Mr. XYZ, M/59
 27th Feb 2012
 Found collapse at home
 Hstix ‘HI’ by ambulance crew
 15:16
 Triage, vitals BP 96/56, T 27.8oC , response to pain
 15:25
 Cat 2, seen in resuscitation room
 15:30
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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
1.
DM complicated with overt nephropathy and retinopathy,
baseline Cr (8/2011) 118
HbA1c 13.4 on insulin injection and Diamicron
2.
HT on Norvasc and hydralazine
3.
IHD
4.
Hep B carrier
5.
Hx of skull fracture with cranioplasty
6.
Old CVA
7.
Hx of retrorectal sarcoma with resection in 1996 QMH
History of present illness
 Information by friend
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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
 Physical examination immediate after ROSC
 Vitals
 BP 80/56, pulse 82/min
 T 27.4oC, cold peripheries
 Cap refill fair
 CNS
 GCS E1VTM1, pupils 1mm sluggish
 Flaccid tone
 Neck soft, no rash
 CVS
 JVP not elevated
 HS dual no murmur
Resuscitation room
 Resp
 SpO2 100% on 100% FiO2, AE satisfactory
 Bilateral crepitations
 GI
 Abdomen: soft, not distended
 No cullen/ Grey Turner sign
 BS positive
 Renal
 yellow urine
 Urine ketone 4+
Resuscitation room
 Bedside investigation
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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
Shock
 Hypovolaemic
 Cardiogenic
 Distributive
 Septic
 Anaphylaxis
 Obstructive
 Endocrine
Hypothermia
 Lost temperature to surrounding environment
 Inability to produce heat, shivering
Altered mental state
 AEIOU TIPS
 Alcohol
 Epilepsy, electrolytes, encephalopathy
 Insulin
 Opioids / overdose
 Urea (Metabolic)
 Trauma
 Infection
 Psychiatric
 Shock, SAH, stroke
Metabolic acidosis
 Respiratory compensation?
pCO2 14+/-2kPa
 Anion gap?
37
 Delta anion gap?
37 - 12 = 25
 Delta HCO3?
24 – 4 = 20
 Delta anion gap / Delta HCO3?
25 / 20 = 1.25
 High anion gap metabolic acidosis with inadequate respiratory
compensation
High anion gap metabolic
acidosis
 MUDPILES
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Methanol
Uraemia
DKA, beta-hydroxybutyrate
Paraldehyde
Isoniazid
Lactate
Ethylene glycol
Salicyate
Reversible causes for cardiac
arrest
5Hs
5Ts
 Hypothermia
 Tension pneumothorax
 Hypoxia
 Tamponade
 Hypo/Hyperkalaemia
 Thromboembolism,
pulmonary
 Hydrogen ion
 Hypovolaemia
 Thromboembolism, cardiac
 Toxin
Take Temperature
POCT, i-stat
Echocardiogram and bedside USG
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
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Tx: amiodarone infusion 150mg in 100ml D5W over 30
min then 1mg/min amiodarone infusion for 6 h
Therapeutic hypothermia: to keep core T 32-34oC for 12-24
hr, however he is already hypothermic, has to be very
cautious especially during transfer for fear of triggering
arrhythmia (VF) again
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
Is a priming dose of insulin necessary in a low-dose
insulin protocol for the treatment of diabetic
ketoacidosis?
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Based on small RCT without clinical outcomes
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37 patients aged 19-66 yrs with DKA randomized to 1 of 3 insulin regimes
1.
Loading dose 0.07U/kg plus 0.07U/kg/hr
2.
0.07U/kg/hr with no loading dose
3.
0.14U/kg/hr with no loading dose
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No sig difference in time to reach
1.
glucose < 14
2.
pH > 7.3
3.
HCO3 > 15
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Supplemental insulin required in 42% of group having 0.07 U with no priming
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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
Inclusion 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 >38oC or <36 oC b) HR > 90/min c) RR>20/min or PaCO2 < 4.3kPa
d) WCC < 4x10 -9/L or >12x10 -9/L
2.
Blood x CBC d/c, LRFT, CaPO4, trop I, PT/
APTT, CRP, ABG/VBG, anion gap, POC
lactate, 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
1. O2 ± endotracheal intubation
2. Consult ICU
Central venous ± arterial catheterization
<10 cmH2O
10- 16 cmH2O
(16- 20 cmH 2 O if
intubated)
CVP
MAP
Hartman solution 20ml/kg bolus, repeat if necessary
<65mmHg
> 65mmHg
Inotrope:
Noradrenaline: 0.5-30 µg/min (ICU)
Dopamine: 5-20µg /kg/min (gen ward)
<70%
ScvO2
≥ 70%
Transfusion of PRC if Hb <
7g/L (can be deferred)
< 70%
≥ 70%
Inotropes
Goals achieved
Antibiotics (door to
needle time <1hr)
Oct 2011
Choice of antibiotics
1. Community Acquired Pneumonia: Augmentin 1.2gm +
Clarithromycin 500mg
2. Urosepsis: Meropenem 1gm and Amikacin 1gm
3. Meningitis: Dexamethasone 10mg + Ceftriaxone 2gm +/vancomycin 1gm
4. Intra-abdominal sepsis: Tazocin 4.5gm
5. Severe soft tissue infection: Tazocin 4.5gm + Levofloxacin
750mg + Clindamycin 600mg
6. Neutropenic sepsis: Meropenem 1gm and Amikacin 1gm
EGDT in QEH
Severe sepsis / septic shock
ARISE study
Our patient
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2 peripheral lines
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1 central line
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1 arterial line
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2 infusion pumps
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1 cardiac monitor
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1 physio monitor (MP20)
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1 ETCO2 monitor
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1 ventilator
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Bear hugger
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Rectal Temp probe etc..
Timeline
triage
15:16
ROSC,
consult
ICU
15:30 15:37
Cardiac arrest
Received call from
ICU/UCH, bed av,
decide to proceed
to PWH after
discussion
No reply from
UCH.TKOH, fax to
PWH
16:00
17:00
No bed in QEH, decide
interhospital transfer
17:30
Bed av in
PWH
18:00
Arrived at PWH
18:39
Depart from
QEH
Length of stay in ED/QEH: 3h23min
18:54
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
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Stay in ICU/PWH for 9 days
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Upon discharge
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Tracheostomized, on 4L oxygen
Wean off inotropes
Cardioembolic stroke with Rt hemiparesis, likely due to VF arrest, GCS E4M4Vt
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Discharge to medical ward then back to QEH
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Further drop in GCS 2 days later
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CT brain: acute infarct in left medial occipital lobe
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Cardiac arrest on the same day
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Failed resuscitation and succumbed