PaCO2 of 34
HCO3 of 31
Elevated gap and base deficit (can’t remember what they were at the moment)

Morbidly obese with poorly controlled HTN and diabetes.

Past history? Smoking status? Drug use? Weight? Family history? Why the heck did a 46yo require a CABG? Why not a stent? How many vessels were involved in the CABG? Did her K+ suddenly spike or had it been creeping up the last 10 days?

Smoker, family history. They were unable to stent a 100% blocked vessel, but only one vessel. No idea on how long about the K+, the staff is seriously wigging out and “can’t remember”

Labs - Specifically CBC, metabolic panel and ABGs.

CBC hasn’t been done post arrest (all other labs are off an iStat) pre-arrest it was a H&H of 10.1 and 42, can’t remember the white count.

What is her K+ now? Does she have any of hyper K meds hanging? Because Glucose/insulin only help while they are being given. Calcium just masks the problem. Bicarb helps with the acidosis not the actual hyper K. And albuterol only gives you 2-4 hours before the K+ starts going back up again.* Since her arrest was 3 hours ago, her K+ has the potential to be creeping back up again.

No meds other than the dopa and levo

Why was she such a hard intubation? Was she that hard to intubate 10 days ago?

“Well she was REALLY anterior….”

 

[Aidey]

Did they just turn the drips up to maximum for the hell of it or is there a reason they made her hypertensive? The versed was the wrong drip to turn off...

PT/INR available?

 

[triemal04]

Get a better run down of what happened before/during the arrest, and what has been done in the last 3 hours, including when she was given the listed meds, and how much of each.
Why the chest tube? At what point was it placed, and how long did it take to pull out 200cc of blood?
If possible get a better story than "from the crich" and where the canister of blood came from. (by suction canister you mean one that holds 800cc?)
Get her med list; probably on blood thinners but find out which and what else.
Even with the near-discharge, find out how her recovery has been; any untoward events at all or completely uneventful?
How much fluid has been pulled from the NG tube?
Restart the flippin' versed (or use fentanyl if you prefer); she probably doesn't need it, but better to have running just in case. Mind the BP as you start fixing the rest though.
Did they take an x-ray to confirm the tube placement? Be nice to see and might also help you find out what is going on in her chest.
Have them start a CBC. If you aren't still there for the results have them contact the recieving hospital and you while still enroute.

While you are finding all that out:
Ensure that the crich has not slipped into the R mainstem and that's what's causing the diminished left lung sounds. Resuction the trachea; any current bleeding?
Secure it by your preferred method, but make sure it is secure. Consider switching it out for a trach tube, or just cut the ET tube down so it isn't so long. Make sure it's secure and in the right place...again.
The diminished lung sounds...any hint of rales? Or does this appear due to the obesity and/or a misplaced tube? Any tracheal deviation or signs of a pneumothorax? The blood from the chest tube; is it still currently draining?
Adjust her tidal volume as needed based on her IBW and 8ml/kg of volume. Drop the rate to 10 and increase the PEEP to 5. A/C is fine on the off chance she starts breathing spontaneously (won't happen). Drop the FiO2 to 0.5 and think about going lower, but 0.5 is probably fine. Before leaving run an ABG again.
Back the dopamine to 10mcg/kg/min (IBW) and the levo to 4mcg/min. Given the GI Bleed and large amount of blood loss it's going to go lower than that, but until you start volume replacement keep it running, but slower. Start a fluid bolus and if you have it or they have it, start giving FFP and PRBC's. If she is on coumadin (likely) start vit K. Whole blood would be an option but that'd take longer. Continue to titrate the pressors down as needed. Volume replacement needs to be done; shoot for a MAP of about 60-65.
Start either another peripheral line (if you can get one to flow) or place/have the MD place another central line.
She's still got a slightly elevated K; could start a continous albuterol neb.
This will have taken awhile; run her labs on the istat again. As needed be ready with more Ca, bicarb, D50/insulin. What is her Ca level anyway?


The patient's got a GI Bleed of some size or another; that's potentially what caused the renal failure when combined with her chronic HTN and diabetes, and between that and the acute blood loss from the resucitation she's hypovolemic. With the constricted/unreactive pupils, HTN, pressors and (likely) blood thinners have to wonder if she also doesn't have a head bleed. Also very likely that she's bleeding into her chest cavity.

Keep her sedated as needed with versed or a versed/fentanyl combo leaning more towards fentanyl. Keep her MAP around 60-65, watch for any kind of urine output, and, just in case she does have a head bleed, signs of herniation. Edit: should probably keep her ETCO2 right around 35mmHg or just a bit higher. Depending on the next set of labs, continue to give fluid/blood (anemic so probably more blood) and continue to titrate the pressors down as needed.

If there is an actual acute hemmorhage that's ongoing and the current hospital has the capabilities, it'd be better to get her into surgery there.

Leave for the next hospital. Mention to the doctor that although I probably just helped kill her by screwing everything up, he should still talk to his malpractise carrier.

 

[thisgirlisamedic]

Ok a few things kinda out order but where is the stack of strips from the code and I know the er did multiple 12 leads what's going on there? What was the rythm before arresting. What changes if any after arrest. The coffee grounds in the n/g may simply be from what went down her throat during this drs attempt at intubation, I guessed it wasn't on continous suction, one thing bothers me the most that is the cpr on the fresh cabg site, I wonder if it has caused trauma and worst case torn the to arteries, with this case I wouldn't be surprised to find a tear somewhere causing the chest tube out put and also the hemo. That made them put it in . I really think that b/p is not only med. Induced but a really big sign. That I would puha cause its fixing to give out and be nothing. She is fixing to code again and i wouldnt want to be the one having to do cpr on her... I

 

[Maine iac]

So... how did the transfer go?

 

[abckidsmom]

BMP around the time of arrest was
Na: 128 K+:8.3 CL: 104 HCO3: 30 BUN: 26 Cr: 2.1 BGL:132

Now it’s
NA:132 K:+5.5 CL:108 HCO3:18 BUN:47 Cr: 3.3 BGL:108

K is down out of the sky, but still up, kidneys took a hit.

Physical exam as follows

HEENT: Intact, pupils are constricted and non-responsive. A clear fluid of unknown orgin is seeping from the nostril, an NG tube putting out some coffee grounds is in place. Airway is “secured” with the ETT in the throat, the physician, RT and nurse all tell you “it’s not really secured very well and if you pull it out she’s dead”, the ETT is full length and appears to have been tied with umbilical tape. There’s dried blood on the neck and a suction canister full of frank blood that came “from the cric (shrug)” at bedside. JVD is noted.

Phyisician is going to secure the airway with sutures before the patient is moved.

Chest: The whole this feels like mush. Equal rise and fall is noted, breath sounds are diminished, esp on the left, where there is a chest tube hooked to a water seal putting out frank blood (200mls). The CABG scar is present over the sternum, it remains closed (thankfully). A dual lumen subclavian cath was placed during the code, connected to it are dopamine at 20mcg/kg/min, norepinephrine at 20mcg/min. The nurse mentions she was getting vasopressin at one point too, but they D/C’d that an hour ago

Scary stuff, this. Was there a post-arrest 12 lead that may show evidence of the integrity or failure of the anastamosis?

Was this a post-arrest chest tube? When were the postop ones pulled and under what circumstances?

Can we get a CVP off of that central line?

Lets try and wean the vasopressin down a bit, and see what her pressure does. I'd like to wean the dopa down a bit too, but little bits at a time.

Abdomen& pelvis: Soft, but absent of any sounds. A foley is in place, there has been zero output since the arrest. A rectal tube it also present.

Extremities are intact, radial pulses are VERY narrow but absolutely bounding. A 20ga is present in the R wrist. The patient is very pale, cool to the touch.


Too late, its off and the patient does…..nothing. A couple of twitches, that’s it. The patient was 100% intact prior to the arrest.


HR of 136, B/P of 177/112, no resp effort outside the vent at 20, SpO2 of 99%, ETCO2 of 34

A/C at 20, vT of 550, 0 PEEP FiO2 of 80%

/rustyonvents. Is this probable hemothorax any reason to have no PEEP? Her pressure can handle this, maybe add some back in? And let's come down off of some of that FiO2 a little.

The patient was extuabted prior to the code, and scheduled to go home with in the next 36 hours or so.

PaO2 of 204
PaCO2 of 34
HCO3 of 31
Elevated gap and base deficit (can’t remember what they were at the moment)

Morbidly obese with poorly controlled HTN and diabetes.



Smoker, family history. They were unable to stent a 100% blocked vessel, but only one vessel. No idea on how long about the K+, the staff is seriously wigging out and “can’t remember”


CBC hasn’t been done post arrest (all other labs are off an iStat) pre-arrest it was a H&H of 10.1 and 42, can’t remember the white count.


No meds other than the dopa and levo


“Well she was REALLY anterior….”

She didn't have the hgb to support all this blood loss. This is really ugly.

To the staff, who want to pressure me to move her before we're ready: "Y'all don't want to push an unstable patient out the door of this facility, right? Let's get her stable, K?"

 

[usalsfyre]

Got tied up in meeting yesterday....

Sorry for the delay.

Aidey,
Pressors were started on the high end and quickly maxed. INR just came back as at 5.6.

Trimeal,
Chest tube was placed in response to a pneumo, likely due to CPR. You can't get a straight answer on the blood, the physician is being somewhat evasive. Chest tube is draining, the 200mls has been over three hours. She's on Lovenox. The physician tells you she's not on PEEP because of the pneumo.

thisgirlsisamedic,
EKG looked something like this immediately prearrrest:

abckidsmom,
Post arrest 12 lead

Chest tube is new, post-ops were pulled day two per the normal procedure there uneventfully.

CVP is 18.

So, we back off on the FiO2 to 0.5, add a little PEEP and decide to start weaning the pressors a bit.

As we turn the levo down from 20 to 15mcg/min, her pressure drops to 70/30 and we lose a radial.

Now what?

 

[Aidey]

Packed RBCs and FFP.

And just a radial or both? lol. What is the CVP now?

 

[abckidsmom]

Dang.

This facility has thoracic surgery And we are really going somewhere else? Holy EMTALA violation, batman.

Your train wrecks are always so morally complex!

Turn the the vasopressin back up to 18. Smaller steps. How much fluid has she had post arrest? She's gonna exsanguinate through her LAD on the way to the other hospital. Maybe the sternum wires are responsible for her pneumo and her tamponade that's forming?

 

[Melclin]

This facility has thoracic surgery And we are really going somewhere else? Holy EMTALA violation, batman.

Yeah whats the go with that? What the cardiothoracic surgeons opinion on all of this? I'm no expert but it kinda seems like they're ganna need to open her up again. They can't do that there? Seems like she should have been in theatre already.

 

[abckidsmom]

Yeah whats the go with that? What the cardiothoracic surgeons opinion on all of this? I'm no expert but it kinda seems like they're ganna need to open her up again. They can't do that there? Seems like she should have been in theatre already.

For real. I guess we, as the only people actively managing the patient, are going to need to do a pericardiocentesis. (lol, autocorrect suggestion was pericardial entrails)

What does her heart sound like?

 

[Veneficus]

Maybe the sternum wires are responsible for her pneumo and her tamponade that's forming?

If that is the case since the rough edges are usually bent towards the sternum I would probably want to go to another facility that deal with anymore care at this one.

Can't really complain about the emergent care, but it seems from the scenario the staff here was not prepared or experienced with this type of patient.

The doc wanting to punt to somebody who can or at least more comfortable with is probably a very good decision.

C/T surgery generates money. Taking the easy cases and referring the troublesome ones is a business decision.

 

[thisgirlisamedic]

This pts in icu and noone noticed lab.value changes, I know the last three labs drawn pre arrest were giving them clues to this it wasn't just a rapid onset it takes a while to get this out of wacky, I wonder what her sob panel shows dedimer

 

[Veneficus]

This pts in icu and noone noticed lab.value changes, I know the last three labs drawn pre arrest were giving them clues to this it wasn't just a rapid onset it takes a while to get this out of wacky, I wonder what her sob panel shows dedimer

It sounds like this patient was sent home and this event occured in the ED unless I understood it wrong.

Renal changes can take days or even a week before clinical symptoms appear.

Prior to that, measurements of GFR and creatinine elevate usually 24 hours+ post insult.

If this lady was bed confined, coagulation events like DVT converting to PE, as well as DVT expanding past the renal arteries are not only possible, but I have seen them.

It really sounds to me like a this very complex resuscitation somehow ended up at a place that doesn't deal with this kind of event.

But I think it demonstrates that simple guidline based resucitation doesn't always work very well.

I also think it demonstrates very nicely the need and value of surgical intensivists.

 

[thisgirlisamedic]

Elevated? Her coumadin kinda high but know she running a rib I wouldn't mess with the vitamin k besides its slow acting, when and what are her meds and last given, why have the not done a stat scan to look at what trauma they caused post arrest, moving her to risky I still think she has a tear in a major blood vessel and i wouldn't want to finish tearing it, I would really talk to staff about testing Murphy's law here......and i would at least like blood to be hanging to cause my fluids won't do anything but make her bleed pink, you can only maintain a b/ p with a drip for so long, I really wonder what was her urinary output pre arrest? Was she able to eat yet. Last meal and blood sugar insulin given, during this stay did she get a transfusion? Possible if there is already this level of incompetence that this onset was from a reaction to the transfusion or wrong meds given . It still bothers me that they should be doing labs q 2 hrs or at least q 4 for sure I wonder what changes took place over the last 12 hours of labs? It would be nice to see here pre and post SOB panel and blood sugars and insulin given