Skinny, Cold and Coded

[DartmouthDave]

Hello,

You are a fixed wing air ambulance crew.

You are dispatched to transfer a post-code patient from a community hospital ED to a CCU in a large teaching hospital. Flight time is 90 minutes.

On arrival, you receive report from the nursing staff.

A 21 year-old women had a witness cardiac arrest at home. CPR was started and an ambulance was called. A BLS crew arrived and a shock was delivered with an AED and there was ROSC.

Once in the ED she was intubated (#7.5 ET 22cm at the lip) and place on a ventilator (AC 12/500/.50/+5). Her BP was low so a femoral line was inserted and Levophed started. Cooling was started as per direction from the CCU. She is unresponsive and on no sedation is running.

Anxious family is milling about. Her father wants to come with you. The staff seem keen on having her out the door.

You enter the resuscitation bay. The patient is very pale and thin (45kg). She is connected to a monitor. Levophed is infusing at .05mcg/kg/min and NS is running at100cc/hr in a IV in her right arm. Bags of ice are in the bed. She is shivering slightly. She is riding the ventilator (rate 12).

You look up at the monitor and see:

HR 60

EKG: slow, wide, diffuse ST depressions, PR depressions with a PVC here and there

BP 80/40

SpO2 100%

Cheers

[MariB]

Shivering is good.

Anorexic?

I would tone down the o2 a bit, post code patients should run around 94%.

The rest is out of my scope as I haven't learned to read EKG etc I will watch this one unfold.

[medicgirl05]

What kind of history does she have? Is she on birth control? Does she smoke?

What are her lab values?

ST depression indicates that the heart is not getting enough oxygen. I would leave the vent settings where they are for now.

[iStater]

Monitor the shivering according to BSAS (Bedside Shivering Assessment Scale) and adjust sedation accordingly. Shivering should be prevented since it will defeat the hypothermia cooling.

Hypothermia shifts the oxyhemoglobin curve to the left and there will probably a decrease in oxygen delivery. Vasoconstriction of peripheral vessels which may also affect a pulse oximeter reading.

If CVP monitoring is accessible, CVP and ScvO2 can be utilized.

Maintain an adequate MAP 80 - 100 mmHg or lower depending on etiology.

Correcting electrolyte values should be considered.

Check H&H values to see if low which is associated with malnutrition. Low Hb would also affect pulse oximeter reading.

Edited August 5, 2013 by iStater

[MariB]

I was stating shivering was good brain function wise, not that she should be allowed to continue

[island emt]

I'm with medic girl: What was the underlying cause and history behind the arrest?

Drug use/ abuse might explain the thin build as would anorexia.. S&S of abuse?

if anorexic then electrolytes are likely way off the scale

21 yo's don't normally have cardiac arrests without underlying medical condition or OD/ trauma.

What are her pupils like? responsive & accommodating? fixed?

was an echo done? enlargement or pericardio effusion?

Pressure seems a little low considering the Levophed drip

Management for now is maintain sedation to prevent shivering keep the core temp at directed level per rosc protocol & handle gently.

maintain pressure at best possible level and hope she doesn't code again.

[DartmouthDave]

Shivering is good.

Anorexic?

I would tone down the o2 a bit, post code patients should run around 94%.

The rest is out of my scope as I haven't learned to read EKG etc I will watch this one unfold.

The patient has a 3 year-old daughter. She has been depressed because she broke up with her common-law husband. She hasn't been eating well and has been obsessed with her body image since the baby.

What kind of history does she have? Is she on birth control? Does she smoke?

What are her lab values?

ST depression indicates that the heart is not getting enough oxygen. I would leave the vent settings where they are for now.

Recent depression. Minor. No suicidal ideation. No medications. Not a smoker.

You review the charts. You find this lab report. BOLD means critical low.

K 2.0

Mg .40

Phos .40

Na 150

Hgb 85

Monitor the shivering according to BSAS (Bedside Shivering Assessment Scale) and adjust sedation accordingly. Shivering should be prevented since it will defeat the hypothermia cooling.

Hypothermia shifts the oxyhemoglobin curve to the left and there will probably a decrease in oxygen delivery. Vasoconstriction of peripheral vessels which may also affect a pulse oximeter reading.

If CVP monitoring is accessible, CVP and ScvO2 can be utilized.

Maintain an adequate MAP 80 - 100 mmHg or lower depending on etiology.

Correcting electrolyte values should be considered.

Check H&H values to see if low which is associated with malnutrition. Low Hb would also affect pulse oximeter reading.

Interesting. I have never heard of this. I am going to look it up.

She has a femoral central line. What you consider a VGB?

Agreed. Regarding the correction of the lytes.

I'm with medic girl: What was the underlying cause and history behind the arrest?

Drug use/ abuse might explain the thin build as would anorexia.. S&S of abuse?

if anorexic then electrolytes are likely way off the scale

21 yo's don't normally have cardiac arrests without underlying medical condition or OD/ trauma.

What are her pupils like? responsive & accommodating? fixed?

was an echo done? enlargement or pericardio effusion?

Pressure seems a little low considering the Levophed drip

Management for now is maintain sedation to prevent shivering keep the core temp at directed level per rosc protocol & handle gently.

maintain pressure at best possible level and hope she doesn't code again.

No history of drug and ETOH abuse.

A neuro exams finds her pupils 3mm and responsive. No movement of her arms and legs. They feel flaccid.

She has been feeling unwell for a week. Her family wanted her to see a GP. She has been having muscle weakness and numbness as well.

Awesome start. Also, I have taken the time to figure out the 'multi quote' option.

Cheers

PS: Her current temperature is 35.5

Edited August 5, 2013 by DartmouthDave

[HarryM]

Hmmm you'd have to wonder why she is not paralysed and sedated if she is tubed. I'd start with some vecuronium and a midazolam infusion. Also maybe increase the NE infusion to maintain a systolic BP of 100. Also want to correct metabolite imbalances. The only fluid we carry is NaCl and I'm the first to admit that as this is the case I really don't have the knowledge to go an start talking about what electrolyte infusions she needs.

Is there a toxicology screen/test available?

Also be good to see results of a head CT?

Therapeutic hypothermia is generally 32-34 degrees so she still has a way to go yet. Maybe once the vecuronium kicks in the lack of shivering will allow her temp to drop to that level. Otherwise consider cooled NaCl to help cooling enroute.

[scubanurse]

Correct the hypokalemia with some KCl, what do the rest of her labs look like?

Agree with the above, id be hesitant to fully knock down her CNS though, but may be a good option until you get to the bigger hospital. I'd want neuro checks q15 and a repeat CBC, BMP, THS, T4,T3 to r/o myxedema coma as a ddx. What's her temp? Any edema? Myxedema coma can cause edema and relative hyponatremia/hypokalemia, and can cause GI paralysis which can cause malabsorption and decreased appetite. Either way, should be ruled out I think.

Any recent ABG?

Pretty sure this is a cardiac arrest secondary to electrolyte imbalance related to malnutrition.

If you don't have access to any KCl, Lactated Ringers at least has potassium in it and will be more beneficial than NS.

The hx of weakness can be from the hypomagnesemia and low phos which can cause high calcium levels as well.

[ERDoc]

Normally, once a pt is intubated, I would not paralyze. There is really no reason to as long as they are properly sedated but if the pt is shivering, I'd consider paralysis. However, are we sure the pt is truly shivering and not seizing? So we have a depressed pt with hypernatremia, hypokalemia, hypomagnesemia and hypophosphatemia. If you don't carry anything with potassium, have the hospital hang some fluids with 40 of K+ if they are not already doing so. A few grams of mag would be good also.