Trainwreck #4

[usalsfyre]

So life has curb stomped my ability to post here lately, but I'll try to get back on track.

Your on a ground CCT unit in a metro area and are dispatched to a LTAC ICU for a 64 YOF post-arrest going to major-university hospital ICU across town. On arrival you find an unconscious, intubated patient who arrested 4 hours ago, had a ROSC and is now on a dopamine drip.

Go...

 

[fast65]

First of all, what is LTAC?

Well lets start off with a little info:

Specs/Orders:
-Transport time?
-Crew?
-Vent settings?
-ETT depth?
-IV's, number/location?
-Dopamine dosage/drip rate?
-Other medications?

History:
-What is the patients medical history?
-Medications?
-Allergies?
-Cause of the arrest?

Vitals:
-HR, rhythm
-BP
-SpO2
-Temp
-LS
-Weight

Forgive all my questioning, I'm not real used to IFT's yet.

 

[systemet]

So life has curb stomped my ability to post here lately, but I'll try to get back on track.

Your on a ground CCT unit in a metro area and are dispatched to a LTAC ICU for a 64 YOF post-arrest going to major-university hospital ICU across town. On arrival you find an unconscious, intubated patient who arrested 4 hours ago, had a ROSC and is now on a dopamine drip.

Go...

What's an LTAC ICU?

Is this an in-hospital or out-of-hospital event? What were the circumstances surrounding the arrest? Was CPR performed, and for how long? Do we have any trauma from the resuscitation attempt? How many defibrillations? What medications were given? What pre-existing medical conditions does the patient have? What are their current medications? Do they have allergies to any meds?

LOC: Patient GCS? Are they paralysed? Have they had sedation / analgesia? When was their last sedation / analgesia dose? Last NMBA, if applicable? Neuro exam?

Airway: confirm tube placement? A/E and capnograph, tube fogging, etc. What size ETT? Is it appropriate for the patient? Is it adequately secured? How deep is it? How does this compare to their documentation - has it moved? Pilot balloon inflated? Do they have CXR verifying placement depth?

Breathing: Is the patient manually or machine-ventilated? What FiO2, what settings, what mode of ventilation, what settings? SpO2? Do they have an ABG? Is the patient breathing spontaneously? Do we know anything about airway pressures? Are their lungs relatively compliant?

Circulation: HR, B/P, do they have an arterial line? Any ECGs? If not, let's do one. Is there a permanent or a transvenous pacemaker present? Do they have peripheral or central IV access? How many sites, are they patent? Are they catheterised? Any urine output?

Meds: What's the dopamine running at? What sort of site is it running through, does it appear to be patent?

Do we have any labs, including a recent blood glucose? Are any other medications running? Does the patient have an NG tube?

Physical exam? And such. Code status? No one has found a DNR since the arrest happened?

Basically, I'd like to know what went wrong, what they've done, and whether it appears to be working. Lots of questions! I don't mean to sound pushy, thanks for putting up a scenario.

 

[usalsfyre]

Sorry for the confusion, LTAC stands for Long Term Acute Care, a facility that can provide acute and intensive care for >90 days. It's sort of a mix between a hospital and a nursing home, but considered a hospital by the government.

The patient is admitted for care of stage IV decubitus on her sacrum and legs. She also has a history of diabetes, hypertension and ESRD which she receives hemodialysis for.The patient takes atenolol,and is on an insulin sliding scale. An hour after receiving dialysis she was witnessed slumping over and found to be in cardiac arrest. The patient received CPR and one round of epi for PEA before regaining a pulse, the systolic B/P was found to be in the 60s so the patient was started on dopamine which was titrated "quickly" to 20mcg/kg/min, in addition the patient had received in the neighborhood of 3 liters of NS. The only access you have is a single lumen IJ where the dopamine is running. The patient was intubated with a 7.5 ETT placed to a depth of 22cm at the lips, vent settings are assist control at a rate of 24, vT of 400mls, PEEP of 5, FIO2 of 1.0 and a 1 second I time. The nurse tells you the patients doctor diagnosed a perforated bowel via chest x-ray. The patient is airborne isolation for MRSA, C.Diff, AND VRE (all the good stuff)

Physical exam shows a an unconscious intubated patient, GCS of 5 (E1, V1, M3).

Head is intact, an NG tube is in place draining draining dark green (and has appx 3l of drainage today). No JVD is present, in fact the jugular veins can't be palpated on the 55kg patient.

Breath sounds are equal, rhonchi is present in the right base, otherwise clear. No spontaneous respiratory effort seems to be present

Abdomen is non-distended, a colostomy and large surgical scar are present. A foley cath is in place, the patient has no UO today.

Extremities are intact except for the frank, multiple decubitus present on the legs.

The current vitals are B/P 136/84 via NIBP, HR of 146, SpO2 of 100% and ETCO2 of 22 with a square waveform. No meds besides the epi or dopamine have been administered.
EKG:

No DNR, the family at beside is just saying "keep her alive, please". Transport time is 30 minutes, your partner is a medic but he has to drive, and is a graduate of a 10 week program and his only other EMS experience is as a non-transporting paramedic on a garbage truck .

 

[usalsfyre]

Crap, forgot labs.

Na: 132
K+: 3.3
Cl: 97
HCO3: 24
BUN:28
Cr: 1.3

H&H: 10.2 & 28
WBC: 12.5

 

[fast65]

And did we have an ABG's?

I suppose all there is to do at this point is to get her ready for transport...and await the subsequent trainwreck

 

[usalsfyre]

No ABGs. What can we do to optimize her for transport? There's a couple of adjustments to be made that will help.

 

[fast65]

Bear with me as I just got off shift, but the only thing I can think of at the moment is to decrease the ventilatory rate to try and bring the ETCO2 up to a more reasonable level. With the ESRD (which I suspect stands for End Stage Renal Disease) her body is going to be relying a lot more on her respiratory status to maintain the acid-base balance, so we'll need to manage that for her. I would also like to attempt to obtain another site for vascular access if possible.

I'm pretty sure that half my paragraph didn't make any sense, am I'm ok with that. h34r:

 

[usalsfyre]

Bear with me as I just got off shift, but the only thing I can think of at the moment is to decrease the ventilatory rate to try and bring the ETCO2 up to a more reasonable level. I would also like to attempt to obtain another site for vascular access if possible.

Sounds great, you back the vent down to 16 with no ill effects, and manage to slide in a 20 ga for further access. Another thought is backing down the dopamine, a pressure of 136/84 is great, but not with a HR in the 140s. Her MAP is 101, back down on the dopa to keep a the MAP above 80 and get the HR down. Finally the patient still seems dry (ultra flat jugulars) so a bit more fluid may be in order.

You do all of the above, the vitals improve (B/P of 106/74, HR of 108, SpO2 of 96% and ETCO2 of 37). and 10 minutes into the transport the sat suddenly drops into the 70s, the HR spikes to 130 and the pressure drops to 50 over ---.

 

[systemet]

Sounds great, you back the vent down to 16 with no ill effects, and manage to slide in a 20 ga for further access. Another thought is backing down the dopamine, a pressure of 136/84 is great, but not with a HR in the 140s. Her MAP is 101, back down on the dopa to keep a the MAP above 80 and get the HR down. Finally the patient still seems dry (ultra flat jugulars) so a bit more fluid may be in order.

You do all of the above, the vitals improve (B/P of 106/74, HR of 108, SpO2 of 96% and ETCO2 of 37). and 10 minutes into the transport the sat suddenly drops into the 70s, the HR spikes to 130 and the pressure drops to 50 over ---.

Wow. This is moving quicker that I can keep up! I was just typing a response to earlier! Rhythm check?

 

[fast65]

Alright, well let's start by checking our vent and making sure nothing malfunctioned with it. I want to recheck my LS, tube depth, and look for secretions. Is there anything that I find that may have caused this rapid decline? Did she buck the tube?

Rhythm?

Lets give her a fluid bolus, pending our check of LS. With her being that "flat", and with those vitals, I'm suspecting there's some sort of hypovolemic shock going on here, so I'm a little hesitant about turning up the dopamine. Let's see how she handles the fluid, then we can start thinking more about turning the dopamine up.

 

[usalsfyre]

Rhythm is now:

Lung sounds are absent in the right, tube is still at 22cm. The chest seems to be rising unequally. All your equipment seems to be workig as before, except the vent is now alarming high PIPs and the monitor is screaming to "check patient".

 

[systemet]

{Edit: ha ha... just posted this, then saw the post above! Looks pretty funny)


Ok. So to the original condition:

* Seems reasonable that she's probably septic; decubitus bed sores are one possible culprit, perforated bowel is another, and the right basilar rhonchi are probably a secondary infection but are also suspcious. She's also got leukocytosis. Might be interesting to know her temp.

* Agree with changing the vent. Although if she is alkalotic (and it seems reasonable that she is), I'm a little worried about what the K+ might do, as she's already hypokalemic. Could also be a cause of the arrest. [<----- Second edit: This is stupid, taking the pH down by reducing the minute volume will increase serum K+. Sorry.]

* Would love to know how much they took off at dialysis, whether she's been normally compliant, and any previous problems. Would be interesting to know about the previous abdo. surgery. How is the colostomy site? Another potential route of infection.

* ECG is difficult to interpret due to quality, as often happens in real life. Sinus tachycardia, with left axis deviation, Sokolow-Lyon criteria for LVH. Possible lateral strain / ischemia I / aVL, V5, V6. Hard to measure the QT, but makes you wonder if it isn't a little long perhaps? No clear infarct pattern. Difficult to say if there's a hemiblock there.

* Agree that she may be volume depleted, wrt the jugulars, and the tachycardia, which seems quite significant for a 60 year old on beta-blockers.

* Assuming the glucose is normal?

* Would be nice to have an in-line filter on the ETT.

 

[systemet]

Rhythm is now:

Lung sounds are absent in the right, tube is still at 22cm. The chest seems to be rising unequally. All your equipment seems to be workig as before, except the vent is now alarming high PIPs and the monitor is screaming to "check patient".

Pulse?

Ok. Run the mnemonic. Tube's not displaced. Let's fire a suction cath down the ETT to make sure there's not been some sort of mucus plug. If the tube's clear, I think it's time to decompress the right side of the chest, and think about cardioversion / defibrillation, if decompression fails to resolve the arrhythmia.

 

[fast65]

Hmmm, well that is most certainly is a problem. Do we have a pulse? I'm going to say that the WCT is being caused by hypoxemia, and I suspect she may in fact have a pneumo. Let's go ahead and decompress her chest on the right side (2nd intercostal space, midclavicular). I imagine that will resolve the absent lung sounds, raise the SPO2 and cause the WCT to convert into a more stable rhythm (hopefully not asystole :rofl.

 

[exodus]

Hmmm, well that is most certainly is a problem. Do we have a pulse? I'm going to say that the WCT is being caused by hypoxemia, and I suspect she may in fact have a pneumo. Let's go ahead and decompress her chest on the right side (2nd intercostal space, midclavicular). I imagine that will resolve the absent lung sounds, raise the SPO2 and cause the WCT to convert into a more stable rhythm (hopefully not asystole :rofl.

Could it be possible the tube went down too far somehow and is only in one lung?

 

[fast65]

Could it be possible the tube went down too far somehow and is only in one lung?

Not likely, we initially had bilateral breath sounds when we left and the tube depth was noted at 22 cm, so it hasn't moved since we left.

 

[exodus]

Not likely, we initially had bilateral breath sounds when we left and the tube depth was noted at 22 cm, so it hasn't moved since we left.

True, I missed the bi-lat breath sounds initially. There's some places around here that wouldn't surprise me if they had an improper placement.

 

[abckidsmom]

Not likely, we initially had bilateral breath sounds when we left and the tube depth was noted at 22 cm, so it hasn't moved since we left.

And 22 at the lip struck me as slightly shallow anyway.

We took her off the vent and are bagging her now, right? Does she have any respiratory drive on her own?

Oh, and cardiovert or defibrillate, depending.

You sure know how to bring a train wreck. IFT scenarios should be "Usals's EMTALA violations."

 

[Handsome Robb]

I'm late to the party, like usual

I'm definitely thinking sepsis/septic shock. I don't think it is hypovolemic in nature due to her receiving ~3L at the sending facility then us putting more onboard and the pt having no urine output. The ulcers and perforated bowel don't help her case either.

I agree with everyone's treatment on the current problem, check the tube, decompress the right side of her chest, cardiovert/defib as appropriate.

Kinda glad we don't do too many IFTs around here, cause this one is making me feel on the slow side.