In this Mind of the Resuscitationist Episode, I discuss stop points: one for when you are using multiple vasopressors and especially about a cognitive stop point whenever things are going south.
2nd Vasopressor Stop Point
Rapid Ultrasound for Shock and Hypotension (RUSH) Exam
The RUSH Exam will allow rapid diagnosis of the cause of non-trauma hypotension
Abdominal Compartment Syndrome
See this crashing patient chapter for more on Abdominal Compartment Syndrome
Update: Added….
- Is there actually hypotension? Consider femoral a-line. Consider dissection/vascular obstruction at the site of BP Measurement.
- Systolic Anterior Motion
- Consider Tox
- Is this actually cardiogenic shock from ischemia/MI rather than sepsis
- Is there occult right ventricular failure that could be treated (e.g. with pulmonary vasodilation)?
- Is there low cardiac output and impaired perfusion (e.g. mottling)? In that case, additional vasoconstriction may simply aggravate matters.
- Is there a failure of surgical source control or incorrect antibiotic selection?
- Is the patient on adequate adjunctive therapy (stress-dose steroid, possibly thiamine/ascorbate)?
- Is there a pH abnormality that merits correction (e.g. treatment of hyperchloremic metabolic acidosis with bicarbonate)?
- Is there autoPEEP
- Is there clinically significant hypocalcemia?
Cognitive Stop Points for the Resuscitationist
Use this method whenever the situation doesn't add up or is going bad:
- Announce you have no idea what the f**k is going on
- Eliminate ALL assumptions
- Troubleshoot like an engineer
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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 have had a similar case. Another clue was that the Pulse Ox was picking up a sat of ~ 95% and the oxygen saturation on the ABG drawn of the “a-line” was significantly different. At the time I thought the labs just ran a VBG and called it an ABG. In retrospect, it was a huge clue that the line was intravenous.
Yep, we saw the same thing when we went back afterwards and looked at the abgs the prior team had sent
Hey Scott
thanks for another insightful podcast!
one question
if you had measured the CVP initially rather than assessing IVC with USS, would that have been more helpful as a cognitive stop point?
interesting question. I imagine if before the drainage of the ascites, the falsely placed a-line would have had a markedly higher pressure than the triple lumen in the neck.
Hi Scott, Thanks a lot for another one of your fantastic podcasts! They (plus a lot of other FOAMy stuff out there) make up for the lack of teaching at …anonymous hospitals. ‘Stop points’ like yours are a very useful structure for any situation in clinical life especially under pressure. From your case as well as from my own experience: we should honour the engineers and make “check your device/equipment” the very VERY first stop point of any list. Especially with ventilated patients with only little time to react (respirators/tubes have this tendency to do bizarre things in the middle… Read more »
absolutely! First step in troubleshooting any vent problem where the pt is not doing well is to disconnect the vent and bag the patient on 100% fio2 with a bvm plus/minus PEEP valve if the patient was on PEEP. Then troubleshoot the vent with a test lung/exam glove rather than the patient.
Thanks Scott Love the concept of Stop Points – also really useful on the diagnostic side when you are stumped for a diagnosis- amazing how often you can get lost in the swirl of data /tests etc and when you stop, strip it back to the 3 or 4 key, certain points on history and exam the diagnosis becomes evident. Especially true when you come into a half-worked up case! I was always taught in Gas school to put in the art line, then run a couple of NIBPs to check for correlation. It is simple, but helps avoid this… Read more »
Casey, great point. What was interesting in this case is that the NBP and A-line were in agreement at the time the a-line was placed. The patient’s BP was in the toilet, which is why they placed the a-line. Very perfect trap.
Doh! That sucks.
US probe in play? i think this makes accidental venous rarer?
If in doubt flush the line and watch the IVC for a turbulent flow to see if it is venous?
C
Scott, Great post! Having had a career in computer support in between undergrad and med school I routinely bug my trainees to “check the connections”. Amazing how often you find easy fixes (likely post-intubation hypoxia b/c the BVM is actually hooked up to the room air supply as opposed to the oxygen…have seen that lead to a long unnecessary troubleshooting operation). Really enjoy the “mind” series – deconstructing the cognitive process behind medical decision making is, I think, the most important and often challenging aspect of effectively training new practitioners. While it’s clearly valuable for critical care and procedures (an… Read more »
You just keep getting cooler, Stone! When you or I figure out the answer to the last paragraph, we can retire on it.
You both know the answer, you both are working on it pretty effectively. Thankfully the “F” in FOAM keeps you from early retirement 🙂 Cheers
Scott
Man, thanks for the teaching. If they were hypothyroid, how would you approach fixing that in a septic patient? The TSH and free T4 levels are tough to interpret in the midst of a critical illness.
Thanks again for this podcast. I know the case based stuff is a little nerve wracking, but this was so helpful to hear how you thought this through in it’s real life context.
Clay
Scott – My impression is that IF the problem is hypothyroidism – then the TSH & free T4 will not be minimally (or even moderately) off, as may occur with “sick euthyroid” – but dramatically off!
Even if the patient had “mild” (or even moderate) hypothyroidism – that probably wouldn’t be a key factor in causing/fixing septicemia – but it might if the patient was profoundly hypothyroid.
Agree with Ken. We are talking about profound hypothyroidism here, the TSH will be sky high.
Thanks Scott,
…a looot for this and everything you did for my Medication. STOP POINTS are great – and lead to verbalization on what is fact and what is concept – sooo rarely done!
Whenever there is a very low BP or I can‘t believe it: I grab a glove, place my fingers in the groin and check for pulse. With time I got a fair idea of how much the BP should be .
Take care and carry on!
Sascha
Sacha, Old school–I love it. Sometimes though, these vasodilated shock patients have a beautiful palpable pulse despite their hypotension as opposed to those vasoconstricted hypotensive patients who demonstrate the thready barely palpable pulses.
Great podcast Scott !!! Rather than “STOP Points” (which is of course an excellent concept) – I always think of “telling a story” – such that when parts of the story don’t “fit” – it’s time to go back and revisit things. Even when one doesn’t know the – – – – what is going on – when the clinical course just doesn’t make sense (ie, no increase in MAP despite drawing off liters of ascitic fluid in your case) – it’s time to revisit. P.S. The positive commentary you’ve already received suggested perhaps you should do some more “case… Read more »
more to come folks…
Thanks Scott: an other example that shows how in critical care and EM you must always take into account the unlikely or the unexpected!!!!!
Very useful the alghoritm with the stop points!!!!!!
Thanks for listening, Valerio
Liquid gold. As ever. EMCrit makes my brain smile and my patients healthy!
Great post Scott , you are teaching me stuff that no text book can ever teach . Come over to India , we need people like you to influence and guide us .
Thanks Dave and Anandan!
Hello,
Great stuff.
Sometimes, you need to stop and start from the top again. Plus, get the team working with you.
Here is a wacky one. A 30 year-old with a high grade SAH arrested. Nothing seemed to work. Lucky, somebody rolled in the u/s and noted dilated cardiomyopathy. She was placed on a IABP and was discharged home a few months later without any deficits. A good outcome considering the team was close to calling it.
Thank you,
now that is a tough case
Last night during my shift I felt like I’d been cursed by Scott Weingart… After listening to this podcast during the day I ended up struggling to get an A.line in a ED pt who had recently arrested. The ED doc had failed the femoral A.line and the cuff pressure wasn’t picking up, carotid pulse was weak. We all assumed a technical issue with the BP cuff not picking up on the morbidly obese arm in the context of moderate hypotension. After fussing around for quite a while trying to thread a radial A.line using U/S, I finally thought I’d… Read more »
hah, hah! Move ultrasound probe proximal and flush to see opac of prox radial artery will answer the ?.
With regard to your shout out to Ken Grauer, I have been giving his ECG pocketbooks to my med students for several years. They are some of the most practical ECG books on the market. (The’re a bit like the TARDIS, a small book on the outside and a huge amount of information of the inside.)
Thanks for the kind words Toby! I think you’ll find my new ACLS-2013-PB book similarly small on the outside but lots of practical info on the inside.
As always – I welcome feedback! – and I welcome suggestions.
First Who reference in the comments; strong work!
Hi Scott. I’m a little slow in getting around to this podcast, but I’m glad I did. I don’t have anything to add to the clinical discussion, but the ‘Cognitive Stop Points’ concept really resonated with me. I’ve been doing the ambulance driver version for many years, and get many strange looks when I tell everyone to stop what they are doing and go back to A…B…C… I’ve found it’s great to break the circuit when everything is getting a little out of control and it’s great to have some validation for my habits from such a lofty source as… Read more »
Yep, funny looks are worth it to save the patient!
Hi Scott, I was very happy to hear abdominal compartment syndrome discussed in this podcast, as it continues to be an unrecognized (and under treated) critical illness. Take a look at this case report from one of my Senior Registrars in Melbourne: http://ccforum.com/content/16/6/452
Keep up the great #FOAMed work!
Saw that case report, great move by the registrar!
Great podcast as always Scott, I think this type of case discussion is much needed as it provides the nuts and bolts to troubleshooting complex issues!
Definitely good to create and use the concept of distinct stop points when things aren’t going according to plan.
My one comment would be the caveat of looking at the IVC in the setting of IAH/ACS, because a “small” IVC may simply represent the net effect of IAP > CVP, hence the IVC should definitely be assessed again post-drainage, since that “hypovolemic” IVC may no longer be so!
cheers!
Phil
Phillipe, Absolutely agree, the small IVC was definitely from the IAH and it is a point worth stressing. That is why I emphasized that it was small, but not expanding with mech ventilation.
Gold. Loved the clinical story, but moreover, just hearing about how to think and troubleshoot was fabulous.
Great!
Pj
Thanks PJ!
Great podcast. One question: in my shop the general opinion is that adding epi to norepi to increase pvr is pointless, because all the alpha-1 receptors are already taken. And if you gave it to increase contractility via beta-receptors why did you not choose dobutamine? what is your take on that? thanks
I you have no ceiling dose of norepi, then you can use dobutamine, but your norepi dose may go up. Many places lock the max dose of norepi at 20-30 mcg/min, in which case epi may spare norepi dose. Don’t think it much matters.
Thanks for intresting info. Would run a case by you all i saw yesterday. pt 70year fit and healthy out playing golf, found unresponsive. paramedic call, was BP210/110,HR70 WEAK THREADY ??/GCS 7/15. TEMP 33.3 Difficult to tube ,so LMA APPLED. On arrival seen by medical reg and ED reg.ITU REG( OH RYT IAM IN UK A&E) vitals above RSI ETT, ECG ON ambulance acute inf changes. ecg in dept LBBB. GCS AS ABOVE. Radial pulses normal. pupils were pinpointed bilat reactive. chest crackles bilat bases, heart sounds normal abd SLNT LL, Cold ,CRF 8SEC. The residants had thought of ?… Read more »
tough hypothetical case! gent needs to be in the hands of a cardiothoracic surgeon ASAP. beyond that, it sounds like you’ve done all you can in the ED. Thrombotic aortas do much worse in dissections.
Awesome. More like this please. Thank you.
Hi Sott, great podcast.
Any thoughts on the use of methylene blue in septic shock as a last resort?
Regards
Sa’ad