See...I dont write everyone off Hern..

[Bostonredsox]

case. admitted about 8 hours before my shift.

64 y/o Wfemale w PMH of laryngeal Ca s/p recent trach/peg, trach now removed, and surgical debulking of tumor. prior history of PE not currently on VKA

PEA arrest in field-->ED--> 60 minutes of CPR. Survives arrest. Unresponsive and in shock.
No bedside echo in ED. CTA shows b/l PE's, non-saddle, mainly segmental PEs.

ED treats as massive PE with subsequent PEA arrest, Lysed with TPA. Started on EPI and Dopa...

Labs in ED
WBC 23k, H/H 9.6/31, Plt 424, normal renal panel except bicarb 15 and phos 11.4

lactate 15.2 initial Cardiacs 218/10/0.7 UA Dirty 4+ bac TNTC whites Chest clear

pH 6.83/47/117/8 on vent (took them 45 min to tube her with some old school Bullard scope?? totally f'd up her teeth and mouth, full of blood, no NGT placed)

Arrives in MICU. CTS consulted for throbectomy. Cards does stat Echo. Normal RV. No strain. Very mild PAP elevation. LV hyperdynamic near 75% but study was done on epi and dopa.

I pick her up at 7p. review chart and labs. Pressor combo seems odd to me. to my own bedside echo. LV is def hyperdynamic. RV is near normal. Massive PE with normal RV?? starting to look more to me like septic shock from UTI, and coincicental segmental PEs in a cancer pt with history of PE. Call the MICU attending who just got back from vaca at home, daytime attending who admitted was one of the fill in hospitalists. She agrees with me.

talk with family. lactate 15. APACHE II 28. high risk of dying in next 24 hours. but i would recommend finishing the next 24 with full press and then reasses.. they agree. tell them even if she survives, high chance of short term dialysis.

lot of ectopy on monitor. Add vasopressin, wean off dopa. Add Levo, wean off epi. add stress dose steroids. Change vent around. Increase rate and TV to help with CO2 exchange and acidemia. pH improves from 7.1 to 7.28. Drop in NGT to decompress the gut full of blood. Cxry with no evidence of ARDS/ALI pattern and she is not terribly hypoxemic, paO2 is 155 on 40%. toss in an IJ to get a real CVP, ED had put in a fem....which after a cvp reading showed 65, i sent dual abgs from it and radial art to demonstrate it was in fem art. CVP from my IJ is 6. Coorelates with bedside imaging of her collapsing IJs on inspiration and an underfilled IVC. bolus her 8+ times throughout the night. . rpeat poc lactates and abgs throughout night to adjust vent and get acidemia corrected. Add sco2 monitoring with my IJ. 51. Repeat imaging. EF not quite so hyperdymanic, but epi and dopa are off. crit is now 23 from oral bleeding due to the horrible techniqued intubation in ed. 3 units prbcs. crit >30. scvo2 still low 60s. add some dobutamine. weaned off vaso. by end of shift had given another 8L of crystalloid. Levo almost off. she is starting to follow commands. poc lactate 2.4

Next day her levo and dobut are weaned off. she is waking and following commands. allowed to rest on VACV for rest of day/night.
Extubated this morning. talking. numbers improving, except UOP which trended down and Cr which trended up as I expected. A bit volume overloaded now. Gettign some albumin/lasix. UOP picking up a little bit. might be able to avoid short term HD.

Saved. This is why I do this job. Nothing is more satisfying then putting in the work that it took to save this lady and actually getting a good outcome.

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[Hernandez]

64 y/o Wfemale w PMH of laryngeal Ca s/p recent trach/peg, trach now removed, and surgical debulking of tumor.

A few points and questions for the crew.....

1) don't count it as a save until they walk out of the hospital......it often isn't the admitting issue that kills them.

2) this sounds like a stage IIIA-IV ca, so you'd make CMO vent's case but not someone with an cancer that can't be cured? I know that many onc docs are claiming that their onc pts have better survival from ICU admission than matched cohorts, but I frankly I'm invoking shenanigans......I don't buy it.

3) why 8+L? Was she 200kg? If she really bled that much from trauma & tPa, I agree with PRBC, but what index promoted 8 additional liters of crystaloid?

4) and what are your thoughts on stress dose steroids? (There isn't a correct answer, but I have my bias) was she really that hard to control with tincture of leave-em-dead?

 

[isquared]

Thanks for posting this. It's nice to hear about a save when it happens. I have had patients ROSC in the field before, but only one has ever made it to discharge. (I'm a paramedic non-trad).

 

[Bostonredsox]

A few points and questions for the crew.....

1) don't count it as a save until they walk out of the hospital......it often isn't the admitting issue that kills them.

2) this sounds like a stage IIIA-IV ca, so you'd make CMO vent's case but not someone with an cancer that can't be cured? I know that many onc docs are claiming that their onc pts have better survival from ICU admission than matched cohorts, but I frankly I'm invoking shenanigans......I don't buy it.

3) why 8+L? Was she 200kg? If she really bled that much from trauma & tPa, I agree with PRBC, but what index promoted 8 additional liters of crystaloid?

4) and what are your thoughts on stress dose steroids? (There isn't a correct answer, but I have my bias) was she really that hard to control with tincture of leave-em-dead?

1) true. but I have a strong suspicion she is going to walk out. you are correct though.

2) Im not sure on the cancer staging. shes not getting chemo. surgery done at outside hospitalt didnt have records yet. and from what I have see, these onc patients just dont die. they withstand the storm like no other. maybe because there so sick they cant mount the same massive inflammatory response as healthy pts? idk. but they seem to survive like black ops commandos.

3) I didnt bolus 8L. I bolues close to 5. 4 and change. but her drips even double concentrated, were totaling around 250ml/hr. and i bolused based on combo of my bedside US, CVP, MAP and UOP. she was consistently showing she was volume down. part of that im sure was her albumin of 1.3 so she was third spacing alot of what I was giving her, hence the replacement albumin. and yes she is a big lady. not 200kg but somewhere around 270 lbs
And yes she bleed alot. I got 700 from NGT. Tpa plus she was on heparin drip which went supratheraputic for a bit and had been on asa. she had dropped to a hb of 7.2

4) my thoughts are if the source is septic shock requiring multiple pressors, or if they are in shock with recent surgery (she was both, i forgot to mention the laryngeal cancer sx was 3-4 weeks ago) i roid them for the 5 days. I did check a random cortisol which was liek 15, but I would have given them if it was 30. there is really nothing to lose except some hyperglycemia, which she had anyway as the admit team put her on a bicarb drip at 200, which is in D5, which tool her sugrs to 600. I promptly stopped the bicarb and used the vent to fix the acidosis. My interpretation of the data is septic shock requiring multiple vasopressors and still not at map goal gets stress dose steroids with resultant improvement in mortality outcomes. now, idk if they need to be tapered or not. i have read study that says yes, and i have read one that says no need to, just give for 5 days.

 

[Hernandez]

2) Im not sure on the cancer staging. shes not getting chemo. surgery done at outside hospitalt didnt have records yet. and from what I have see, these onc patients just dont die. they withstand the storm like no other. maybe because there so sick they cant mount the same massive inflammatory response as healthy pts? idk. but they seem to survive like black ops commandos.

"Debulking" is palliative in most cases and not curative, althought a trach/peg combo would suggest(in my biased experience) that it was a radical neck that was done so potentially a lower grade, but higher grade cancers don't do well in ICU setting.

3) I didnt bolus 8L. I bolues close to 5. 4 and change. but her drips even double concentrated, were totaling around 250ml/hr. and i bolused based on combo of my bedside US, CVP, MAP and UOP. she was consistently showing she was volume down. part of that im sure was her albumin of 1.3 so she was third spacing alot of what I was giving her, hence the replacement albumin. and yes she is a big lady. not 200kg but somewhere around 270 lbs

3 of those do not predict intravascular status, nor do they predict fluid responsiveness. Marik just released another meta-analysis on CVP and is getting more colorful in his quest to kill CVP.

4) my thoughts are if the source is septic shock requiring multiple pressors, or if they are in shock with recent surgery (she was both, i forgot to mention the laryngeal cancer sx was 3-4 weeks ago) i roid them for the 5 days. I did check a random cortisol which was liek 15, but I would have given them if it was 30. there is really nothing to lose except some hyperglycemia, which she had anyway as the admit team put her on a bicarb drip at 200, which is in D5, which tool her sugrs to 600. I promptly stopped the bicarb and used the vent to fix the acidosis. My interpretation of the data is septic shock requiring multiple vasopressors and still not at map goal gets stress dose steroids with resultant improvement in mortality outcomes. now, idk if they need to be tapered or not. i have read study that says yes, and i have read one that says no need to, just give for 5 days.

Did the new SS guidelines to back to recommending a random cortisol level? I thought the new consensus was its a waste of money? If you read corticus, and the original anon studies, the cortisol doesn't predict responsiveness to stress dosing steroids, if you're thinking of giving it, just give it

I can only guess, but if you're giving 250cc of Ivf with drips, she must have had an enormous pressor requirement, which is precisely when I give SDS



......yes, you'd HATE being on rounds with me.....but at the end of the day I'd still say good job, a win is a win, there's just a lot of things to learn, and I want the residents to justify what they do and why they do it and not just blindly accept dogma as medicine

 

[Bostonredsox]

"Debulking" is palliative in most cases and not curative, althought a trach/peg combo would suggest(in my biased experience) that it was a radical neck that was done so potentially a lower grade, but higher grade cancers don't do well in ICU setting.



3 of those do not predict intravascular status, nor do they predict fluid responsiveness. Marik just released another meta-analysis on CVP and is getting more colorful in his quest to kill CVP.



Did the new SS guidelines to back to recommending a random cortisol level? I thought the new consensus was its a waste of money? If you read the corticus trial, .......pending

2) I agree on the increasing level of scrutiny and recommendations against using CVP. hence I am doing the bedside US. Of note from my own personal expericine, I have many times seen a very poorly filled IVC that correlated with a CVP of 3, bolused, seen an improvement in the CVP and the IVC measurements. using CVP alone is not the greatest tool. but If I am doing bedside US and correlating it with my CVP, well, is there a better way to assess fluid status in a community icu??

3) havent seen the newest data, and I have read corticus obviously. I give roids based on <MAP goal on 2 pressors in septic shock. I draw the cortisol level because my attendings have asked me too.

yes her pressor requirement was enourmous.

and I disagree, I would enjy rounds with you. I am in this to learn. I want to be an extremely proficient intensivist, and the only way to become one is to learn from one. And with the compliments I have received for being an above-average medicine resident in terms of CCM skills, I have also receive my share of pimping, grilling, questioning and flat out 'dont to that **** again", from my good caliber attendings. Trust me, coming from someone who ALWAYS wants to know why, I would not have a problem with you qustioning as to why I am doing what I am doing. that can only make me a better doctor.

 

[bigtuna]

just because RV was normal post-lytics does not mean that the arrest was not due to PE....nice job on management.

 

[Bostonredsox]

Thanks man. She transferred to SDU today

 

[VentdependenT]

i would have been pissed if ed pushed tpa with that ct scan, no rv strain on ekg, and for not breaking out the echo if they are gonna call this a massive PE. Jesus christo, you can even see rv strain on a ctpe protocol... It ficks up lines and cracked and crushed ribs and busted sternums bleed.

ive never seen someone survive after 1hr of cpr. At least not in someone who hasnt been pulled out of a frozen pond or saved from cold exposure.

Anyways nice work dude. You got the skills to pay the bills. Now god can sort out the rest.

And yes new SS guidelines say no more random cortisol and yes they still support cvp. Good article in journal of ccm on cvp. They are putting the nail in the coffin. marik, one of the authors, is the bingbambombdiddybomb yall.

 

[soonereng]

64 y/o Wfemale w PMH of laryngeal Ca s/p recent trach/peg, trach now removed, and surgical debulking of tumor....

pH 6.83/47/117/8 on vent (took them 45 min to tube her with some old school Bullard scope?? totally f'd up her teeth and mouth, full of blood, no NGT placed)

ENT resident here. Bad idea on the ED's part to try to intubate someone with laryngeal cancer with a just removed trach. Should have just reopened the trach site. Much faster than 45 minutes (even easier than a cric with the surgical scar as a guide) plus who knows how big the tumor is. Might still be unable to intubate even after "debulking" if the tumor has regrown any at all.

"Debulking" is palliative in most cases and not curative, althought a trach/peg combo would suggest(in my biased experience) that it was a radical neck that was done ...

Agreed about the palliative nature of debulking a laryngeal tumor. Hard to tell without the records although you would definitely be able to see the (lateral) surgical scars from a neck dissection. Usually two treatments for laryngeal cancer with chemo/xrt being used primarily for organ preservation and salvage laryngectomy should that fail or recur.

 

[Hernandez]

ENT resident here. Bad idea on the ED's part to try to intubate someone with laryngeal cancer with a just removed trach.

Hate actually a good point, I didn't even focus on the difficult airway part, but that would be a disaster to try and tube.


Of course where I trained, ENT wasn't in house, so we'd have called trauma who would have recommended a palliative care consult and refused to do any procedures

 

[bigtuna]

I tend to be quite conservative with lytics for PE but I have to say I don't disagree with them in this particular case. Of course, bedside echo should have been done immediately in ER but if not available and pt in refractory shock I would give them. Hard to know if additional clot since ct, etc. Something about this case doesn't smell like your run of the mill case of urosepsis. Hard to say without being there I guess. Did the blood cultures turn positive later?

How many would have put this patient of hypothermia? I probably would have with that long of down time. We tend to be very liberal with the hypothermia indications - I have not seen much problem with increased bleeding though that would be a theoretical concern.

 

[Bostonredsox]

I tend to be quite conservative with lytics for PE but I have to say I don't disagree with them in this particular case. Of course, bedside echo should have been done immediately in ER but if not available and pt in refractory shock I would give them. Hard to know if additional clot since ct, etc. Something about this case doesn't smell like your run of the mill case of urosepsis. Hard to say without being there I guess. Did the blood cultures turn positive later?

How many would have put this patient of hypothermia? I probably would have with that long of down time. We tend to be very liberal with the hypothermia indications - I have not seen much problem with increased bleeding though that would be a theoretical concern.

I agree. With only a CT and a pea arrest I would have assumed massive pe and subsequent shock and lysed too. But an echo would have changed that.

I thought about cooling her too. Our protocol is new and only allows for cooling in vf vt arrests. In addition septic shock is an exclusion. I asked my MICU attending about it and she said based on our current protocol she could not have been put on it but she agrees, it may have actually been a good idea. She survived anyway though.

And to hern and the ent, I agree, disaster to try and tube. If she had coded, just access the trach site IMO. However I thought she may have self extubated upstairs and I stuck a Mac in and carefully followed the tube and was actually able to see the cords and the tube going through it. Her mouth was unable to really be widened so it was somewhat difficult for me to manipulate but based on what I was able to see I don't see why she took 45 min to tube. It would have been easy to slide a bougie in the narrow opening and then a tube over it.

 

[VentdependenT]

I tend to be quite conservative with lytics for PE but I have to say I don't disagree with them in this particular case. Of course, bedside echo should have been done immediately in ER but if not available and pt in refractory shock I would give them. Hard to know if additional clot since ct, etc. Something about this case doesn't smell like your run of the mill case of urosepsis. Hard to say without being there I guess. Did the blood cultures turn positive later?

How many would have put this patient of hypothermia? I probably would have with that long of down time. We tend to be very liberal with the hypothermia indications - I have not seen much problem with increased bleeding though that would be a theoretical concern.

You dont put someone requiring multiple pressors and septic ahock on hypothermic protocol

With a ctpe not showing rv strain or large emboli or engorged PAs no fuggin way in hell id push lytics

Hypovolemia (multiple causes), pump failure (multiple causes), Obstruction to flow (multiple causes), and hypoxia(multiple causes), all cause pea. lytics MAY save some lives for PE(small studies with endpoints of death or recurrence) they do improve numbers and cut down on pulm htn from developing and recurrence of future PE's. If you can keep em going with pressors then get an echo before pushing a drug notorious for brain bleeds. This aint a stroke or stemi.

 

[bigtuna]

You dont put someone requiring multiple pressors and septic ahock on hypothermic protocol

.

I don't think this is true. I was told this in training but in practice have found hypothermia to be very well tolerated from both a hemodynamic and cardiac rhythm standpoint. You can always raise your goal temperature a bit if you think the hypothermia is causing problems.

The argument could be made that this patient doesn't meet strict criteria for hypothermia since it wasn't vt/vfib but I think the potential benefit outweighs risk - most pt's with CPR this long end up with some significant neurologic sequelae.

 

[Bostonredsox]

edit:

trasnferred back from SDU to MICU today. Some pulm edema coupled with agitation and COPD--> back on the vent. Trach probably tomorrow. which she should have had on arrival to ED.

 

[redy]

I believe septic shock is a contraindication for hypothermia, whether its a relative or absolute contraindication I am not sure. In a patient requiring 2 pressors I wouldn't do anything to worsen her immune status.

I cannot believe that after 1 hr downtime she woke up and followed commands.

 

[ORL10]

Most people don't roll into the ER with septic shock in PEA and get ROSC in general and hypothermia is generally tolerated even if on vasopressors. There are studies that suggest an increase in infection rate which is a "contraindication" for TH.

But, if you had thought it was a PE this might be a great pt to give TH to even if no VFIB/VTACH, even if the evidence isn't based on good RCT's at this point.

As for steroids the original Annane paper had a much higher mortality rate (near 60%) compared to Corticus, not to mention the Corticus trial was completed after the Annane study was published and a lot of physicians did not want to enroll their patients in a trial in which they may not be getting steroids.

therefore I think a patient on 2 pressors you couldn't fault someone for starting hydrocortisone.

 

[Hernandez]

The corticus trial was a crap study, underpowered, high inappropriate antibiotic selection, and allowed enrollment up to 72 hours after presentation. The trial should be stricken from our lexicon.

 

[bigtuna]

Most people don't roll into the ER with septic shock in PEA and get ROSC in general and hypothermia is generally tolerated even if on vasopressors. There are studies that suggest an increase in infection rate which is a "contraindication" for TH.

But, if you had thought it was a PE this might be a great pt to give TH to even if no VFIB/VTACH, even if the evidence isn't based on good RCT's at this point.

As for steroids the original Annane paper had a much higher mortality rate (near 60%) compared to Corticus, not to mention the Corticus trial was completed after the Annane study was published and a lot of physicians did not want to enroll their patients in a trial in which they may not be getting steroids.

therefore I think a patient on 2 pressors you couldn't fault someone for starting hydrocortisone.

I'm not aware of any data stating that pre-existing infection is a contraindication to TH. Retrospective data suggests increased rates of infection (especially pna) after TH but thats not surprising given this is a group that is ripe for aspiration and then paralyzed and mechanically ventilated.

I wouldn't use the etiology of the shock (PE vs sepsis vs other) as part of my decision whether or not to chill. Everyone is on 2 pressors after 60 minutes of CPR.

 

[VentdependenT]

Most people don't roll into the ER with septic shock in PEA and get ROSC in general and hypothermia is generally tolerated even if on vasopressors. There are studies that suggest an increase in infection rate which is a "contraindication" for TH.

But, if you had thought it was a PE this might be a great pt to give TH to even if no VFIB/VTACH, even if the evidence isn't based on good RCT's at this point.

As for steroids the original Annane paper had a much higher mortality rate (near 60%) compared to Corticus, not to mention the Corticus trial was completed after the Annane study was published and a lot of physicians did not want to enroll their patients in a trial in which they may not be getting steroids.

therefore I think a patient on 2 pressors you couldn't fault someone for starting hydrocortisone.

Would you start TH on someone who you just gave lytics to?

I still wouldnt deep freeze a septic shock pt

 

[Bostonredsox]

Would you start TH on someone who you just gave lytics to?

I still wouldnt deep freeze a septic shock pt

We just had an in service on TH from one of the cardio guys at duke. He said they have not had many cases, but a pea arrest from massive pe that gets lysed can and has been cooled. Bleeding is higher risk, but not a contraindication. He said they're pretty much cooling everything except septic shock arrests and patients who are already fixed/dilated for a prolonged period before they ever regained Rosc.

 

[bigtuna]

Would you start TH on someone who you just gave lytics to?

I still wouldnt deep freeze a septic shock pt

No hesitation to TH someone after lytics if I thought at risk for hypoxic brain injury.

I think the sepsis issue is a judgment call.

PEA arrest in bacteremic pt with MOSF/DIC/etc - probably not
PEA arrest in patient with PNA on some pressers - probably so

 

[gro2001]

I don't see why she took 45 min to tube. It would have been easy to slide a bougie in the narrow opening and then a tube over it.

How can you say that it's a 'bad idea' to try orotracheal intubation in the same breath with 'actually it should have been easy, I don't know why they had so much difficulty'?

Pick your side, either it was a crazy airway to even attempt orotracheal intubation and they should have gone straight to surgical airway OR it might have been a reasonable one to attempt, after all you could confirm tube placement by DL without too much difficulty. You can't have it both ways.

 

[Bostonredsox]

How can you say that it's a 'bad idea' to try orotracheal intubation in the same breath with 'actually it should have been easy, I don't know why they had so much difficulty'?

Pick your side, either it was a crazy airway to even attempt orotracheal intubation and they should have gone straight to surgical airway OR it might have been a reasonable one to attempt, after all you could confirm tube placement by DL without too much difficulty. You can't have it both ways.

From what I saw it was easy to see on DL. That said, they could only get a 6.0 in both times. She's trached now with a much bigger tube. I would have trached from the start.

 

[gro2001]

From what I saw it was easy to see on DL. That said, they could only get a 6.0 in both times. She's trached now with a much bigger tube. I would have trached from the start.

An emergent open trach should never be a bedside procedure. Percutaneous trach, sure, but I don't think that should be your go to surgical airway. Cric is what you should do emergently if you are going for it. I challenge you to find a difficult airway algorithm that says to go straight to surgical airway except in cases I described (jaw wired shut, complete tracheal trans section).

 

[Bostonredsox]

Her mouth didn't open more than a few cm. she has a plastic jaw. They couldn't see and took 45 min to tube Initially. After 5, I would have sliced open her trach scar, stuck a bougie in it and then a tube over that. Technically that is a cric. Later upstairs I would have converted it to a formal trach with surgeries assistance.

 

[gro2001]

Her mouth didn't open more than a few cm. she has a plastic jaw. They couldn't see and took 45 min to tube Initially. After 5, I would have sliced open her trach scar, stuck a bougie in it and then a tube over that. Technically that is a cric. Later upstairs I would have converted it to a formal trach with surgeries assistance.

So now you say you would have given DL a shot? And only after 5 (not sure if you mean minutes or attempts) would go to surgical airway? Was she easy to bag in between attempts? If it was a can't intubate - CAN ventilate situation it still does not make surgical airway a must, just one of many options. You also have the options for: bougie, fiberoptic, nasotracheal, ahem... retrograde (mostly joking about this one), intubating LMA... Now if you are saying they were not able to bag ventilate her for 45 minutes (sounds somewhat implausible however), then you are absolutely right, emergent surgical airway is the right step.

Also, no, that is not 'technically a cric'. A cricothyroidotomy is when you puncture the cricothyroid membrane. When you incise the trachea, which is what you were suggesting, albeit with the guidance of a surface scar, is a tracheostomy. What makes you think that having had a trach before makes for an easier procedure? Do adhesions and scarring, let alone her neck malignancy, make it more or less likely that you will encounter an unexpected complication, vascular catastrophe, create a false track or be unable to complete the procedure? Correct me if I am wrong, but even if you have some experience with cric's you probably don't have a lot of experience with open trachs, unless your CCM heavy IM residency is even more amazing than you led us to believe.

You speak of 'slicing' her neck as if you do have a lot of surgical airway experience. If that's the case, humor (or educate) me, how many crics and how many trachs have you done? How many of the trachs were emergent? How many complications have you seen or encountered in your own practice?

 

[jdh71]

So now you say you would have given DL a shot? And only after 5 (not sure if you mean minutes or attempts) would go to surgical airway? Was she easy to bag in between attempts? If it was a can't intubate - CAN ventilate situation it still does not make surgical airway a must, just one of many options. You also have the options for: bougie, fiberoptic, nasotracheal, ahem... retrograde (mostly joking about this one), intubating LMA... Now if you are saying they were not able to bag ventilate her for 45 minutes (sounds somewhat implausible however), then you are absolutely right, emergent surgical airway is the right step.

Also, no, that is not 'technically a cric'. A cricothyroidotomy is when you puncture the cricothyroid membrane. When you incise the trachea, which is what you were suggesting, albeit with the guidance of a surface scar, is a tracheostomy. What makes you think that having had a trach before makes for an easier procedure? Do adhesions and scarring, let alone her neck malignancy, make it more or less likely that you will encounter an unexpected complication, vascular catastrophe, create a false track or be unable to complete the procedure? Correct me if I am wrong, but even if you have some experience with cric's you probably don't have a lot of experience with open trachs, unless your CCM heavy IM residency is even more amazing than you led us to believe.

You speak of 'slicing' her neck as if you do have a lot of surgical airway experience. If that's the case, humor (or educate) me, how many crics and how many trachs have you done? How many of the trachs were emergent? How many complications have you seen or encountered in your own practice?

It the attitude you find in this post that annoys the hell out of me about most people who end up in critical care.

I don't know why this profession and specialty seems to go out if its way to mother**** other people practicing all the time. The passive aggression and condescension are just not helpful. Ever.

 

[gro2001]

It the attitude you find in this post that annoys the hell out of me about most people who end up in critical care.

I don't know why this profession and specialty seems to go out if its way to mother**** other people practicing all the time. The passive aggression and condescension are just not helpful. Ever.

If you read the whole exchange, my response was in frustration to the offhand comment that someone else did something stupid with the airway management. Exactly the mother****ing you abhor.

 

[jdh71]

If you read the whole exchange, my response was in frustration to the offhand comment that someone else did something stupid with the airway management. Exactly the mother****ing you abhor.

Mildly justified then.

I just think the whole issue of trying to mother**** each other during the duscussion of difficult cases doesnt help any of us get to the right (or "right enough" answers). No man is an island when it comes to some of these critical care trainwrecks where nothing seems to be the right answer in the situation.

 

[Bostonredsox]

Not sure what all the aggression is about. Maybe you had a bad day? Dunno. What I am saying is a patient who had a trach placed and removed in the last 3 weeks, who presents as an arrest, that although they can ventilate, they can't intubate, and finally after 45 min mucking around in a tight mouth and causing a lot of bleeding from the oral cavity, why not do a bedside trach? You have a relatively fresh trach scar, and you have been unsuccessful in getting a conventional airway. I don't have an intubating LMA, a fiber optic, lol retrograde, or much of what you mentioned. I am not an anesthesiologist. I have in my bag, DL, bougie, LMA, recently a McGrath Mac, and a surgical airway.no I don't have many perc trachs still <10, but I know what to do if I need an airway and can't get one. She had a maxillectomy with flaps, technically not a neck cancer. And her repeat trach which I assisted with, took 2 minutes. The anatomy from the trach access spot down was completely normal. Would you have known that in the Ed? No. But, if you have been trying for > 10 minutes amidst chest compressions in an arrest, why would you not attempt to access the trachea through the scar and get a bougie/tube in it? What do you have to lose? She is after all still coding.

Point I was trying to make is in a crashing let alone coding patient, I would never spend 45 minutes attempting an airway. If I can't get one in 10-15, I agree 5 was too low of a # and not practical, I'm pursuing a surgical airway, either on my own or if surgery is available, preferably with their higher level of experience if possible.

 

[VentdependenT]

Agree with you.

BTW the LMA counts as an advanced airway per acls. No reason to dick around. I would have punched through that **** with my cric kit.

 

[Bostonredsox]

Final update. Weaned to trach collar after diuresis. Fit for a passi valve. Passed swallowing study. Transferred to floor. Denied by LTAC once I had got her off the vent naturally. Discharge to rehab facility today.

 

[gro2001]

Final update. Weaned to trach collar after diuresis. Fit for a passi valve. Passed swallowing study. Transferred to floor. Denied by LTAC once I had got her off the vent naturally. Discharge to rehab facility today.

Strong work! That definitely counts as a win.

 

[Bostonredsox]

Strong work! That definitely counts as a win.

thanks. It was gratifying too. Although she had a cancer, she was an otherwise very healthy 60 year old with almost no comorbididites.

she is actually a testament to herns earlier post about not giving up even if you think its hopeless. they coded her in the ED for 60 minutes almost. without a persistant family and an ED doc who kept up resuscitation, she would have never even made it to me.

on another note had a sad case of a 63 y/o a few days ago, pretty healthy, choked on some French fries at home, keeled over and went apneic, husband was too debilitated to do CPR supposively, ems arrived 20 min later and worked for another 30. 50 min downtime before ROSC. Major anoxic brain injury. they decided not too cool her. ed doc said she was fixed and dilated after pulse returned. Not sure about that decision. either way she went CMO next day.

 

[Doctor Bob]

on another note had a sad case of a 63 y/o a few days ago, pretty healthy, choked on some French fries at home, keeled over and went apneic, husband was too debilitated to do CPR supposively, ems arrived 20 min later and worked for another 30. 50 min downtime before ROSC. Major anoxic brain injury. they decided not too cool her. ed doc said she was fixed and dilated after pulse returned. Not sure about that decision. either way she went CMO next day.

Hmm... If was in the department and got someone with a 20min apneic episode before the start of CPR I'm not sure I'd cool them either even if I got ROSC back...

If I was at an academic setting maybe... because then the ICU residents can get some learning from the case before the person dies. If I'm at a small community hospital... probably not. Hmm... tough to call from the ED side. Usually it's just easier to cool and let the IP team decide whether to continue cooling/care or not. But then that's also just passing the buck along and not being willing to make the tough call.

Those are the times where it's no-win to be the ED guy.

 

[Bostonredsox]

Hmm... If was in the department and got someone with a 20min apneic episode before the start of CPR I'm not sure I'd cool them either even if I got ROSC back...

If I was at an academic setting maybe... because then the ICU residents can get some learning from the case before the person dies. If I'm at a small community hospital... probably not. Hmm... tough to call from the ED side. Usually it's just easier to cool and let the IP team decide whether to continue cooling/care or not. But then that's also just passing the buck along and not being willing to make the tough call.

Those are the times where it's no-win to be the ED guy.

They got ROSC in the field after 9 min of CPR. she came into ed with a pulse. presumed downtime is 15-20. My initial numbers were incorrect once I reviewed the EMS records which finally were made available for viewing.

But I agree with you. I talked to the other ICU senior ont hat night as to why she didnt cool her. Her answer was she has not done the protocol yet and the hospitalist on that night wasnt comfortable with it either. It looks like ED doc asked them about cooling and they said no. I would have said yes and had ED doc initiate and I would have continued it upstairs. But i have experience with it and those on that night didnt so I understand their decision, particularly seeing as she was an on the fence candidate (pulm arrest, probable anoxic injury...not a straight forward VF/VT to cath lab arrest).

Of note I have initiated cooling upstairs even if ED doc had decided not too if I thought it was warranted. If they come in, get resussitated and get to me in 2 hours, I still have 4 hours to get to goal temp per our protocol, so we can reverese the decision and still cool them upstairs. Have done this before.

 

[VentdependenT]

60 WM with stage IV NHLymphoma with hx nml renal function/cbc. Not a candidate for chemo for whatever reason. comes in with Dirty urine, Ca 3.4, BUN 208, Cre 8, lactate 6, wbc 16, hb 8, INR 2, Phos 8, LFTs 1000's, glucose 40. I called it tumor lysis, started rasburicase, ph 7.2, called renal, uric acid 18, tubed dude so he could get dialysis (jerkin from hypocalcemia). Had resident calculate apache on admit: 80%.

Pan sensitive ecoli bacteremia. Extibated w/in 48h. Home within 5 days. pt left AMA to get his methadone. We shoved some amoxil in his hand and slapped him on the arse on his way out...


Also had suspected CCB od on 30yr old maxed on 5 pressors with systolics hangin in high 60's for like 10 HOURS. Bicarb hit 4 at one point. A billion liters positive by the time i was called in. Anyways extubates w/in 72h. Brain, kidneys, gut, and toes and fingers intact. Off to psych w/in 6days. I literally spent hours of my day in that room tinkering and ultrasounding. Pulled the lipid rescue out on top of bicarb, insukin/glucose, calcium ggt. Tried glucagon bolus (her CO was never an issue, so i only suspected dihydroperodine)= massive diarrhea and vomiting with sugars in 400-500's despite 50u insulin per hour. Too unstable for transfer for VA ECMO. I didnt write her off but I wasnt too optimistic about many of her organs.

 

[Hernandez]

60 WM with stage IV NHLymphoma with hx nml renal function/cbc. Not a candidate for chemo for whatever reason. comes in with Dirty urine, Ca 3.4, BUN 208, Cre 8, lactate 6, wbc 16, hb 8, INR 2, Phos 8, LFTs 1000's, glucose 40. I called it tumor lysis, started rasburicase, ph 7.2, called renal, uric acid 18, tubed dude so he could get dialysis (jerkin from hypocalcemia). Had resident calculate apache on admit: 80%.

Pan sensitive ecoli bacteremia. Extibated w/in 48h. Home within 5 days. pt left AMA to get his methadone. We shoved some amoxil in his hand and slapped him on the arse on his way out....

I hope his lytes were corrected. Methadone and severe lytes abnormalities don't mix. Had an anorexic to into torsades twice cause of that crap.

 

[jdh71]

Also had suspected CCB od on 30yr old maxed on 5 pressors with systolics hangin in high 60's for like 10 HOURS. Bicarb hit 4 at one point. A billion liters positive by the time i was called in. Anyways extubates w/in 72h. Brain, kidneys, gut, and toes and fingers intact. Off to psych w/in 6days. I literally spent hours of my day in that room tinkering and ultrasounding. Pulled the lipid rescue out on top of bicarb, insukin/glucose, calcium ggt. Tried glucagon bolus (her CO was never an issue, so i only suspected dihydroperodine)= massive diarrhea and vomiting with sugars in 400-500's despite 50u insulin per hour. Too unstable for transfer for VA ECMO. I didnt write her off but I wasnt too optimistic about many of her organs.

Did you guys talk about methylene blue?

 

[Bostonredsox]

60 WM with stage IV NHLymphoma with hx nml renal function/cbc. Not a candidate for chemo for whatever reason. comes in with Dirty urine, Ca 3.4, BUN 208, Cre 8, lactate 6, wbc 16, hb 8, INR 2, Phos 8, LFTs 1000's, glucose 40. I called it tumor lysis, started rasburicase, ph 7.2, called renal, uric acid 18, tubed dude so he could get dialysis (jerkin from hypocalcemia). Had resident calculate apache on admit: 80%.

Pan sensitive ecoli bacteremia. Extibated w/in 48h. Home within 5 days. pt left AMA to get his methadone. We shoved some amoxil in his hand and slapped him on the arse on his way out...


Also had suspected CCB od on 30yr old maxed on 5 pressors with systolics hangin in high 60's for like 10 HOURS. Bicarb hit 4 at one point. A billion liters positive by the time i was called in. Anyways extubates w/in 72h. Brain, kidneys, gut, and toes and fingers intact. Off to psych w/in 6days. I literally spent hours of my day in that room tinkering and ultrasounding. Pulled the lipid rescue out on top of bicarb, insukin/glucose, calcium ggt. Tried glucagon bolus (her CO was never an issue, so i only suspected dihydroperodine)= massive diarrhea and vomiting with sugars in 400-500's despite 50u insulin per hour. Too unstable for transfer for VA ECMO. I didnt write her off but I wasnt too optimistic about many of her organs.

Strange he wasn't severely bradycardic. All of my ccb ODs that have required pressors for hypotension have also had so much ccb on board that I had to throw in a TV pacer.

Any thoughts on dialysis for the refractory acidosis? I know I'm gonna catch hell from hern for this but I would wager emergency HD improving the acidosis would render the pressors more effective and improved perfusion/decreased pressor requirements.

 

[VentdependenT]

Did you guys talk about methylene blue?

GTFO. Didnt knowbout that one.

Boston,it must been purely dihydroperidine because her CI was sky high.

Concerning acidosis, she was too unstable to tolerate any form of dialysis.

We later found out she was living with a dude who had a heart transplant so who knew what she really took ya know? Can exactly get a serum tox for that crap...

 

[Hernandez]

Concerning acidosis, she was too unstable to tolerate any form of dialysis.

Wait...what?

 

[Hernandez]

Did you guys talk about methylene blue?

Now there is some esoteric crap right there.

 

[jdh71]

Now there is some esoteric crap right there.

I know right? I've never heard of anyone using it outside if the reported literature. Sounds like one of those cases where someone might. I just wondered if anyone bad brought it up. Sounds like no. It's interesting to see that it's not really on the radar screen for the most part.

 

[Hernandez]

I know right? I've never heard of anyone using it outside if the reported literature. Sounds like one of those cases where someone might. I just wondered if anyone bad brought it up. Sounds like no. It's interesting to see that it's not really on the radar screen for the most part.

I had a crazy co-resident who talked some world famous docs into giving it on a septic pt... . I've also seen it used in a guy who was being evaled for heart/lung to for pulm HTN that was so bad the cards guys diuresed him till he was deaf, poor guy had a mustard procedure as a kid then developed pulm HTN on top of it, his systemic pressures were lower than his pulm pressures ..

 

[Hernandez]

How'd ya dose the lipids vent? Y'all top off at 3mL/kg of 20% or y'all go ballsy to 5-8 to start seeing what like like janeways nodes on finger tips?

 

[VentdependenT]

Wait...what?

No way they gonna spin her with systolics in the 60's on 5 pressors. If she was on VA ECMO SURE, too unstable for transport to our other facility which has it. i dont remember her ph off hand but it was >7....very reassuring....

 

[VentdependenT]

How'd ya dose the lipids vent? Y'all top off at 3mL/kg of 20% or y'all go ballsy to 5-8 to start seeing what like like janeways nodes on finger tips?

I had the resident order it after she called me about the pt on my way in at 4am. I assume the toxicologist she spoke to afterwards told her the dose. I just wanted it started asap.