Grand Rounds Recap 8.22.18

/

AirCare Grand Rounds: Procedural Cases with Drs. Bernardoni and Whitford

Case 1: Middle aged male with witnessed V-fib arrest undergoing CPR.  Old scars on both knees.  Where to place IO?

  • Humeral IO:
    • Pros: faster infusion rate, easier access in air craft, less painful than tibial  
    • Cons: increased risk for displacement, may limit access to lateral chest for procedures given limited shoulder mobility
  • Infusion Rates (ml in 5 min) from this article
    • Sternum: 469ml
    • Humerus: 218ml
    • Tibia: 154ml

Case 2: Middle aged male fell asleep on train tracks s/p BLE amputations.  No active bleeding.  HR 100, 107/52, GCS 14.  What is your next step? 

  • Bleeding not occurring because patient in shock, once you start giving blood, will likely start bleeding.  Consider placing early bilateral tourniquets above amputations.

Case 3: Middle aged male (is there a theme?) pedestrian struck, RLE partial amputation distal to knee and bilateral femur deformities.  Active bleeding from amputation site.  Where do you place tourniquet?

  • Patient likely has bleeding in thigh from fractures.  Placing a tourniquet distal to fracture may increase venous backflow and bleeding.  Therefore place tourniquet in groin to prevent bleeding to fracture and amputation.  

Canthotomy Case Series

Case 4: Elderly male on warfarin who fell.  GCS 15, left periorbital swelling, pain with eye movement, blurred vision bilaterally but counts fingers.  Do you perform a lateral canthotomy? 

Case 5: Middle aged female after assault.  GCS 15, right eye tense to palpation, light perception only.  Do you perform a lateral canthotomy? 

Case 6: Young male after car accident, intubated for GCS 6, HDS.  left eye proptotic, tense to palpation, pupil non-reactive.  Do you perform a lateral canthotomy? 

  • Lateral Canthotomy:
    • Air Care protocol calls for two of the following three criteria to perform lateral canthotomy: Proptosis, gross visual dysfunction and/or APD, elevated pressure by palpation. 
    • Contraindications: concern for open globe.
    • Case 4 does not meet criteria for canthotomy, Case 5 does meet criteria.  Case 6 also does meet criteria, but the patient needs immediate transport.  Do not delay transport to perform canthotomy, consider during flight.

Case 7: Elderly male struck by a vehicle, left chest wall crepitus, stable vitals, GCS 14, O2 sat 88% on NRB, diminished breath sounds on left.  Whats your next step?

  • Classically needle decompression occurs in the 2nd intercostal space, mid-clavicular line.  
  • Chest wall often thick in this area, increasing failure rate
  • Laan et al showed that 4th intercostal space, anterior axillary line had less distance to enter chest (34.3mm vs 42.8mm) and lower failure rate (13% vs 38%) when compared to classic location

Case 8: Young male after MVC, HDS, GCS 15 s/p EMS right sided needle thoracostomy with improvement in hypoxia.  In flight O2 requirement increases from 4L to 15L with O2 sats 89%, complains of progressive SOB.  Next step?

  • Classically a tension pneumothorax presents as respiratory distress, hypoxia, and hypotension
  • This review of papers on tension pneumothorax showed that the intubated patient will develop the classic hypoxia and hypotension with tension pneumothorax.  However, the spontaneously breathing patient rarely develops hypotension and is more likely to have isolated hypoxia and respiratory distress.  So the lack of hypotension does not eliminate the possibility of a tension pneumothorax.

Case 9: Young female in PEA arrest prior to arrival and reportedly pregnant.  When do you consider resuscitative hysterotomy?

  • AirCare Protocol Indications for Resuscitative Hysterotomy:
    • Viable pregnancy (>20-24 weeks, uterus palpable at or above umbilicus)
    • Strongly consider if CPR ongoing < 15min
    • Discuss with crew for CPR ongoing 15 - 20 min 
  • See this post on the resuscitative hysterotomy for more information

Case 10: Young male with self inflicted GSW to head, intubated, PEA arrest with CPR in progress 1 min.  Next step?

  • Isolated TBI often results in significant pre-hospital derangement of cardiovascular physiology.  Unclear mechanism.
  • Consider running these arrests more like a medical arrest with epi, calcium, and bicarbonate.
  • See this article and this article for more information

AirCare Grand Rounds : M&M with Drs. Bernardoni and Whitford

Case 1: Elderly male with unknown PMH, struck by vehicle, +LOC, head trauma, GCS 14, on 15L NRB satting 88%, BP 96/52, HR 97.  On AirCare arrival, there was no massive external bleeding, airway is intact, there is L chest crepitus with decreased breath sounds, a stable BP, and a contusion on the patient's head.  There is no extremity trauma, his abdomen is non tender.  Needle decompression performed on L chest with a rush of air and sats improved to 92%.  However, he began to have worsening mental status and was intubated with ketamine/succ (DASH-1A achieved).  Patient given 3% hypertonic saline, then 1:1 of PRBC:FFP.  In ED received bilateral chest tubes, had a positive FAST as well as a subdural on head CT.  He was taken to OR emergently for splenectomy.

Learning Points:

  • Shock Index (SI): HR/SBP
  • This study separated shock index into four groups:
    • Group 1: SI < 0.6, no shock, mortality 10.9%
    • Group 2: SI 0.6 - 1, mild shock, mortality 9.7%
    • Group 3: SI 1 - 1.4, moderate shock, mortality 22.9%
    • Group 4: SI > 1.4, severe shock, mortality 39.8%
  • Higher SI associated with increased mortality, so consider occult shock in patients with an elevated SI, even if they have a normal BP

Case 2: Middle aged male with history of hypertension, seizures on lamotrigine / phenytoin who presented to OSH in status epilepticus.  At OSH suffered a peri-intubation PEA arrest with ROSC after 2-3 min.  On AirCare arrival, patient on propofol drip, s/p levetiracetam 1g and lorazepam 1mg.  No apparent seizures on evaluation. 

Learning Points:

  • Status Epilepticus Treatment
    • Benzodiazepines (lorazepam 4mg IV = midazolam 10mg IM)
    • Antiepileptic Drugs (fosphenytoin 20mg PE/kg = valproate 40mg/kg = levetiracetam 60mg/kg)
    • Intubate and start IV infusion (midazolam 0.2 mg/kg load, rate .1 mg/kg/hr; propofol 1-2 mg/kg load, rate 20 mcg/kg/min, ketamine 1 mg/kg load, rate 5 mcg/kg/min)
  • Medications available on AirCare: lorazepam, midazolam, keppra, propofol, ketamine.

Case 3: Elderly male with self inflicted GSW to left chest, single wound 3cm below left nipple.  GCS 3, tachycardic, and hypotensive for EMS.  The patient also had DNR paperwork present.  On AirCare arrival, unable to get BP, tachycardia to 115, GCS 3.  Due to suicide attempt, DNR paperwork was deemed not valid.  A L finger thoracostomy was performed prior to intubation.  The patient then had a cardiac arrest.  Bilateral finger thoracostomy, pericardiocentesis performed.

Learning Points:

  • DNR in the setting of suicide attempt:
    • Common notion that suicide attempt invalidates DNR.  Based on the assumption that suicidal patients are suffering from reversible mental illness that if treated would resolve their suicidality.
    • This article is a great review of this topic and argues that not all patients who attempt suicide are necessarily incapable of making a rational decision about their health care and that withholding resuscitation may be appropriate.
  • Prehospital Resuscitative Thoracotomy
    • Pericardiocentesis often not adequate as blood can clot and it is not a definitive management due to rapid re-accumulation.
    • Currently being performed pre-hospital by both London and Sydney HEMS by non-surgeons.  This article documents 13 cases of prehospital thoracotomy.  All patients survived, many with good neurological outcome.
    • EAST and WEST guidelines for thoracotomy

Board Review Cases with Drs. LaFollette and McDonough

Case#1

75F with h/o atrial fibrillation, hypertension, hyperlipidemia presenting with abdominal pain and AMS.  She was found at home covered in vomit.  Last seen normal 2 days ago.  On exam, alert and oriented to self only, otherwise unable to give further history.  Exam is nonfocal, no peritonitis.  Labs show hyperkalemia, AKI, elevated digoxin level.  Vitals decompensate with EKG showing bidirectional ventricular tachycardia.  Responds to cardioversion, hyperkalemia management, digi-FAB.  Admitted to MICU.

Case #2

29M s/p MVC with L abdominal pain and L hip pain.  Patient hypotensive and tachycardic.  Responds to 2:2.  FAST + in RUQ.  L hip dislocation.  Procedural sedation performed with reduction of hip, patient then goes to OR.

Case #3

33F with no PMH presenting with headache x 1 day.  Exam significant for 6th nerve palsy and papilledema.  Pregnancy negative.  CT head and CTV negative.  LP performed with elevated pressure.  Headache improved after LP.  Neurology consulted who recommended acetazolamide and follow up in a few days. 

Quarterly Sim with Dr. Hill

Dual Patient Encounter

Patient 1: 55M h/o ESRD who missed dialysis, presents with elevated potassium.  Difficult IV access.  Patient becomes agitated because of the IV sticks and requests to leave.  Patient has capacity and so signs AMA paperwork and he is discharged.  

Learning Points:

  • Determination of Capacity:
    1. Ability to communicate with the provider
    2. Understanding of treatment options
    3. Understanding of the consequence of leaving
    4. Ability to reason and explain why they are making their choice
  • Attempt to understand why the patient does not want to stay and remove any barriers that are preventing the patient from staying (child care, work note, coordinating care etc)
  • If patients have capacity and to leave, they have the right to leave AMA
  • See this post for more information on this topic

Patient 2: 34F who presents with nausea, vomiting, abdominal pain, and hypotension.  While in the ED she developed some runs of vtach.  Labs showed hypokalemia and hypomagnesemia.  These were repleted.  Patient then admitted to stepdown level of care.

Learning Points:

  • Causes of QTc prolongation:
    1. Drug induced 
    2. Electrolyte abnormalities (hypoK, hypoCa, hypoMg)
    3. Congenital
    4. Hypothermia
    5. Hypothyroid
  • Treating vomiting in patients with prolonged QTc:
    • Why do they have prolonged QTc and can we fix this (electrolyte repletion)
    • Other options: benzodiazepines, compazine, metoclopramide, adding dextrose to fluids (to reduce ketosis)
  • This article developed a risk score for the development of QT prolongation and this website is a great resource for checking if a medication can cause QT prologation