Category: Cases

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A typical case of severe intraparenchymal hemorrhage with resulting herniation.

Takeaway lessons

1. DOACs like apixaban (Eliquis), although not usually monitored using routine coagulation assays, tend to elevate the INR only slightly (e.g. 1.0–1.3 or so). A strikingly INR in warfarin-like ranges should raise suspicion for an additional occult cause of coagulopathy.
2. Manage elevated ICPs using the ENLS “tiered” approach. All neurosurgical patients should receive the tier 0 (basic management) therapies.
3. In the neuro-injured patient, seek “euboxia” to limit further brain injury: normal pH, normal PCO2, normal PaO2, normal BP, normal temperature etc.
4. Be wary relying solely upon the GCS to describe, or even to trend neurological function. A descriptive, granular survey of function (particularly motor function) is usually more useful, as well as easier to remember.

References

Nestor MA, Boling B. Reversing Direct Oral Anticoagulants in Acute Intracranial Hemorrhage. Crit Care Nurse. 2019 39 (3): e1–e8.

ICH score

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Part two of our interfacility transfer from Hell. Tyler Christifulli, FP-C, EMT-P (@christifulli88) and Sam Ireland FP-C, EMT-P (@ireland_sam1) show us how they handle GI bleeding, arrhythmias, shock, cardiac arrest, and more, all from the confines of a helicopter. Listen to Part 1 here.

Check out the great educational content from Tyler and Sam over at FOAMfrat, including blogs, podcasts, and online EMS continuing education.

Takeaway lessons

1. When faced with an unstable patient in a wide complex tachycardia, stop thinking and just shock it.
2. As the nature of the transport (and the patient) changes, change your focus with it. The initial diagnosis is a starting point, not a headline.
3. Consider esmolol as an easily-titratable means of rate control in unstable patients.
4. Communicate ahead with the receiving hospital if urgent interventions will be needed upon your arrival.
5. Non-invasive positive pressure ventilation offers a preview of the hemodynamic response to intubation.

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A grueling interfacility transfer gives Tyler Christifulli, FP-C, EMT-P (@christifulli88) and Sam Ireland FP-C, EMT-P (@ireland_sam1) the opportunity to show us how they handle airway management, GI bleeding, mechanical ventilation, cardiac arrest, and more, all from the confines of a helicopter.

Check out the great educational content from Tyler and Sam over at FOAMfrat, including blogs, podcasts, and online EMS continuing education.

Takeaway lessons

1. Prepare the best you can before departing the sending facility, while acknowledging that that time may be a factor, and that some things can’t be predicted.
2. The close attention by 1:1 (or more) clinicians possible during critical care transport allows some issues, such as borderline airways, to be managed by close observation rather than early intervention.
3. Due to the limited medications and lab studies available, particular care should be used when managing DKA. Insulin therapy should target gentle glucose correction to avoid precipitous changes in pH, osmolarity, potassium, etc.
4. Transport medicine, whether from the back of an ambulance, helicopter, jet, or rickshaw, is an austere environment. Personnel, equipment, and time are all limited. A thoughtful approach to logistics, prioritization, workflow, timing, and detail is at least as important as a high-level understanding of pathology.

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A restless patient experiences a series of dyssynchrony events during mechanical ventilation. Come see how Bryan wades through it all, and allow us to offer an academic, yet practical approach to this sometimes-confusing subject.

Case files

Takeaway lessons

1. Start with ABCs and stabilizing the patient, then put on your thinking cap and try to optimize synchrony. It’ll reduce sedation requirements, lessen the risk of lung injury, and prevent mechanical ventilation from feeling like black magic.
2. Sedation is a last resort, but sometimes needed if the patient wants something (e.g. more volume) that we think is unwise.
3. Most dyssynchrony is the patient fighting the ventilator, so it can often be managed by allowing the patient to determine more variables within the breath. Go from volume control to pressure control, or pressure control to pressure support.
4. Sometimes, you won’t figure it out.
5. In the decompensating patient, use DOPES to remember the causes
   1. D isplaced tube
   2. O bstructed tube
   3. P neumothorax
   4. E quipment failure
   5. S tacking of breaths
6. Remember “peak pressure apnea,” a phenomenon of iatrogenic hypoventilation caused by the high pressure alarm setting.

Resources

References

• Oto B. Peak pressure apnea: An under-recognized, high-risk form of ventilator asynchrony [published online ahead of print, 2020 Feb 10]. Heart Lung. 2020;S0147-9563(20)30012-1. doi:10.1016/j.hrtlng.2020.01.012

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The book

Buy the new textbook (Bryan edited, Brandon authored a chapter) here or on Amazon:

Concepts in Surgical Critical Care, First Edition

ed. Bryan Boling, DNP, ACNP; Kevin Hatton, MD, FCCM; Tonja Hartjes, DNP, ACNP-BC, CCRN, FAANP

The podcast

The second piece of our in-depth look at the management of right heart failure, with a focus on preserving peri-intubation hemodynamics using the SAVIOR protocol—featuring its co-creator, anesthesiologist and intensivist from the University of Kentucky, Habib Srour. Check out part 1 here.

Takeaway lessons

1. You don’t want to intubate patients with right heart failure, but if you do, you don’t want to do it in a hurry; a well-prepared approach will be far safer. That means doing it at the right time, not sooner and not later, and making what preparations you can before they’re needed.
2. Using awake intubation to gently transitioning from spontaneous breathing to mechanical ventilation via up-titration of pressure support (starting at zero) offers a gradual, reversible approach.
3. Sedation is often not needed for intubation. The KPET rule gives guidance if desired, but really only applies in isolation; combining drugs creates synergy in their effect and less is often needed.
   • 1 mg/kg ketamine
   • 2 mg/kg propofol
   • .3 mg/kg etomidate
   • 4 mg/kg thiopental

Resources

References

• Srour H, Shy J, Klinger Z, Kolodziej A, Hatton KW. Airway Management and Positive Pressure Ventilation in Severe Right Ventricular Failure: SAVIOR Algorithm. J Cardiothorac Vasc Anesth. 2020;34(1):305‐306. doi:10.1053/j.jvca.2019.05.046

Podcast: Play in new window | Download

Subscribe: Apple Podcasts | Spotify | Android | Pandora | iHeartRadio | TuneIn | RSS

The book

Buy the new textbook (Bryan edited, Brandon authored a chapter) here or on Amazon:

Concepts in Surgical Critical Care, First Edition

ed. Bryan Boling, DNP, ACNP; Kevin Hatton, MD, FCCM; Tonja Hartjes, DNP, ACNP-BC, CCRN, FAANP

The podcast

An in-depth look at the management of right heart failure, with a focus on preserving peri-intubation hemodynamics using the SAVIOR protocol—featuring its co-creator, anesthesiologist and intensivist from the University of Kentucky, Habib Srour.

Takeaway lessons

1. When facing undifferentiated shock and a complex picture, look for one point of data to help distinguish the etiology. Try touching the feet: cold is a good indicator of a significant cardiogenic component.
2. The flip side of hypoxic vasoconstriction is hyperoxic vasodilation of the pulmonary vasculature—i.e. an overly high FiO2 will tend to worsen V/Q matching.
3. To hemodynamically manage RV failure without worsening RV afterload, consider the Rule of 8s cocktail:
   1. Epinephrine .08 mcg/kg/min
   2. Dopamine 8 mcg/kg/min
   3. Vasopressin .08 units/min
   4. Inhaled epoprostenol (Veletri/Flolan) 8 ml/hr
4. The “lung pump” of negative pressure respiration provides a substantial amount of cardiac output, particularly in the setting of RV failure. Paralysis, sedation, and intubation removes this. The period of apnea also worsens acidosis which increases PVR.
5. The dead space to tidal volume ratio increases by at least 50% after intubation; it will be impossible to match an already-high spontaneous minute ventilation on the ventilator.

Resources

References

• Srour H, Shy J, Klinger Z, Kolodziej A, Hatton KW. Airway Management and Positive Pressure Ventilation in Severe Right Ventricular Failure: SAVIOR Algorithm. J Cardiothorac Vasc Anesth. 2020;34(1):305‐306. doi:10.1053/j.jvca.2019.05.046

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The second part of our look at a case of catastrophic intracranial hemorrhage, with a focus on goals of care, family interaction, prognostication, and other end-of-life aspects, with neurointensivist and palliative care physician Jess McFarlin (@JessMcFarlinMD).

See Part 1 here.

Takeaway lessons

1. Useful phrase: “Can I tell you what to expect during the dying time?”
   1. Discuss the possibility of secretions, etc. Use glycopyrrolate.
2. Use opioids if you expect dyspnea, otherwise not always needed. Can try a pressure support trial on the ventilator to get a sense for tachypnea.
3. Let both family and the nurse know what to expect after extubation.
4. Other than the occasional incidence of troubling myoclonus with fentanyl, and restrictions on its use outside of the ICU in many centers, all opioids are probably equally good for end-of-life care. Consider hydromorphone in renal patients.
5. In general, stop tube feeds at the end of life, and stop trying to ensure full nutrition, but do offer food and drink for comfort. Dying tends to limit hunger and caloric needs anyhow. Stop IV fluids as well.
6. When families invoke a “miracle scenario,” reframe by asking what a miracle might look like for them, or raise the possibility that the miracle won’t be survival, but another outcome such as surviving until the rest of the family arrives, or being comfortable and pain-free during the dying process.
   1. Use “I wish [it would work]” statements to express empathy and a shared perspective, while maintaining a fact-based reality. Stop there and don’t wade into details.
   2. Turn miracles into concrete plans by establishing a time trial with a deadline, with clear markers for what success will look like.

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Neurointensivist and palliative care physician Jess McFarlin (@JessMcFarlinMD) walks us through a case of catastrophic intracranial hemorrhage, with a focus on goals of care, family interaction, prognostication, and other end-of-life aspects.

See Part 2 here.

Takeaway lessons

1. We can undo most things except death, so in most cases, a short trial (perhaps 3 days) of fully aggressive care after an ICU admission is reasonable to help clarify the eventual prognosis. Set clear guideposts for when you’ll regroup to make more decisions about the direction of care.
2. The ICH score is a helpful guide for early prognostication in spontaneous intraparenchymal hemorrhage.
3. When prognosticating, express the range of outcomes in terms of three possibilities, as determined by the currently available data: the best case, the worst case, and the most likely case.
4. Useful questions for families:
   1. If your [loved one] could hear this prognosis, what would he/she say is most important to him/her?
   2. What’s most important to you at this stage? What are you most afraid of?(Many are more concerned about discomfort, pain, or “struggling” at the end of life than about the prospect of death itself.)
5. When you’re asked, “What would you do if it were your mom?” the question is not really about your mom; it’s a request for a recommendation about theirs.
6. Transition from open-ended questioning, and translate their values/goals into an actionable plan, by using alignment statements: “What I’m hearing you say/it sounds like…” leads to “Hearing that, may I make a recommendation?”

Resources

References

• ICH score: mortality prediction score for spontaneous intraparenchymal hemorrhage
• Vital Talk: training resources for the skills of executing palliative and end-of-life conversations

[this episode was reposted on the website 4/27/2020 due to a database reversion after an unfortunate system breach —ed.]

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Neurologist and neurointensivist Gracia Mui shows us the workup, initial management, and escalation of care for a case of refractory status epilepticus.

Takeaway lessons

1. First-time unprovoked seizures usually need no further workup except screening for an underlying trigger, such as a tox screen, basic chemistries, and imaging as appropriate.
2. Initial seizure therapy: wait around 5 minutes, then give 2–4 mg lorazepam. Repeat every minute or so until convulsions stop, up to 0.1 mg/kg total.
3. Give an anti-epileptic concurrently: fosphenytoin or phenytoin (15–20 mg/kg), levetiracetam, or valproic acid (40 mg/kg, up to 3000 mg) are all acceptable. If using levetiracetam (Keppra), give a real dose of 60 mg/kg (max of 4.5 g).
4. After loading with benzos and/or anti-epileptics, if convulsions stop and the patient remains unresponsive, consider the duration of the drug you used. If it’s wearing off (e.g. after about an hour for lorazepam) and they remain unresponsive, suspect non-convulsive status epilepticus.
5. Any patient not waking up needs an EEG. If not available, they may need empiric deep sedation and intubation until EEG can prove the absence of seizures.
6. If convulsions are absent, that’s good, as convulsive seizures are more harmful than non-convulsive, but not as good as obviating seizure activity on EEG.
7. Other than the practical, there is no upper limit for benzodiazepine dosing.
8. Once you’ve successfully achieved the desired EEG result (either burst suppression or simply the absence of seizure activity) using anesthetics, hold them for about a day, then lighten sedation to see if seizures recur. If so, re-deepen sedation (perhaps for twice as long), increase anti-epileptic agents, then try again.
9. The patient in status should routinely be screened for underlying triggers, including brain imaging and LP (remember autoimmune causes such as NMDA encephalitis). But about half the time, even in severe refractory status, no underlying cause will be identified.

Resources

References

• Kapur J, Elm J, Chamberlain JM, et al. Randomized Trial of Three Anticonvulsant Medications for Status Epilepticus. N Engl J Med. 2019;381(22):2103–2113. doi:10.1056/NEJMoa1905795

[this episode was reposted on the website 4/27/2020 due to a database reversion after an unfortunate system breach —ed.]

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Cardiothoracic critical care PA Brendan Riordan (@concernecus) shows us his initial approach to the patient in cardiogenic shock, including initiating mechanical support, managing ECMO (plus Impella), and eventual weaning and discontinuation of support.

Some pearls

1. Anticoagulation on VA ECMO can be titrated to bleeding risk, with a balance between bleeding and circuit longevity—the latter being more than an inconvenience, as changing the circuit in a patient fully dependent on the pump is fraught. Anti-Xa levels are more reliable than the PTT. In a patient with HIT, you may be able to treat through it with bivalirudin, as the heparin-bonded circuit usually cannot be switched out.
2. “Hypoxemia” on VA ECMO is either regional hypoxemia/North-South syndrome/harlequin syndrome, or oxygenator failure. Rule out the latter by checking a post-oxygenator ABG or just looking to ensure the outflow blood is bright red. Rule in the former by evaluating the ABG or SpO2 from the right upper extremity.
3. Preemptively placing an anterograde perfusion catheter in the femoral artery is not absolutely mandatory, but is probably simpler and perhaps safer than placing one reactively.
4. A PA catheter is more useful for weaning ECMO than during the period of full support.
5. Readiness for weaning is evaluated by recognition of improving cardiac pulsatility, followed by a trial of weaning down pump flow, and finally decannulation in the OR. Consider leaving the Impella if there are any lingering concerns.

Resources

References

• How to monitor anticoagulation during ECMO: Saifee NH, Brogan TV, McMullan DM, et al. Monitoring Hemostasis During Extracorporeal Life Support. ASAIO J. 2020;66(2):230–237.