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

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