Clinical Case 039: the wrap up
This is the wrap up of Clinical Case 039: Ectopic ectopic. Thanks for all the comments and plans posted by Tim, Ray, Aaron, Bill, Minh and Jonathon. Nice stuff guys! There are always a few ways to skin a cat, and I think you would all have saved the day.
‘Twas a tricky case and I think we are all on the same page with regards to the goals, plans and anticipated troubles. Completely agree with all that was said. I delibrately did not give any BP etc as I wanted to keep it as general as possible. For me this case revealed how much I have learned online in 2011! It allowed me to put into practice a lot of the stuff I had been blogging, learning and thinking about over the last 12 months – all in the space of about 30 minutes! I thought I would summarise the key decision points and give some links to some of my favourite places to go for great information and education in 2011.
- Massive transfusion, lactate and coagulopathy – look no further than Broome Docs Clinical Resources: Massive Transfusion Protocol
- Have to put a plug in for Life in the Fast Lane – the ultimate resource for anyone in an ED anywhere. For example – managing the critical bleeder
- Severe acidosis / intubation – go listen to His Highness S Weingart, on the crashing metabolic acidosis podcast @ Emcrit.
- Also used Scott’s “Delayed Sequence Intubation” concept in there.
- Induction for the hypovolemic patient – check out Dr Dutton’s lecture about the techniques used at the Shock Trauma centre in Baltimore. Which induction agent?? short answer: it’s the dose not the drug that kills!
- Intubation positioning – it is all about the positioning – you do not want to flail in this case! A few good summaries out there including this from Zvara in Anaesthesia-Analgesia, RESUS.ME showed us “win with the chin” in BJ Anaesth
- ROC was used – not SUX – check out Roc vs Sux at EM Updates
- Ketamine remains, and is increasingly my friend in tough situations. Check out EM updates. I think Ruben might use similar volumes of ketamine that I do!
- Ventilation stuff – there are a lot of good resources – but the discussion on EM:RAP Critical Care / Ventilator management is pretty thorough and has completley changed my practice in both elective and sick patients.
So what actually happened?
For the record, all ended well. Calcium gluconate – bolus – good for high K+ and great for coagulopathy / citrate toxicity from tansfusion. Insulin bolus given. The monitor looked OK, no wide QRS after this so we carried on and repeated the gas later – it was 6.7 after the dust settled.
I called for a mate to help, got a DSI scenario happening, optimised position and went with ketamine ~ 1mg/kg and Roc ~ 1.2 mg/kg. Ventilated during induction. Active warming as much as possible (though in Broome room temp is about 100 deg currently!)
The rapid infuser decided to quit soon after this – so the fluid resus got a bit hairy. The team were great and got clamps on and control quickly. Access was just a few big IVCs in the antecubital fossae. Maybe a big CVC line would have been useful, but we did not have time (I’m not as quick as Aaron, and like to use the US as I do too few to be slick!), and she was steady by the time we did have time.
Started peeing IDC, used a smidge of pressors (phenylepherine) up front then fentanyl once we had a reasonable volume in and things were looking calmer.
Patient ate dinner about 5 hours later! We breed em tough up in the NW!
Hope you have enjoyed Broome Docs in 2011, and promise more and better stuff in 2012 (Mayan end-of-time prophecies not withstanding)
Casey
Clinical Case 100: Back to the Future
Lessons Hard Learned – Episode 8 with Dr Rob Orman
Clinical Case 145: Stump the Chumps Perth
About The Author
Casey Parker
I am a GP working in Broome, NW of Western Australia. I work as a hospital DMO (District Med Officer) doing Emergency, Anaesthestics, some Obstetrics and a lot of miscellaneous primary care. Also on the web as @broomedocs | + Casey Parker | Contact
cor blimey, well done! jolly good show, Casey! I have to ask the controversial question. given your positive experience here in replacing sux with rocuronium for this emergency intubation. …is there any point in your mind now of ever using sux again??
My service has just replaced vecuronium with roc, and I have quite a few colleagues who are nervous about having to relearn RSI using roc. They are so used to Sux it gives them the willies thinking about using roc and the prolonged apnoea it will produce! We still carry Sux though and my suggestions to use Roc are meeting entrenched resistance! Sugammadex just complicates matters, given its expense and the questionable benefit of waking an emergency patient up after a failed intubation..you either need the airway secured or you dont, there is no halfway as Mr Miyagi once wisely said during a karate lesson.
Give ’em roc. Surely it’s wooly thinking for retrieval cases to expect to ‘wake them up’ if fail intubation – as you say, they either need an airway, or they don’t
Once made that decision tgo secure the airway…well, you just have to push on, doncha?
Have you sat down and done this as a group discussion to achieve a consensus? Or challenged them to argue the logic of ‘put to sleep for a tube, but wake up if can’t, even though they need a tube’?
On another issue, what did everyone think about bicarb for the patient in Casey’s gendankenexperiment – too ‘old school’? Interested to hear more about HTS in future posts too…
Hi Tim. Firstly, lets deal with the NaHCO3 issue. I believe in the case study of the ectopic pregnancy, it was being used to treat Hyper K and acidosis. There is little evidence it works to a significant degree in reduce K levels. check out the following useful review articles
http://www.uthsc.edu/Internal/syllabus-journalclub/hyperkalemia.pdf
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2952010/?tool=pubmed
Secondly, the Weisberg article above, cites the use of HTS for Hyper K, in the setting of low Na.In a hypovoloemic patient in acute renal failure, it is useful as a volume expander with lower fluid bolus volumes. its handy to have around as it produces similar ICP reduction than mannitol without the diuresis and loss of intravascular volume with subsequent hypotension. in other words, its a versatile resuscitation fluid. Its also what you need for the seizing hyponatraemic patient.
Finally, the question about when would you want to wake up an emergency retrieval patient after a failed intubation? Believe it or not…in agitated mental health patients..some would argue that if you encounter an unexpected difficult airway, cant get the tube in, then waking them up should be an option. SO if you have used Rocuronium, the arguement is this backs you into an unnecessary corner that could have been prevented if Sux had been used in first place. I have some thoughts on dealing with the predicted or unpredicted difficult airway, regardless of the patients primary condition, but Tim how would you address colleagues who put the above arguement to you?
Hi Minh
A question – what would 3% saline do for the acidosis – my guess is it would make it worse
The SID of saline is 0 – so you would have to use a bicarb mix with it?
Check out Emcrit for deeper explanation
Casey
good question. of course it will make the arterial ph lower. some animals studies indicate this may worsens gut microcirculation but overall haemodynamics seemed the same compared with lactated ringers comparison. most of the studies seem to indicate that at least in trauma, you get the same effect for a lower volume of HS cw lactated ringers. there also appears to be an immunomodulatory effect that maybe beneficial. overall it seems the best evidence suggests the less isotonic resus crystalloids we use the better in bleeding patients. Using some is beneficial to a point but then it gets deleterious. I now try to avoid using normal saline in my critical care resuscitations if hartmanns or HS is available. I also try to minimise the amount of hartmanns I give, in particular in the bleeding shocked patient. in the trauma patient, if its a choice between HS or N saline or Hartmanns whilst waiting for blood or if it is not available, I would bolus small volumes of HS in preference to puoring in large volumes of isotonic cyrstalloid in the traditional 3:1 ratio. the acidosis may look worse but you can follow the lactate clearance in particular since you are not using lactate in your resus fluids.
this is a useful recent lit review of the use of HS in TBI patients..not applicable to this case but a useful review otherwise
http://resusme.em.extrememember.com/?p=5759
Ah, I reckon the RSI for a psych patient for transfer is a different kettle of fish to the emergency laparotomy – happy to use sux and wake ’em up for the former (bit even happier if I’ve just used ketamine to sedate and transfer on that).
For the hyperkalaemic eLap…well, they need a tube (or LMA). So it’s roc all the way baby.
How to sort it out with dissenters? Only one way…fight!
TFIC