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….”