Shadowboxing

First brought to my attention by Gary Klein in EMCrit 179, shadowboxing is considered one of the best ways to relay tacit knowledge. Shadowboxing has a situation presented to an expert with a pause before they answer at critical junctions. During the pause, the learner should mentally commit to what they are thinking and what they would do.

Prior Shadowboxing Cases

• EMCrit Shadowboxing Case 3 – Chicken or Egg – Which Organ Failed First?
• EMCrit 322 – Shadowboxing Case 2 – Frack the EJ
• EMCrit 314 – ShadowBoxing Ep. 1 – In the end, it’s always…

The Guests

Christina Lu

Christina Lu completed her fellowship in Advanced Resuscitation and emergency medicine residency at Stony Brook University Hospital. She is an Assistant Professor of Emergency Medicine and currently serves as the Associate Director of the Emergency Critical Care and Resuscitation Fellowship, and Associate Director of the Emergency Critical Care Division at Hartford Hospital. She has an interest in critical care education and advancing the field of resuscitation medicine.

Ryan Barnicle

Ryan Barnicle is one of the newest faculty in the Education Section at Yale University School of Medicine’s Department of Emergency Medicine. He completed his emergency medicine residency at Stony Brook University Hospital followed by fellowship in Advanced Resuscitation. A former high school teacher, he has maintained his passion for teaching with residents and medical students. His interests include resuscitation education and critical care echocardiography.

Lucas Goss

Lucas is an emergency medicine chief resident at Carolinas Medical Center in Charlotte, NC. He has interests in resuscitation and critical care with plan to pursue critical care fellowship when he graduates.

The Case

EMS arrives with a 45-year-old F on NRB that is immediately rolled into a resuscitation room.

Per EMS report, a family member found the patient unresponsive on the floor. They were told that the patient has a history of heart transplantation, insulin dependent diabetes, and is unvaccinated for COVID-19. She was diagnosed with COVID within the past 1-2 weeks. Over the past 2 days she has been experiencing SOB, weakness, slurred speech, confusion, and non-bloody emesis.

EMS Vitals: Highest HR 141, lowest BP 91/57, unable to obtain SPO2, RR 40, GCS 8 (E1 V2 M5). POC glucose was unreadably high. They placed her on NRB due to inability to obtain SPO2. They were unable to obtain IV access.

Time – 0:00 

ED Vitals: HR 135-160, BP 100/64, Temp 96.2, RR 30-40, poor oxygen saturation pleth on sat probe, but at times in 90s when reading well on NRB facemask. POC glucose reading “high – out of clinical range”.

Initial exam:

Gen: ill appearing, obtunded

Head/neck: No signs of trauma, no swelling, dry MM, airway intact and managing secretions

Resp: Clear B/L, tachypneic, increased WOB on NRB.

CV: Extremities cool to touch and poorly perfused. 1+ radial pulse B/L, tachycardic

Abdomen: Soft, NT, ND

Neuro: GCS 8 (E1, V2, M5), incomprehensible sounds, w/d all 4 extremities to pain, pupils 4 RRL B/L.

Skin: No signs of cellulitis, breakdown, infection or fournier gangrene

Sinus Tach, RBBB, LPFB, no obvious signs of hyper K, QT normal, no ischemia, no prior for comparison.

ECHO

Full bedside echo/IVC US interpretation: underfilled LV, normal LV function, RV normal in size with no signs of right heart strain, small pericardial effusion with no signs of tamponade, IVC is collapsed with difficult visualization suggesting hypovolemia. 

Discussion Point: Initial Impressions and where to start with the resuscitation

•  This patient has multiple abnormalities (hypotensive, tachycardic, tachypneic, etc).  Where do you start in the resuscitation?

Hypovolemic shock, hypoxemic respiratory failure, likely DKA vs HHS, potential acidosis, immunocompromised, no IV access, and last but not least – COVID. 

Planned to obtain multiple points of access, begin resuscitation with LR, send cultures, labs, VBG.

Shortly after her arrival we had multiple trauma patients get brought in, pulling nursing staff, RT, and attending away.

Time ~ 0:08

Nursing staff were able to get a RUE USGIV (likely basilic vein), which came out shortly after starting IVF infusion. They were able to obtain VBG and labs.

Discussion Point – Difficult IV access in the critically ill

• What options do you consider in this situation and what is your approach to obtaining access?

-USGIV

    Catheter type

    Location of placement

    Avoiding line failure

Our USGIV catheters we typically use

-IO

-Central line

    Crash vs Full sterile technique?

-Midlines in the ED?

-EJ

~ Time ~ 0:12

This patient received L tibial IO placement while I placed a triple lumen R fem line as this patient was in shock and going to require fluids, likely antibiotics, insulin drip, electrolyte replacement, etc.

Potential Discussion Point – Prioritizing tasks during resuscitations when only a small team is available

• How does team size affect the resuscitation?

Often at academic medical centers there are at least 2, many times 3-4 providers in a room during a medical or trauma resuscitation. Tasks are performed simultaneously by members of the team under direction of the team leader. When you are the sole provider with help from one nurse, task prioritization is essential.

In this case, my priorities were IV access, fluids resuscitate, get labs back in order to begin insulin in the case of likely DKA

Time ~ 0:15

Vitals – HR 140s-150s, SPO2 intermittent good pleth in low 90s with sat probe on ear on HFNC + NRB, RR high 30s, BP 115/90

VBG –  pH (7.09), PCO2 (36), PO2 (38), HCO3 (11), Base deficit (18)

K (6.3), Na (144), Glucose (>740) (unable to detect above that), lactate (4.3.)

Time ~0:30

BMP – Na (138) (corrected-160), K (6.2), Cl (92), CO2 (7), Anion Gap (39), Glucose (1451),

BUN (98) (previous result- 25), Cr (4.49) (previous-1.81 ), Calcium (9.8), Magnesium (5.3),

Phosphorus (9.9)

Lactate (formal) – 4.5

CBC – WBC (25.9), HGB (14.1), PLT (373), ANC (24.9)

LFTs – Albumin (4.1), Total protein (9.1), AST/ALT (11/8), Bili (0.5), Alk Phos (130)

Serum osm – 436 (calculated)

Beta hydroxybutyrate (9.28 – ULN is 0.27 mmol/L)

Blood cx, urinalysis, urine cx pending

After L femoral triple lumen is placed, isotonic crystalloids (LR) begin infusing via pressure bag.

Portable CXR

Discussion Point – Should this patient be intubated? 

• What are the dangers of intubating a DKA patient?

• What considerations do you need prior to intubating a DKA patient?

• Are there alternative methods or temporalizing measures?

Considerations in this patient

• Metabolic acidosis secondary to DKA and elevated lactate, likely with inadequate compensation evidenced by VBG bicarb

• Unable to obtain good oxygen saturation pleth due to shock, what to do in that situation? 

• HFNC vs BiPAP

• BiPAP will likely assist more with her WOB and ventilation, as I suspect she has significant shunt physiology

• How altered is too altered for BiPAP and how do you make this decision?

• Opinions on HFNC + NRB in this case?

• What pH should you be highly concerned about causing someone to be high risk for peri-intubation arrest?

• Do you get arterial line and ABG to look at CO2 to assess for compensation or is VBG adequate?

• In this patient with COVID, I would suspect that her COVID pneumonia would make ventilating her enough to compensate for her acidosis very difficult?

Since we were having trouble getting a good oxygen saturation pleth, immediately on arrival the patient was placed on HFNC 60L 100% and NRB. We felt she was too altered for BiPAP and were concerned about reported vomiting. This would to some degree help her work of breathing/ventilation with a small amount of positive pressure. I was concerned about how her IVF would eventually cause worsening shunt physiology by worsening her ARDS secondary to COVID. Additionally, I did not think she would tolerate intubation given her current physiology of acidosis, hypovolemic shock, and difficulty obtaining a consistent/reliable oxygen saturation would make monitoring saturations during intubation problematic. . My goal was to fluid resuscitate her enough to obtain a reliable saturation and improve her metabolic acidosis with insulin so that should she end up needing intubation she would be better optimized.

At this point, I felt she likely had a mixed DKA/HHS clinical presentation with hypovolemic shock, lactic acidosis, and potential superimposed infection.

Discussion Point – Treating mixed DKA/HHS

• Diagnosis

• Considerations prior to starting insulin

• Concern for osmotic shifts in treatment of HHS or someone with this high of a glucose?

• Insulin Bolus up front in this situation?

• Insulin drip and rate?

• Does Bicarb ever have a role?

Time ~ 0:45

We started insulin gtt at 0.14 units/kg/hr

Hyperkalemia was treated with 3g Calcium Gluconate (given that I had femoral central line should have just opted for calcium chloride)

She had an episode of tachycardia into the 180s with stable BP that self-resolved by the time pads were placed. EKG was obtained during one episode but limited due to artifact. No further episodes were seen.

Dr. Pendell Meyer’s assisted with interpretation and felt this was likely not VT, but more likely RBBB morphology SVT.

Discussion Point- Fluid Responsiveness 

• What are ways of determining fluid responsiveness.   In this patient with tenuous fluid balance, how do you know when to stop?

This patient requires large volume fluid resuscitation, however has COVID-19 as well. How will this affect her respiratory failure, as not all of this fluid will remain in the intravascular space. 

Time ~ 1:00

Vitals HR 125, RR 32, BP 127/87 (s/p 2L LR), O2 Sat 97% now with consistent good oxygen saturation pleth.

Re-evaluation

Clinical exam with improved peripheral perfusion, eyes opening to voice, intermittently following commands. Brief verbal responses.

Trop 30, BNP 215

UPT negative

Catheterized UA with >500 glucose, >80 ketones, moderate hgb, negative RBCs, negative nitrite/LR, 3 WBCs, rare bacteria

Vancomycin and Zosyn ordered

Further History

She was last seen by her outside hospital cardiologist 4 months prior and was not noted to have any issues at that time. Patient developed COVID-19 infection 13 days prior to presentation at our hospital.  Patient is not vaccinated for COVID-19. Her baseline creatinine is 2.

Time: 1.50

ICU team was contacted for admission Antibiotics infusing

3L LR infused

Repeat VBG pH 7.15, PCO233, PO2 36, HCO3 11, Base deficit 16, glucose undetectably high still, Lactate 4.3, K 5.8.

R Radial A-line placed

ABG 7.21/27/88/11 on 100% FIO2 60L HFNC

Time 2:00

Transferred to ICU

Brief hospital course:

Repeat Labs 3 hours after initial presentation. Na (146) (corrected – 158), K (4.9), Cl(110), CO2 14, Anion Gap 22, Glucose (834), BUN (82), Cr (3.33), Ca (9.0) Phos 4.8

Serum Osm (Calculated) – 392

Lactate 1.6,

TSH 0.821

She was continued on a nurse titrated DKA protocol (endotool) for DKA. 

Anion Gap and bicarb normalized ~12 hours after presentation

Her mental status gradually improved throughout the first 24-48 hours with opening eyes spontaneously, answering questions, following commands, however still with intermittent confusion. 

Her HFNC O2 was able to be weaned significantly in the first 48 hours, with transient worsening of respiratory status thereafter. She ultimately did not initially require intubation and was able to be transferred out to the floor after ~ 1 week. 

TTE report ~10 hours after presentation: 

1. Left ventricle: The left ventricular cavity size is normal. Wall thickness is normal. Systolic function is normal. LVEF 65%, estimated visually. No segmental wall motion abnormalities. Tachycardia throughout study.
2. Right ventricle: The right ventricular cavity size is normal. Systolic function is normal as estimated by visual and quantitative measures.
3. No significant valve stenosis or regurgitation.

Discussion/ Shadow Boxing Points:

1. Initial Impression
2. What do you prioritize in the resuscitation, where do you start?
3. What is the approach of obtaining access in the patient with difficult anatomy or access?
4. Would you intubate the patient?   How would you approach the intubation of the COVID patient?
5. Management of DKA
6. How much fluid is enough?

Useful Papers

1. Spiegel RJ, Eraso D, Leibner E, Thode H, Morley EJ, Weingart S. The Utility of Midline Intravenous Catheters in Critically Ill Emergency Department Patients. Ann Emerg Med 2020;75(4):538–45.
2. Elia F, Ferrari G, Molino P, et al. Standard-length catheters vs long catheters in ultrasound-guided peripheral vein cannulation. Am J Emerg Medicine 2012;30(5):712–6.
3. Prasanna N, Yamane D, Haridasa N, Davison D, Sparks A, Hawkins K. Safety and efficacy of vasopressor administration through midline catheters. J Crit Care 2021;61:1–4.
4. Chua HR, Schneider A, Bellomo R. Bicarbonate in diabetic ketoacidosis – a systematic review. Annals of Intensive Care [Internet] 2011;1(1):23. Available from: http://www.annalsofintensivecare.com/content/1/1/23

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Scott Weingart, MD FCCM

Editor-in-Chief, at EMCrit.org

An ED Intensivist from NY.
Professor
Nassau University Medical Center
No conflicts of interest (coi).

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