Skinny, Cold and Coded

[iStater]

She has a femoral central line. What you consider a VGB?

The femoral central line was noted previously and the ScvO2 would be more closely to a VBG while an SvO2 would be from the pulmonary artery. Yes, a sample from that line would be ok with the differences in measurements known to the care providers.

[Just Plain Ruff]

Have they considered correcting the critically low Potassium magnesium and Phosphate? Any chance there might be a bananna bag sitting around somewhere (not sure if this will be benficial as I forget what's in it but we used to give this for patients with very low electrolytes.).

[triemal04]

Start with the investigation:

Current chem7/BMP

ABG

CBC

Foley content (if one isn't placed, do so)

Ideal body weight?

Lungs sounds and chest xray?

What, if any meds have been given by the ER?

You said no meds at home, but she is obsessed with body image; any supplements, OTC vitamins? What exactly has she been eating? What is her daily routine; extreme exercising, couch potato?

Any clinical signs of dehydration?

Any known blood loss or GI bleeding at home?

History of anemia?

Treatements:

I don't think this is someone I'd cool. It was apparently a vf arrest, so it's the right situation...but there's more going on here and she's to unstable for me to want to risk it. Remove the ice packs, let her rewarm passively and with some warmed fluid.

Start correcting the hypokalemia and hypomagnesemia.

She's on a lot of levo without a lot of result; how much if any fluid has she gotten? My guess is none, so start some (warmed) fluid boluses and titrate the levo down as needed. Might think about switching to dopamine.

Her hemoglobin is low, guessing her hematocrit is also low, think about a transfusion but that is probably going to be done by the recieving hospital.

If she starts to wake up then sedate with fentanyl and versed. Carefully.

She's anemic, and malnourished. That's probably the root cause of everything.

[Just Plain Ruff]

Im agreeing with the malnourished and anemic thought process.

She should have been caught in her downward spiral towards this devastating outcome but I'ld bet that she hid it well.

If you could get the electrolytes rectified and the anemia fixed, we might have a fighting chance but just what are we salvaging? How much brain tissue has been fried?

Have we done a EEG? IF so what's it's results?

My suspicion is that there will be very very very long term sequelae out of this incident and she is going to have a very long road to recovery if in fact she ever recovers basic functions. Lots of relearning ahead of her.

Overall a very bad situation for her and her family.

[triemal04]

^^^^^That.

An EEG wouldn't be done that early, but there are other ways of checking for brain death/damage. But again, to early to be sure at this point.

Should also add in that knowing the time of the arrest and ROSC and total downtime are very important. If it's been awhile and the patient isn't currently sedated (and possible never was) the odds of there being an anoxic brain injury are going up; no movement and apparently no respiratory drive well after the fact plus no sedation is a bad thing.

Depending on how long it would take the family to drive to the next hospital, and depending on how the father was acting I'd be inclined to bring him with me. Someone from the patient's family who can make medical decisions for her needs to be there.

Edited August 6, 2013 by triemal04

[chbare]

Generally agree with labs and a chest X-ray; however, if we are considering a Chem-7, we may as well go all the way and look at a CMP/Chem 12. Additionally, I would look at cardiac enzymes if ordered in addition to coagulation studies, and I would also like a urine tox screen and a draw for ASA & APAP levels. The known electrolyte abnormalities are curious to say the least and warrant further investigation. Agree with Potassium supplementation.

We need an ABG and I would correlate to quantitative capnography monitoring if able. If we have a central line in place, what is her CVP? What was the CVP prior to the norepinephrine infusion?

Review the ventilator settings as well and make sure the pressure problem is not related to auto PEEP, air trapping, pneumothorax or high airway pressures.

Regarding hypothermia, if there is no history of trauma, I would not recommend stopping and re-warming without significant history or findings. At this point, she had ROSC status post defibrillation with a history (presumably) of a non-traumatic arrest. Additionally, the patient remains comatose and hypothermia has already been initiated. I am not compelled to make significant changes without markedly more compelling information. Additionally, EEG monitoring if available, may be of benefit, particularly if we administer neuromuscular blockers, so we can monitor for seizure activity.

[DartmouthDave]

Hello,

She had a very short down time.

Have they considered correcting the critically low Potassium magnesium and Phosphate? Any chance there might be a bananna bag sitting around somewhere (not sure if this will be benficial as I forget what's in it but we used to give this for patients with very low electrolytes.).

Start with the investigation:

Current chem7/BMP No BMP possible. A new set of lyes is drawn off the central line (see below)

ABG One is sent (see below)

CBC A new one is sent (see below)

Foley content (if one isn't placed, do so) Good urine output 100 to 150 cc/hr

Ideal body weight? Sorry, I can't remember the formula....but her VT is set as per ideal weight

Lungs sounds and chest xray? Clear and ET is in good position

What, if any meds have been given by the ER? Versed 2mg + Roc 75mg during the intubation. Versed PRN has been order but not given.

You said no meds at home, but she is obsessed with body image; any supplements, OTC vitamins? What exactly has she been eating? What is her daily routine; extreme exercising, couch potato? Skin and unfit. She hasn't been eatting well for the last while. Stress and depression.

Any clinical signs of dehydration? No. She has had 1000cc NS

Any known blood loss or GI bleeding at home? No

History of anemia? No

Treatements:

I don't think this is someone I'd cool. It was apparently a vf arrest, so it's the right situation...but there's more going on here and she's to unstable for me to want to risk it. Remove the ice packs, let her rewarm passively and with some warmed fluid. (see below)

Start correcting the hypokalemia and hypomagnesemia. KPhos started

She's on a lot of levo without a lot of result; how much if any fluid has she gotten? My guess is none, so start some (warmed) fluid boluses and titrate the levo down as needed. Might think about switching to dopamine. (see below)

Her hemoglobin is low, guessing her hematocrit is also low, think about a transfusion but that is probably going to be done by the recieving hospital.

If she starts to wake up then sedate with fentanyl and versed. Carefully.

She's anemic, and malnourished. That's probably the root cause of everything.

Generally agree with labs and a chest X-ray; however, if we are considering a Chem-7, we may as well go all the way and look at a CMP/Chem 12. Additionally, I would look at cardiac enzymes if ordered in addition to coagulation studies, and I would also like a urine tox screen and a draw for ASA & APAP levels. The known electrolyte abnormalities are curious to say the least and warrant further investigation. Agree with Potassium supplementation.

We need an ABG and I would correlate to quantitative capnography monitoring if able. If we have a central line in place, what is her CVP? What was the CVP prior to the norepinephrine infusion?

Review the ventilator settings as well and make sure the pressure problem is not related to auto PEEP, air trapping, pneumothorax or high airway pressures.

Regarding hypothermia, if there is no history of trauma, I would not recommend stopping and re-warming without significant history or findings. At this point, she had ROSC status post defibrillation with a history (presumably) of a non-traumatic arrest. Additionally, the patient remains comatose and hypothermia has already been initiated. I am not compelled to make significant changes without markedly more compelling information. Additionally, EEG monitoring if available, may be of benefit, particularly if we administer neuromuscular blockers, so we can monitor for seizure activity.

The vent setting are correct for the patient. No auto PEEP, high PIP, PLT ect. She is just riding the vent.

Ok...on with the scenario!!!

In consensus seems to be:

• keep cooling
• fix lytes
• start sedation
• give some fluids

With consideration giver to:

• PRBC
• Paralytics
• Increse Levophed gtts
• Start Dopamine gtts

The sending Physician arrives. You are still here? Yep.

You give her a 1000cc bolus of RL. KPhos and MgSo4 are started. An ABG is sent. Sedation (Fentanyl + Versed) is started. The shivering stops with sedation.

VS:

GCS: 3

Pupils: 3mm + brisk

Absent x 4

HR 58-60

BP 90/50

EKG: Slow, wide like before

The ABG shows suprenormal PaO2 (110) and a normal PaCO2 (40) with a mild medabolic acidosis (Lactate is 4.5). With the KPhos her K is up by .2 and the Phos is the same. Her Mg is now .8 (normal) her random glucose is 8.0 (normal....I don't want to mess up the Americans with their funny scale..lol)

Excellent work Lost of good posts.

Point to ponder:

Hypothermia a K level?

Edited August 7, 2013 by DartmouthDave

[triemal04]

Regarding hypothermia, if there is no history of trauma, I would not recommend stopping and re-warming without significant history or findings. At this point, she had ROSC status post defibrillation with a history (presumably) of a non-traumatic arrest. Additionally, the patient remains comatose and hypothermia has already been initiated. I am not compelled to make significant changes without markedly more compelling information. Additionally, EEG monitoring if available, may be of benefit, particularly if we administer neuromuscular blockers, so we can monitor for seizure activity.

I don't know. I'd agree in a little different situation but I'm not so sure here. If there was some type of anoxic injury to the brain (or other type of insult to the brain) the hypothermia would probably be beneficial, but I'd still be hesitant here. This is pretty unstable patient with an unknown problem; there is the possibility that she has in issue that will be made worse by cooling. I don't think that the hypothermia is going to help with her management as it is either, just make it more difficult. As it stands she has only been cooled to 35.5C; letting her rewarm from that won't be an issue. Could even avoid the warmed fluids if concerned.

Out of curiosity, for the situation (a fixed-wing transfer from low care to high care) would you really ask (if it was even available, which I doubt) for an EEG prior to leaving?

[ERDoc]

This pt is being transferred from an ER at a community hospital. There is no way in hell you are going to get an EEG. You'd be lucky if they could consult a neurologist in the next week.

[Just Plain Ruff]

This pt is being transferred from an ER at a community hospital. There is no way in hell you are going to get an EEG. You'd be lucky if they could consult a neurologist in the next week.

I don't know doc, my small ed I used to work for was able to get an EEG but only between the hours of 8am and 3pm. Any other times, you were out of luck. Oh yeah, the EEG Tech had to be working and he did have days off.