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)