The Case (Refractory Anaphylaxis and Difficult Airway)
Please place your vote on the verdict below!
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Editor-in-Chief, at EMCrit.org
An ED Intensivist from NY.
Professor
Nassau University Medical Center
No conflicts of interest (coi).
Professor
Nassau University Medical Center
No conflicts of interest (coi).
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I assume many of us will side with the defense here given our chosen professions. I think both sides did a great job at pleading their case, and while the theatrics provided by the prosecution did a great job to convey poor care to the jury, the merits of the decisions, when weighed by medical professionals, just feel to be on the side of the defense. ECMO, retrograde intubation, some of these procedures, at least where I’m from, are almost unheard of and to insinuate that you would have to be uneducated to not consider them is ridiculous to me.… Read more »
yep!
A jury of EM physicians being polled will likely lead to a different verdict than that of the typical jury. I think both sides argued well however the plaintiff’s argument was more effective. I think this is true in most cases as it is far easier to argue something different should have been done when there is a poor outcome than it is to defend the actions which clearly could have changed in hindsight as per the art of medicine and variations in acceptable practice. The plaintiff argued for a long time regarding the intubation however this was not a… Read more »
yep
Was this anaphylaxis? Patient presented to primary care with some relatively non specific symptoms prior to attending ed. So some of the symptoms preceded the new drugs she was given. Failure to respond to adrenaline (sorry epinephrine) and the goitre make me wonder about other possible differentials (just grabbing at straws for fun). I am no endocrinologist so my apologies for any lack of understanding! – lrti with assoc aki -> Propranolol toxicity – That goitre is interesting no? Impending myxoedema coma perhaps precipitated by infection could explain altered mental state, bradycardia, hypotension and oedema (including difficulty cannulating). Against this… Read more »
It’s an interesting point but to my mind the temporality of the symptoms and signs go against this. Given drugs by her GP – sudden acute onset shortness of breath, rash, then acutely increasing airway oedema does not fit with tempo of myxoedema. Altered mental status was said to be in keeping with anxiety on triage note, similarly fitting with anaphylaxis more so than myxedema coma. And indeed, tempo and case details seem classic for anaphylaxis.
Not guilty! Defense witness did a good job deflecting the prosecution’s assertions that the airway issue killed the patient. I think defense could have done better job emphasizing the riskiness of all the airway options that the prosecution was touting as easy-cheezy-“no brainer”s. I’m guessing I’ve never heard of retrograde intubation for a reason- in the youtube video I just watched it took the team 5 minutes to get it done, sans goiter, which is probably why ED providers aren’t keen? I actually agree with the prosecutor that the defendant saying “we decided” repeatedly made it sound like he was… Read more »
good thought on the glucagon, patrick. emesis is certainly not a desired effect here. (could you imagine? in this airway?) and
2. i kind of (maybe wrongly) like the beta-2 blockade of the lopressor on board, allowing less- opposed alpha, i.e., vasoconstriction (one of the major concerns here in this presumed distributive shock.
yes. the plaintiff’s lawyer played a nice bad guy. not sure if that is a good thing , if you want to win a case.
think i prob would have tried the glucagon but certainly no where near the levels the plaintiff attorney alluded to
Not guilty. As there is no evidence for critical desaturation mentioned, the airway problems were a red herring. If severe hypoxia or impending loss of airway were present, some form of advanced airway management would have been necessary – but this did not occur. It’s not clear to me even that the ED management would have contributed to her death if the case happened today. She died of MODS, not of acute shock – it is unclear if more rapid titration of epi would have prevented this (though, being based in Europe, the doses mentioned seem rather small to me).… Read more »
Not guilty. As there is no evidence for critical desaturation mentioned, the airway problems were a red herring. If severe hypoxia or impending loss of airway were present, some form of advanced airway management would have been necessary – but this did not occur. It’s not clear to me even that the ED management would have contributed to her death if the case happened today. She died of MODS, not of acute shock – it is unclear if more rapid titration of epi would have prevented this (though, being based in Europe, the doses mentioned seem rather small to me).… Read more »
good points, Maarten. retro-vision is often better, if not 20/20. but there’s much to consider. some thoughts: 1. if one decides that the airway is to be secured , if that decision is made, there is a certain pathway that one can follow. scott has multiple pods on this site discussing just this one issue. the difficult and the failed airway. the horrific video of the Elaine Bromley case comes to mind. the seven intubation attempts in the mock trial case remind me in a way of that. in 2013 , scott described the STC-shock trauma center failed airway algorithm.… Read more »
agree with all of these
not guilty, more because plaintiff side used wrong arguments, speculated and misinterpreted words (i know it’s their work, but sometimes it frightens me when i see this in action). Agree with other comment, that it is difficult to judge your proffesion, colleagues. Is there a room for learning here – yes. I learned a lot from this “trial” and it was interesting to watch. There are a lot of things to comment on, but still, on i thing i don’t agree with defence is : ABC stays ABC, regardless of hemodynamics oxygenation should be done appropriately – decause even if… Read more »
yep
Excellent Podcast ! I have to go with “Not Guilty” either, i don’t think there’s any action that could have prevented the final outcome in this patient. 1) Quinolone I don’t think the administration of another antibiotic would have change the outcome. 2) Airway management I don’t think a more aggressive airway management would have change the outcome in this patient. However, i was a bit uncomfortable with “We focused on circulation since the patient was oxygenating well and protecting her airway”. Just to be clear, i am not saying i would have done a better job, it’s pretty easy… Read more »
well obv. you and i are going to be on the same page given how we have interacted, but for people who feel necessary to call anesthesia in a case like this (showing level of airway familiarity/exp) then waiting for drug to wear off is not a bad idea. this pt would have been perfect for awake intubation, reason not chosen is familiarity.
not guilty. a beautiful (though very painful to watch) presentation. these are always, i think, difficult, for inherent reasons. however, they are invaluable, or certainly could be. that is why i had found the monthly Risk-Management series (by dr greg henry and his team) of podcasts valuable, informative, enlightening. mike weinstock was an occasional guest if i recall. years back, they recommended a book by Mike called “bouncebacks”. i finally purchased it three days ago. thank you, scott for giving us this, and thank you of course, to mike weinstock, and his team. painful, invaluable. tom ps: this video is… Read more »
am i allowed one more thought?
although i have no love for the plaintiff’s lawyer, he comments on ECMO. while that was not commonly used (i believe) in 2008, the time of this case, today it is a significant powerful tool/option in appropriate cases, including anaphylaxis.
please enjoy the incredible pod (by the Reanimate team of scott, joe bellezzo, and zack shinar) on the edecmo.org site: pod #31. exactly this scenario, i think.
no. i am not the PR person.
not sure if this pt was really ecmo eligible, should have gotten much higher and additional pressors and prob. would have been fine
I don´t understand the role of ECMO in this case. The problem is primarily vasoplegic shock and an AV ECMO doesn´t help with that, the pat would likely have a hyper dynamic circulation with increased cardiac output. The cases Ive found seems to be patients already in cardiac arrest secondary to anaphylaxis. The role for VV ECMO does also not seems to be fulfilled as the pat was not refractory hypoxic.
Can someone explain to me what I don’t understand?
What was the actual verdict? Wondering if a jury of layperson would follow the case and come to the same conclusion as most of the docs here.
I actually think the verdict should be guilty. The airway issue is such a red herring, not relevant to outcome from info provided, but concerning given the way it was approached. The antibiotic issue: weird choice (geographic differences I suspect), but just random guessing from the plaintiff. Glucagon: reasonable to try. Reasonable dose. Could have gone higher if more adrenaline had failed. ECMO: whatevs. Wasn’t standard of care in 2008. Don’t think it would be necessary with proper management. Adrenaline: this is the negligence. Either you suspect anaphylaxis and you treat to your end point (reasonable MAP and oxygenation) or… Read more »
My verdict would be for the defense. But I would bet money that a lay jury would find for the plaintiff