- Joined
- Apr 28, 2013
- Messages
- 169
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Trauma 1 (emergent) paged out for 69 yo M with stab wound to LUQ, ETA from OSH ~45 minutes. Word from ED RN getting report said patient was hypotensive despite 3L crystalloid bolus, OSH ED RNs reportedly said they didn't expect the patient to make it here. (That was basically all the info I had at the time. I really wondered why the original ED didn't have a general surgeon that could do an ex-lap, but what do I know?)
We (my residents and I) are in the OR, patient rolls in, hypotensive (SBP in the 60s), 2 PIVs (16g, 18g), fluids hanging. RSI, intubate, RN preps chest and abdomen. I notice patient is still hypotensive, except now I notice he's bradycardic in the 30s (EKG and pulse ox weren't picking up real well initially, movement etc.). (Then the resident tells me he was like this as soon as he arrived to our ED.) I give 25 mg ephedrine (first thing I saw) - no response. Resident 1 places RIJ CVL, resident 2 places arterial line. Epi was on the cart, so I start giving 100-200 mcg at a time. Improvement in BP, but no change in HR. EKG looked like junctional bradycardia. We start suspecting BB overdose. Glucagon 4 mg IV - nothing. Continue epi boluses, helps with BP. ABG pretty good (roughly 7.36, 39, 260, 21, -4, Hb 9.5 after half unit pRBCs in, K+ 4.0, iCa++ WNL). Surgery resident later gets med list from our EMR and says patient wasn't on BB but was on CCB, so CaCl given. Otherwise, it's a pretty similar treatment from what I read. I started to doubt medication overdose as a cause, but didn't have anything better except possibly RCA territory ischemia leading to SA node dysfunction. I was also thinking, how odd would it be for a guy to be stabbed and OD on cardiac meds at the same time (I was out of the loop again, because basically everyone else knew the knife wound was self-inflicted, so he very well could have OD'd). We were able to keep the BP up with epi infusion. Surgeon found no bleeding, so closed up. Once drapes down we transcutaneously paced. BP better, but still requiring epi. Another med list showed he was on Coreg, diltiazem, and amlodipine, so likely OD'd on all those. Cardiology consulted, to cath lab for transvenous pacers. Started on glucagon and insulin infusions in ICU. Extubated, stable, off infusions, and intrinsic SR the next morning.
TL; DR:
Old guy stabbed himself and OD'd on BBs and CCBs. Ended up with no surgical emergency (no internal damage), only a medical emergency. One I haven't seen before. Required epinephrine, infusion, pacing (transcutaneous then transvenous), glucagon bolus and infusion, and high dose insulin infusion. Better the next day.
Feel free to slam my management. I won't be (too) offended.
We (my residents and I) are in the OR, patient rolls in, hypotensive (SBP in the 60s), 2 PIVs (16g, 18g), fluids hanging. RSI, intubate, RN preps chest and abdomen. I notice patient is still hypotensive, except now I notice he's bradycardic in the 30s (EKG and pulse ox weren't picking up real well initially, movement etc.). (Then the resident tells me he was like this as soon as he arrived to our ED.) I give 25 mg ephedrine (first thing I saw) - no response. Resident 1 places RIJ CVL, resident 2 places arterial line. Epi was on the cart, so I start giving 100-200 mcg at a time. Improvement in BP, but no change in HR. EKG looked like junctional bradycardia. We start suspecting BB overdose. Glucagon 4 mg IV - nothing. Continue epi boluses, helps with BP. ABG pretty good (roughly 7.36, 39, 260, 21, -4, Hb 9.5 after half unit pRBCs in, K+ 4.0, iCa++ WNL). Surgery resident later gets med list from our EMR and says patient wasn't on BB but was on CCB, so CaCl given. Otherwise, it's a pretty similar treatment from what I read. I started to doubt medication overdose as a cause, but didn't have anything better except possibly RCA territory ischemia leading to SA node dysfunction. I was also thinking, how odd would it be for a guy to be stabbed and OD on cardiac meds at the same time (I was out of the loop again, because basically everyone else knew the knife wound was self-inflicted, so he very well could have OD'd). We were able to keep the BP up with epi infusion. Surgeon found no bleeding, so closed up. Once drapes down we transcutaneously paced. BP better, but still requiring epi. Another med list showed he was on Coreg, diltiazem, and amlodipine, so likely OD'd on all those. Cardiology consulted, to cath lab for transvenous pacers. Started on glucagon and insulin infusions in ICU. Extubated, stable, off infusions, and intrinsic SR the next morning.
TL; DR:
Old guy stabbed himself and OD'd on BBs and CCBs. Ended up with no surgical emergency (no internal damage), only a medical emergency. One I haven't seen before. Required epinephrine, infusion, pacing (transcutaneous then transvenous), glucagon bolus and infusion, and high dose insulin infusion. Better the next day.
Feel free to slam my management. I won't be (too) offended.
