This week a case to test your Resus chops. The care is not hard, the logistics definitely are.
Items of Interest
- Dirty Double
- Push-Dose Pressor Update
- RUSH Exam
- Hyperkalemia
- HOP Killers
- Peripheral Vasopressors
- SLED
Additional New Information
More on EMCrit
Additional Resources
You Need an EMCrit Membership to see this content. Login here if you already have one.
- EMCrit Wee – Ross Prager on 10 Heuristics for the New ICU Attending - April 13, 2024
- EMCrit 372 – FoundStab Intubation SOP - April 5, 2024
- EMCrit RACC-Lit Review – March 2024 - March 28, 2024
Hi Scott! Interesting case for discussion! And yes, these cases occur frequently. Agree that HD catheters are perfectly fine to use in an emergency situation. A sterile and non-touched HD catheter isn’t worth much in a dead patient. A similar case in which we needed our logistics to work perfectly: 60 y/o male with altered mental status, 160 kg of body weight. Brought in my EMS with “strange ECG”. PMH of type 2 DM. I would throw in “BGA” very early for the assessment of A to G, because it gives you so much information. pH was 7.0, Potassium of… Read more »
great case
How do you feel about intubation in your patient retrospectively? Would you still do it or maybe wait a bit longer?
Peter, I don’t think the appropriate answer is really to ever wait in a patient with minimal responsiveness unless you are sure of the cause of your patient’s AMS and that cause is benign. Not sure what was meant by your comment of wasting precious time. Intubation takes 3-4 minutes; recovery from aspiration takes far longer. If you had intubated your patient, you should have been able to extubate at the identical point at the end of your shift.
Agree totally that minimally responsive patients need to be intubated.
What I meant was the time until the life-saving hemodialysis with potassium of 9.9 mmol/l and sinus wave ecg which I deemed the number one priority in that case. Maybe I should have intubated the patient in retrospect and was just lucky he didn’t aspirate.
Nevertheless, I think it can take way longer intubating very obese patients.
That’s why it is important to discuss those cases. Thanks for your comments and great posts! Always helpful.
Awesome. Learned a lot. More such Podcasts please.
I second Sebastian, great case, well presented, one learns while one thinks “uh-huh, would I have taken those right steps and that quickly?” but that’s what learning is for.
thanks folks
Do you routinely give 50grams of IV Dextrose for hypoglycemia? Or was that because you had rightfully suspected hyperkalemia from the beginning?
i give 2 amps for v. low fingersticks
This case brings up your often discussed “LAMW pH Problem”. Your podcast about that issue is quite “old” though. Does your today’s approach for the really tough cases (very low pH with very low pCO2) differ from your original work?
nothing has changed
You seem to have moved even further in the “dry” direction. Is your current view really that virtually nobody needs fluid for hypotension unless they’re bleeding?
usually will give 2 liters empirically. If patient is one who fluid could be a problem in, we give 500 and then start HIP ultrasound assessment. Would rarely give more than 3-4 liters in any patient.
No argument with that! Your approach sounded rather more strict in the podcast.
Love the case discussion podcasts, would like to see you keep them going!
Hi Dr. Weingart,
This podcast was outstanding. I have learned a tremendous amount from the Mind of the Resuscitationist series. My own implementation of logistics has improved from these podcasts. I look forward to hearing more cases like this one. I appreciate all of the hard work of the contributing members of EMCrit. Thank you guys so much!
-Pri Patel
-Hospitalist
thanks bro
Hi Scott, I’m a keen emcrit follower and have benefited hugely from your site as a resource. RE this case agree completely with the management steps. As devils advocate just wondering opinion in your shop RE trying a synchronised dc cardioversion right at the beginning alongside k lowering and cardiac stabilisation with calcium (seeing as you had hypotension, altered mental status with an unknown ?new/?old broad complex tachy ?sine wave ?VT) or do you reckon it will just be refractory with that potassium anyway or worth a shot as per ALS tachycardia algorithm, before you really know if this is… Read more »
be very wary of thinking “slow” tachycardias (this pt was 108) as vtach
it is very unlikely (not impossible) that v tach is the cause and you are prob. missing something (compensatory tachycardia with BBB, hyperk, sodium-blockade, etc.)
I would rarely consider shocking until I hit 130 or 140. Below that, the rate is prob. not the cause unless the pts are so reliant on atrial kick (unlikely with pharm. augmentation).
Hi Scott
Loved this episode. I’m not completely clear how the case concluded. Did you start the SLED in your ED/ICU or did they go up to an ICU bed?
My institution has no resident nephrology service, only a satellite dialysis unit for well patients. I genuinely feel the logistics of accomplishing this in a hospital without nephrology support is extremely difficult.
Does your ICU use SLED in preference to CRRT?
I have no experience of using this RRT modality but would like to understand a bit better.
Thanks for sharing this case.
Best wishes
Dean
Hey buddy. thought I had mentioned it. our ICU uses CVVH, but this requires ICU nurse. So in the ED we use SLED, which is what we did in this patient
Hi Scott,
We have SLEDD in our ICU, but have a reverse osmosis system to produce the water for it….around 500ml/min is needed, as opposed to the 1500ml/hr that CRRT uses making it possible to use bags of dialysate.
I’m interested in the cost/benefit ratio of this where you work….how often do you need to SLEDD someone in ED? How did they justify spending the money to set it up? And how do your nurses keep proficient in something they surely don’t do much of?
Adam
Intensivist
Australia
I’m really diggin the “running through a case” format, I think it helps cement the knowledge and gives a good framework for visualization practice. These cases would also likely be easy for others to adopt into high fidelity simulations as well, so I think they’re incredibly useful. I do have a question for you on this case though, what is your rationale behind giving the 2 amps of D50 for the severe hypoglycemia? I completely understand the impetus to do so, however, I had switched my practice over to utilizing a 200mL D10 bolus for severe hypoglycemia. Is it primarily… Read more »
Hi. Can you comment on the safety, patient selection, and technique for exchanging a PIV with the midline? Great idea but I’ve been hesitant to do this for sterility reasons
Scott or anybody, Just to elaborate more on the question: Within the last six months or so most of our central lines have been replaced by a two-lumen 7fr (?) midline catheter. They are quite slick. Placing them, however, is still in my opinion slightly more difficult than the average central line. Smaller vein, and a tendency to create a lot of edema if you back wall the vessel during the stick… With regards to exchanging a PIV for a midline, what is your experience with this? Are you simply threading the wire through the PIV? Are you utilizing PIVs… Read more »
Hi, just want to know if such patient with such a low BP (no radial pulse) but conscious oriented,comes with history of diarrhea (hypovolemia), would u
still first go for push pressure or will go for fluid than if refractory than vasopressor?and do you take age (young/old) into consideration for this
Hi Scott – Great case. I like that it pulls together many techniques/skills from different podcasts (push dose epi, reversal of HOP killers, DSI, etc) You mentioned briefly IO access… I am in the process of getting our RRT RNs certified in placing intraosseous lines on the wards for RRT/Code Blue. In addition to the the cure-all propaganda, the company really pushes the humeral site because of higher quoted flow rates of 5L/hr vs. 1L/hr at the tibial site as well as proximity to the heart. However, there still seems to be a stigma amongst trainees regarding the humeral site,… Read more »
you have mentioned exactly why I go tibial–it is really foolproof. Humerus seems like blind hope even though it usually works. I go tibial in codes
scott
superb review, with some new thrown in. thank you once again
tom
i have never accessed the AV fistula in the patients arm. i suspect its the same thought: if you have a coding or near coding patient its probably excellent access, though i imagine it may be like accessing an artery (?) and may need some pressure device?
you can really mess up a fistula. would stay away from it unless EVERYTHING else has failed. If i had to access it, i would use a port access needle (non-cutting)
Great podcast. Would like more like this. Definitely got me thinking
Hey Scott,
I appreciated this podcast and thoroughly enjoyed it. I like the idea of a case like this once in a while. I wanted to ask more about the critical care “pan-scan” you suggested. What is your trigger to get a CT of the chest, abdomen/pelvis in these patients (in the ED)? Suspected sepsis? Shock without clear etiology? Anyone who is sick and getting CT head?
Thanks,
Mike
shock or sepsis with no obv. cause
Why not give the Calcium first, it’s quick, already premixed, can push while getting the push dose pressor, have had several cases where B/P comes up rapidly as QRS narrows back from sine wave pattern.
you def could. it’s whatever you have on hand
Very good podcast. Case-based discussion very captivating because everything you hear you relate back to a case of your own. Keep them up.
I know I’ m late but this was super!! Very useful! Gonna make all of my friends to listen.