Mr. XYZ, M/59Mr. 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 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 historyPast 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 History of present illnessillness

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 roomResuscitation 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 roomResuscitation 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 roomResuscitation 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

ShockShock

Hypovolaemic

Cardiogenic

Distributive Septic Anaphylaxis

Obstructive

Endocrine

HypothermiaHypothermia

Lost temperature to surrounding environment

Inability to produce heat, shivering

Altered mental stateAltered mental state

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

Metabolic acidosisMetabolic 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 High anion gap metabolic acidosismetabolic acidosis

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

Reversible causes for Reversible causes for cardiac arrestcardiac arrest

5Hs

Hypothermia

Hypoxia

Hypo/Hyperkalaemia

Hydrogen ion

Hypovolaemia

5Ts

Tension pneumothorax

Tamponade

Thromboembolism, pulmonary

Thromboembolism, cardiac

ToxinTake TemperaturePOCT, i-statEchocardiogram and bedside USG

ECGECG

CT brain

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

DispositionDisposition

ICU consulted Response from ICU colleague: no bed available Suggested inter-hospital transfer after

discussion among ICU seniors Now what?

GuidelineGuideline

Head Authority Head Office Operations Circular No. 10/2006

IndicationsIndications

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 networkService network

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

Parent teamParent 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)

TransportTransport

How to stablize?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 32-34oC 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?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

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

Hyperglycemic Crises in Adult Patients With Diabetes2009 by the American Diabetes Association

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

of diabetic ketoacidosis?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

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

No sig difference in time to reach

1. glucose < 14

2. pH > 7.3

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?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

EGDT in QEHSevere sepsis / septic shock

ARISE study

Our patientOur patient

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..

TimelineTimeline

15:16

triage

15:30

Cardiac arrest

15:37

ROSC, consult

ICU

16:00

No bed in QEH, decide interhospital transfer

17:00

No reply from UCH.TKOH, fax to

PWH

Bed av in PWH

17:30 18:00

Received call from ICU/UCH, bed av, decide to proceed

to PWH after discussion

Depart from QEH

Arrived at PWH

18:39 18:54

Length of stay in ED/QEH: 3h23min

Later on, results Later on, results coming back…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

ProgressProgress

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