Case: GSW c compartment syndrome and DTs

[amyl]

37 yo BM presented with GSW to LLE developed into compartment syndrome....to OR emergently for fasciotomy. the catch is that he started going through alcohol withdrawls so was placed on so much ativan he was non-communicative in pre-op. past medical history significant for ESLD, chirrosis, hep C, etoh abuse. allergic to PCN so vanco was hung. history of trauma surgery but no records. his numbers sucked before the OR. some i recall: Hb 7.0 platelets 47,000 and coagulopathic but i can't remember specific INR, etc. appeared volume depleted by PE and dark urine output. in pre-op was noted to be somewhat rigid in his upper extremities, spastic and shaking... attributed to DTs. we called for FFP and Platelets and PRBCs. propofol, sux -- he was a somewhat difficult intubation, resident missed but attending got with some effort... anatomy a little off. intra op was mostly uneventful except some phenylephrine to keep the pressure up, ran lots of fluids, FFP showed up but was waiting on the rest. Sevo and nimbex. no pain meds as pressure was running low. all okay enough. extubate him and then i point out to surgeons he is bleeding through the bandages. they start to take down the dressing and want to redo hemovacs when he goes into laryngospasm... etCO2 sucks, tachypneic, no tidal volume, desats.... re-open room and prep for emergency trach while surgeons attempt stopping the red tide gushing from his leg...at last minute attending gets the tube back in but noted severe edema in airway.
so my question is what went wrong? my attending said something about withdrawl syndrome causing laryngospasm and that the only thing we could have done to stop this was either: ativan or forget the plan to extubate (and piss the surgeons off entirely) anticipating this would happen. reaction to vanco or something else? any ideas as to cause or alternative way to manage?

---

Members don't see this ad.

 

[Planktonmd]

37 yo BM presented with GSW to LLE developed into compartment syndrome....to OR emergently for fasciotomy. the catch is that he started going through alcohol withdrawls so was placed on so much ativan he was non-communicative in pre-op. past medical history significant for ESLD, chirrosis, hep C, etoh abuse. allergic to PCN so vanco was hung. history of trauma surgery but no records. his numbers sucked before the OR. some i recall: Hb 7.0 platelets 47,000 and coagulopathic but i can't remember specific INR, etc. appeared volume depleted by PE and dark urine output. in pre-op was noted to be somewhat rigid in his upper extremities, spastic and shaking... attributed to DTs. we called for FFP and Platelets and PRBCs. propofol, sux -- he was a somewhat difficult intubation, resident missed but attending got with some effort... anatomy a little off. intra op was mostly uneventful except some phenylephrine to keep the pressure up, ran lots of fluids, FFP showed up but was waiting on the rest. Sevo and nimbex. no pain meds as pressure was running low. all okay enough. extubate him and then i point out to surgeons he is bleeding through the bandages. they start to take down the dressing and want to redo hemovacs when he goes into laryngospasm... etCO2 sucks, tachypneic, no tidal volume, desats.... re-open room and prep for emergency trach while surgeons attempt stopping the red tide gushing from his leg...at last minute attending gets the tube back in but noted severe edema in airway.
so my question is what went wrong? my attending said something about withdrawl syndrome causing laryngospasm and that the only thing we could have done to stop this was either: ativan or forget the plan to extubate (and piss the surgeons off entirely) anticipating this would happen. reaction to vanco or something else? any ideas as to cause or alternative way to manage?

And who's idea was it to extubate this guy??

Let's see:
You have a patient with severe acidosis, DT's and liver failure who came to the OR with altered mental status and was difficult to intubate!
Why on earth would anyone try to extubate this guy after adding General anesthesia to the above picture??

 

[amyl]

i am just the lowly med student on the case and didn't hear the whole discussion between resident and attending but it boiled down to he wasn't intubated before the case so they could pull the tube. this was my first trauma case ever.

 

[elwademd]

And who's idea was it to extubate this guy??

Let's see:
You have a patient with severe acidosis, DT's and liver failure who came to the OR with altered mental status and was difficult to intubate!
Why on earth would anyone try to extubate this guy after adding General anesthesia to the above picture??

seriously!!! the guy's liver failure alone makes him a somewhat moderate risk even if he's a child pugh class a (5-10% mortality depending on the text you read)... and i wouldn't be surprised if he was class b (15-25% mortality) or c (50-60% mortality). with that said, the guy emergently needed the surgery, but to extubate him that quickly seems highly questionable.

i'm curious (i'm an internist) as to what the bun and creatinine were. you already have a guy with risk factors for bleeding (liver disease, low platelets)... was he uremic as well?

in your scenario, you state that ffp was hanging, but never say if it was given as you guys were "waiting on the rest"... which i take to mean he hadn't received ffp, platelets, or prbc's.

 

[Planktonmd]

i am just the lowly med student on the case and didn't hear the whole discussion between resident and attending but it boiled down to he wasn't intubated before the case so they could pull the tube. this was my first trauma case ever.

Ok,
This is actually the best way to learn: you see some one make a mistake and you see the immediate result of their mistake.
This patient should have been intubated even before he came down for surgery because:
1- He has severe acidosis (PH= 7.0) and being given Benzodiazepines which are depressing his ability to hyper ventilate to try to compensate for his acidosis.
2- He is obtunded and in fully blown DT's which makes his ability to protect his airway questionable.

And after he came to the OR there are a few more reasons why he should not have been extubated:
1- He is still acidotic most likely.
2- We have just given him General anesthesia which is not going to improve his baseline altered mental status and his ability to protect his airway.
3- We had difficulty intubating him and possibly traumatized his airway which makes it more likely that he might have airway edema.
4- He is a young black man and even when they are healthy they tend to have more secretions and higher incidence of complications at emergence including laryngospasm (every practicing anesthesiologist knows that).
5-His immediate future is not vey promising.
So if you don't learn anything from this just learn these 2 things:
1- Never extubate anyone with a PH of 7.0
2- The argument that: "he wasn't intubated before then he shouldn't be intubated now" is very stupid.

Good job reporting the case though.

 

[Mman]

Ok,
This is actually the best way to learn: you see some one make a mistake and you see the immediate result of their mistake.
This patient should have been intubated even before he came down for surgery because:
1- He has severe acidosis (PH= 7.0) and being given Benzodiazepines which are depressing his ability to hyper ventilate to try to compensate for his acidosis.
2- He is obtunded and in fully blown DT's which makes his ability to protect his airway questionable.

And after he came to the OR there are a few more reasons why he should not have been extubated:
1- He is still acidotic most likely.
2- We have just given him General anesthesia which is not going to improve his baseline altered mental status and his ability to protect his airway.
3- We had difficulty intubating him and possibly traumatized his airway which makes it more likely that he might have airway edema.
4- He is a young black man and even when they are healthy they tend to have more secretions and higher incidence of complications at emergence including laryngospasm (every practicing anesthesiologist knows that).
5-His immediate future is not vey promising.
So if you don't learn anything from this just learn these 2 things:
1- Never extubate anyone with a PH of 7.0
2- The argument that: "he wasn't intubated before then he shouldn't be intubated now" is very stupid.

Good job reporting the case though.

I think you misread an important part of the case. You keep referring to him being acidotic with a ph of 7.0. The original post says he had a hemoglobin of 7.0, not a ph of 7.0. He's anemic. And while he is likely acidotic, he might not be as he didn't list an abg value.

If the guy had a gas of 7.40/40/100 on 30% oxygen and minimal vent support at the end of the case and was following commands, would you extubate him?

It's possible he was ventilating just fine before surgery, but was not following commands because of DT's/benzos whatever.

I'm not saying this guy is someone that definitely should have been extubated, but I haven't seen enough posted yet to say no way. There is some other info I'd want to know.

 

[Planktonmd]

I think you misread an important part of the case. You keep referring to him being acidotic with a ph of 7.0. The original post says he had a hemoglobin of 7.0, not a ph of 7.0. He's anemic. And while he is likely acidotic, he might not be as he didn't list an abg value.

If the guy had a gas of 7.40/40/100 on 30% oxygen and minimal vent support at the end of the case and was following commands, would you extubate him?

It's possible he was ventilating just fine before surgery, but was not following commands because of DT's/benzos whatever.

I'm not saying this guy is someone that definitely should have been extubated, but I haven't seen enough posted yet to say no way. There is some other info I'd want to know.

Yes,

My bad, I thought the PH was 7.0
Still though:
DT's + Altered mental status pre-op + Difficult intubation + general anesthesia = Keep the tube in.

 

[VentdependenT]

What makes everyone so sure that its DT'S and not something else? The dude just bought himself a CT SCAN OF BRAIN.

Who gets a gold friggen star for extubating this guy? Nobody. This ain't your elective lap appy. Surgeon can now blame anesthesia for what he/she will call "prolonged intubation" or some equally useless clinical jargon. WHO CARES if they are p1ssed off because this disaster medicare/ade patient stays on the vent? PLUS you're at an academic institution where it DOESN'T MATTER. Just leave the tube in and call it a day.

Look man, if you gotta guy who you cannot follow commands before intubation due to presumed DT's AND possible still uncertain/proven etiology then he stays on the tube until he shows some sort of higher cognitive function.

Sure we get lots of obtunded neruo disasters who get extubated upstairs in the unit after they've stablizied and everyone realizes their brains are just toast, but we don't do that crap in the OR. At least I don't.


Laryngospasm could've been caused from a number of things, but I don't think DT's is one of em. DT people don't just laryngospasm out of nowhere. My bet is secretions mixed with decreased LOC from benzo's and residual anesthesia.

I'd stick this fella in the unit with a precedex drip and breakthrough ativan 2mg Q 2H and fentanyl for breakthrough pain. Why precedex? Cause I can still do a friggen neuro exam with it. Why ativan also? Its the mainstay of withdrawl treatment.

 

[Intubate]

I'm not saying this guy is someone that definitely should have been extubated, but I haven't seen enough posted yet to say no way. There is some other info I'd want to know.

I wouldn't say that I definitely wouldn't extubate either, but (and I know some of this has been mentioned):
He was altered preop. He is hemodynamically unstable, and probably still volume depleted and with O2 carrying capacity (anemic). He received "lots of fluid," little of which was blood products, and he's a cirrhotic with a (probably) very low albumin (read edema). He was a difficult intubation. He's going to the ICU anyway, right?? Let them extubate later when things are stable.

 

[Mman]

I wouldn't say that I definitely wouldn't extubate either, but (and I know some of this has been mentioned):
He was altered preop. He is hemodynamically unstable, and probably still volume depleted and with O2 carrying capacity (anemic). He received "lots of fluid," little of which was blood products, and he's a cirrhotic with a (probably) very low albumin (read edema). He was a difficult intubation. He's going to the ICU anyway, right?? Let them extubate later when things are stable.

It doesn't say anywhere that he was hemodynamically unstable at the end of the case.

I'm just saying that the from the information presented, I don't think you can say that he definitely should not have been extubated.

What if he had a perfect blood gas and was hemodynamically stable and following commands at the end of the case? He's still coagulopathic and anemic, however.

I'm not even arguing that I would extubate him, just that I don't yet have enough information from what the observing medical student presented. What is "a lot of fluid"?

It's easy to have perfect hindsight, but I'm not sure if there was enough yet to say that it was a mistake to pull the tube. Then again, I don't know what somebody means by difficulty intubating. Was it a CA1 resident 2 months into their training? Was it a senior resident that couldn't get it? Did the attending struggle to get it in, or just need to reposition a little?

 

[Planktonmd]

It doesn't say anywhere that he was hemodynamically unstable at the end of the case.

I'm just saying that the from the information presented, I don't think you can say that he definitely should not have been extubated.

What if he had a perfect blood gas and was hemodynamically stable and following commands at the end of the case? He's still coagulopathic and anemic, however.

I'm not even arguing that I would extubate him, just that I don't yet have enough information from what the observing medical student presented. What is "a lot of fluid"?

It's easy to have perfect hindsight, but I'm not sure if there was enough yet to say that it was a mistake to pull the tube. Then again, I don't know what somebody means by difficulty intubating. Was it a CA1 resident 2 months into their training? Was it a senior resident that couldn't get it? Did the attending struggle to get it in, or just need to reposition a little?

Would you extubate someone who is in DT's who just had GA?

 

[amyl]

he had gotten four units of ffp during the case. he went back to the or today to try to cauterize something in his leg as he is still bleeding profusely. the units of prbc's etc he is given liberally cannot keep up with his coagulopathy. yup, i learned a lot from this case and still am. specifically patients with AMS regardless of eitology are likely not to be able to properly follow commands and thus will be, at less, very slow wake-ups with extubation LATER rather than sooner. maybe if we would have waited a little more he would have been extubated successfully. HR, BP, O2 sats were all good before we pulled the tube.
now this guy bucked pretty well and that's why they pulled the tube.
this may be a stupid question but what if you reversed the benzo's waited for him to wake up enough to function, pulled the tube and then ativan'ed him back into submission?

 

[amyl]

between this guy and my patient today i don't know how anyone can say anesthesiology is boring. trauma is awesome. i love it when you hear about a car crash on the news on your way into work and then sure enough there they are in your OR. this has been anything but boring.

 

[Mman]

Would you extubate someone who is in DT's who just had GA?

Depends. Intubation isn't exactly a treatment for DTs. How long were they in the OR and what did they have done? Also, it's a very rare patient who shows up in the ED in DTs. I mean how many alcoholics have stayed away from alcohol to the point where they've gone past withdrawal and into DTs and then gotten shot and dropped off in the ER? I doubt he got much of a workup in the ER aside for something other than the GSW.


I'm not arguing this guy should be extubated, just that from the information provided it isn't a slam dunk that he shouldn't be.

If DTs was the only reason to keep him intubated, you could give him a little ETOH in the IV and fix that.

 

[fval28]

Ok,
This is actually the best way to learn: you see some one make a mistake and you see the immediate result of their mistake.
This patient should have been intubated even before he came down for surgery because:
1- He has severe acidosis (PH= 7.0) and being given Benzodiazepines which are depressing his ability to hyper ventilate to try to compensate for his acidosis.
2- He is obtunded and in fully blown DT's which makes his ability to protect his airway questionable.

And after he came to the OR there are a few more reasons why he should not have been extubated:
1- He is still acidotic most likely.
2- We have just given him General anesthesia which is not going to improve his baseline altered mental status and his ability to protect his airway.
3- We had difficulty intubating him and possibly traumatized his airway which makes it more likely that he might have airway edema.
4- He is a young black man and even when they are healthy they tend to have more secretions and higher incidence of complications at emergence including laryngospasm (every practicing anesthesiologist knows that).
5-His immediate future is not vey promising.
So if you don't learn anything from this just learn these 2 things:
1- Never extubate anyone with a PH of 7.0
2- The argument that: "he wasn't intubated before then he shouldn't be intubated now" is very stupid.

Good job reporting the case though.

That quote reminds me of a case I had in training with a complete A$$ of a general surgeon, good cutter but the personality of a wet dishrag.. anyway, he brings a 70+ yo man to the OR from the ED where he presented with a distended abd, difficulty breathing (SpO2 ~90% on NRB), CT shows air/fluid levels, = perfed viscus.

My attending and I bring him in the OR, tube him uneventfully and begin to discuss intra and post op management when I say "I'll call the ICU to get a vent ready", Surgeon hits the roof and says- "My philosophy is a patient that comes to the OR extubated should leave extubated". I listen to the rant for a bit longer and say, "Well Dr, there is some strong evidence that he should have been intubated before he got to the OR, but I'll do my best to get him extubated by the end of the case". With that I pushed 10cc' s of Pavulon, turned up the Forane and sat down to get caught up on my charting.

2 hours of fluid, blood loss and more fluid later, patient went to the ICU, intubated- stayed tubed for ~ a week and got reintubated when the intensivist gave into the surgeon's chest thumping and pulled the tube a little too early.

Take home for me from that little lesson is that with some surgeons you have to whisper sweet nothings in their ear, while at the same time take a pi$$ on their shoes. You wind up keeping the patient AND the surgeon out of trouble. They don't ask us about what type of suture to use and they sure as hell shouldn't be piping in about how to manage an airway.

 

[Planktonmd]

Depends. Intubation isn't exactly a treatment for DTs. How long were they in the OR and what did they have done? Also, it's a very rare patient who shows up in the ED in DTs. I mean how many alcoholics have stayed away from alcohol to the point where they've gone past withdrawal and into DTs and then gotten shot and dropped off in the ER? I doubt he got much of a workup in the ER aside for something other than the GSW.


I'm not arguing this guy should be extubated, just that from the information provided it isn't a slam dunk that he shouldn't be.

If DTs was the only reason to keep him intubated, you could give him a little ETOH in the IV and fix that.

So let's say the diagnosis of DT's is correct and you had to take that guy to the OR for emergent surgery, you induce general anesthesia and now you are done.
Could you walk us through your plan for extubating him and at what point you are going to give him alcohol IV?
And let me ask you another hypothetical question too:
Let's say we don't really know if it's DT's but he came to the OR obtunded because of unknown etiology, can we extubate him at the end of surgery and send him to the recovery room?

 

[VentdependenT]

what if you reversed the benzo's

Not having been there, and not knowing how the team arrived at severe alcohol withdrawl as being part of this persons symptomatology, as a general caviat don't reverse benzo therapy in these patients.

You can kill em.

In fact, alcohol and benzodiazapine are the ONLY two classes of medications which have potential LETHAL withdrawl.

One can argue back and forth not knowing exactly how things transpired. The point remains, WHO BENEFITS FROM EXTUBATING THIS GUY IMMEDIATELY? Seriously? Who gets the friggen brownie points?

 

[amyl]

exactly. if the anesthesiologist stood up to the surgeon and said no extubation....? btw, none of the anesthesiologists gave the surgeons sh-t for not fixing all the bleeders during the fasciotomy then for breaking scrub, not paying attention at all, standing around b.s.'ing, etc while the medical student on anesthesiology has to tell them there is about a liter of blood soaking out of their bandages onto the patients bed. no one told any of them how to do their job ;-). yes, this case taught me a lot about anesthesiology in more ways than one.
still loving every minute of it and no desire to hop to the other side of the blue sheet though.

 

[tussionex]

Not having been there, and not knowing how the team arrived at severe alcohol withdrawl as being part of this persons symptomatology, as a general caviat don't reverse benzo therapy in these patients.

You can kill em.

In fact, alcohol and benzodiazapine are the ONLY two classes of medications which have potential LETHAL withdrawl.

One can argue back and forth not knowing exactly how things transpired. The point remains, WHO BENEFITS FROM EXTUBATING THIS GUY IMMEDIATELY? Seriously? Who gets the friggen brownie points?

i second that. reverse the benzo's and you will for sure kill him...or at least come darn close.
i've got plenty of ativan, precedex etc in my pharmacy...keep him tubed and i'll help you keep him down.

 

[VentdependenT]

i second that. reverse the benzo's and you will for sure kill him...or at least come darn close.
i've got plenty of ativan, precedex etc in my pharmacy...keep him tubed and i'll help you keep him down.

Wanna work at Rush? 🙂

 

[Mman]

So let's say the diagnosis of DT's is correct and you had to take that guy to the OR for emergent surgery, you induce general anesthesia and now you are done.
Could you walk us through your plan for extubating him and at what point you are going to give him alcohol IV?
And let me ask you another hypothetical question too:
Let's say we don't really know if it's DT's but he came to the OR obtunded because of unknown etiology, can we extubate him at the end of surgery and send him to the recovery room?

I specifically said he wasn't obtunded at the end of the case for argument's sake. I mean if he's obtunded then he isn't really following commands too well is he?

Why would anybody pull the tube on somebody that is currently obtunded?

 

[Planktonmd]

I specifically said he wasn't obtunded at the end of the case for argument's sake. I mean if he's obtunded then he isn't really following commands too well is he?

Why would anybody pull the tube on somebody that is currently obtunded?

😕
Ok,
I don't think we are communicating here.
Here is my 2 cents again:
Anyone who is in DT's or you think might be in DT's and happen to come to the OR for whatever surgery, should not be extubated at the end of surgery.
Anyone who has acutely altered mental status preop (of any etiology) and comes to the OR for surgery should not be extubated.
When extubating a young black man you need to keep in mind that they have more secretions and they tend to be strong and combative at emergence which exposes them to laryngospasm and negative pressure pulmonary edema, so you never pull the tube out just because they are (bucking) too much.

 

[tussionex]

Wanna work at Rush? 🙂

sorry...i'm a new yorker through and through.
my cousin is at univ of chicago law....when i visit him i'll give you a shout!
i'll bring the precedex!