Mr. XYZ, M/59

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27th Feb 2012

    Found collapse at home Hstix ‘HI’ by ambulance crew 15:16  Triage, vitals BP 96/56, T 27.8

o C , response to pain 15:25  Cat 2, seen in resuscitation room

 15:30       Witnessed cardiac arrest in cubicle Initial rhythm VF Defibrillation x 1 1mg adrenaline given x 2 Down time 7 minutes Intubated with #7.5 ETT

Past history

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HbA1c 13.4 on insulin injection and Diamicron HT on Norvasc and hydralazine IHD Hep B carrier Hx of skull fracture with cranioplasty Old CVA Hx of retrorectal sarcoma with resection in 1996 QMH

History of present illness

 Information by friend  Teacher in career development     Flu like symptoms in recent few days, on TCM No reply from phone call Broke in by fireman Allergic to penicillin  angioedema

Resuscitation room

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Physical examination immediate after ROSC

 Vitals  BP 80/56, pulse 82/min     T 27.4

o C, cold peripheries  Cap refill fair CNS  GCS E1VTM1, pupils 1mm sluggish Fla c cid tone  Neck soft, no rash CVS  JVP not elevated  HS dual no murmur

Resuscitation room

   Resp  SpO2 100% on 100% FiO2, AE satisfactory  GI  Bilateral crepitations Abdomen: soft, not distended   No cullen/ Grey Turner sign BS positive Renal   yellow urine Urine ketone 4+

Resuscitation room

 Bedside investigation       H’stix HI i-stat: pH 6.709, pCO2 4.4, pO2 58, BE -30, HCO3 4 Na 138 K 4 iCa 1.26 Hct 0.42 iCa 1.4 Cl 101 Hemocue 13 Urine ACON kit –ve Urine ketone 4+ glu 2+ WC/nit –ve

 Hypovolaemic  Cardiogenic  Distributive   Septic Anaphylaxis  Obstructive  Endocrine

Shock

Hypothermia

 Lost temperature to surrounding environment  Inability to produce heat, shivering

Altered mental state

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AEIOU TIPS

 Alcohol  Epilepsy, electrolytes, encephalopathy        Insulin Opioids / overdose Urea (Metabolic) Trauma Infection Psychiatric Shock, SAH, stroke

Metabolic acidosis

     Respiratory compensation?

Anion gap?

Delta anion gap?

Delta HCO3?

Delta anion gap / Delta HCO3?

pCO2 14+/-2kPa 37 37 - 12 = 25 24 – 4 = 20 25 / 20 = 1.25

 High anion gap metabolic acidosis with inadequate respiratory compensation

High anion gap metabolic acidosis

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MUDPILES

  Methanol Uraemia       DKA, beta-hydroxybutyrate Paraldehyde Isoniazid Lactate Ethylene glycol Salicyate

Reversible causes for cardiac arrest

5Hs

 Hypothermia  Hypoxia  Hypo/Hyperkalaemia  Hydrogen ion  Hypovolaemia Take Temperature POCT, i-stat Echocardiogram and bedside USG

5Ts

 Tension pneumothorax  Tamponade  Thromboembolism, pulmonary  Thromboembolism, cardiac  Toxin

ECG

CT brain

CT brain:left craniectomy. Encephalomalacia at high left parietal lobe, probably old

Disposition

 ICU consulted  Response from ICU colleague: no bed available   Suggested inter-hospital transfer after discussion among ICU seniors Now what?

Guideline

Head Authority Head Office Operations Circular No. 10/2006

Indications

Critically ill patient(s) require intensive monitoring and treatment which will only be available in ICU, and the patient(s) is likely to benefit from such ICU care

Service network

Fax the form to your sister hospital ICUs, wait for a reasonable period of time Contact them direct if no reply after a reasonable period of time Group fax to all ICUs over the territory, wait for one hour Contact them direct if no reply receive then

Parent team

Our AED colleagues should call receiving hospital parent team, say medical in our case, for agreement to take over before transferring to the receiving hospital ICU (subject to futher discussion)

Transport

How to stablize?

1.

 Post VF arrest Tx: amiodarone infusion 150mg in 100ml D5W over 30 min then 1mg/min amiodarone infusion for 6 h  Therapeutic hypothermia: to keep core T 32-34 arrhythmia (VF) again o C for 12-24 hr, however he is already hypothermic, has to be very cautious especially during transfer for fear of triggering

How to stablize?

2. DKA - Insulin bolus 12 U then 4 U/hr - NS bolus keep CVP 12-15mmHg - A total of 3L NS given in 2 hr - Sodium Bicarbonate 8.4% 100ml given i-stat pH 6.86, pCO2 4.66, pO2 48.4 BE -27, HCO3 6.2

Hyperglycemic Crises in Adult Patients With Diabetes

2009 by the American Diabetes Association

Diabetes Care. 2009 July; 32(7): 1335 –1343

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Is a priming dose of insulin necessary in a low-dose insulin protocol for the treatment of diabetic ketoacidosis?

Based on small RCT without clinical outcomes 37 patients aged 19-66 yrs with DKA randomized to 1 of 3 insulin regimes Loading dose 0.07U/kg plus 0.07U/kg/hr 0.07U/kg/hr with no loading dose 0.14U/kg/hr with no loading dose No sig difference in time to reach glucose < 14 pH > 7.3

HCO3 > 15 Supplemental insulin required in 42% of group having 0.07 U with no priming No supplemental insulin required in priming or 0.14 U groups Diabetes Care 2008 Nov; 31(11): 2081-2085

How to stablize?

3. Septic shock - Early goal directed therapy - Inotrope support Noradrenaline 8mg in 100ml D5@ 20ml/hr, ~27mcg/min, latest ABP 108/59 before departure - Rocephin 2g IV - Klacid 500mg IV - Hydrocortisone 100mg IV

Algorithm for severe sepsis/ septic shock (Early Goal Directed Therapy)

Exclusion criteria

: Age < 18, Pregnancy, Poor Pre-morbid or aggressive treatment deemed not appropriate

I nclusion criteria

: 1. Evidence of organ dysfunction eg. Altered mental status, oliguria (uo< 30ml/hr), hypoxemia, lactate acidosis (lactate > 4mmol/L) or hypotension (SBP< 90mmHg) AND 2. Patients with 2 or more of the following: a) T >38 o C or <36 o C b) HR > 90/min c) RR>20/min or PaCO 2 < 4.3kPa d) WCC < 4x10 -9 /L or >12x10 -9 /L 2. 1. O 2 ± endotracheal intubation 2. Consult ICU Central venous ± arterial catheterization <10 cmH 2 O Blood x CBC d/c, LRFT, CaPO 4 , trop I, PT/ APTT, CRP, ABG/VBG, anion gap,

POC lactate

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C/ST, Hstix, Hemocue

± T&S Urine x UA, C/ST, PT (if fertile female) ECG CXR Bedside USG (infectious source identification) Foley to BSB 10- 16 cmH 2 O (1 6 - 2 0 c m H 2 O i f intubated) CVP MAP Hartman solution 20ml/kg bolus, repeat if necessary > 65mmHg ≥ 70% ScvO 2 <65mmHg Inotrope: Noradrenaline: 0.5-30 µg/min (ICU) Dopamine: 5-20µg /kg/min (gen ward) <70% Transfusion of PRC if Hb < 7g/L (can be deferred) < 70% ≥ 70% Inotropes Goals achieved Antibiotics (

door to needle time < 1hr

) Choice of antibiotics 1.

Community Acquired Pneumonia: Augmentin 1.2gm + Clarithromycin 500mg 2.

3.

Urosepsis: Meropenem 1gm and Amikacin 1gm Meningitis: Dexamethasone 10mg + Ceftriaxone 2gm +/- vancomycin 1gm 4.

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Intra-abdominal sepsis: Tazocin 4.5gm

Severe soft tissue infection: Tazocin 4.5gm + Levofloxacin 750mg + Clindamycin 600mg Neutropenic sepsis: Meropenem 1gm and Amikacin 1gm Oct 2011

EGDT in QEH Severe sepsis / septic shock ARISE study

          2 peripheral lines 1 central line 1 arterial line 2 infusion pumps 1 cardiac monitor 1 physio monitor (MP20) 1 ETCO2 monitor 1 ventilator Bear hugger Rectal Temp probe etc..

Our patient

Timeline

triage ROSC, consult ICU No reply from UCH.TKOH, fax to PWH Received call from ICU/UCH, bed av, decide to proceed to PWH after discussion 15:16 15:30 15:37 Cardiac arrest 16:00 17:00 17:30 No bed in QEH, decide interhospital transfer Bed av in PWH 18:00 Arrived at PWH 18:39 Depart from QEH 18:54 Length of stay in ED/QEH: 3h23min

Later on, results coming back…

Hb 11.7 WC 30 Na 137, K 4, Cl 101, HCO3 4 Anion gap 37 Urea 15 Cr 267 (baseline 112) RG 46 Trop I 0.23, CK 369, LDH 289 Lactate 3 BHBA 13.6

Progress

      Stay in ICU/PWH for 9 days Upon discharge  Tracheostomized, on 4L oxygen   Wean off inotropes Cardioembolic stroke with Rt hemiparesis, likely due to VF arrest, GCS E4M4Vt Discharge to medical ward then back to QEH Further drop in GCS 2 days later  CT brain: acute infarct in left medial occipital lobe Cardiac arrest on the same day Failed resuscitation and succumbed