DKA arrest...

[davbrucas]

I was sitting at the computer yesterday typing on a patient chart when I hear over the PA, "doctor to room 3 now!" So I head over there and this young 18yr old was on the bed and appeared to be dead. He was pale, almost blue and having agonal respirations. His blood pressure was 51/29 and his heart rate was 40 with a wide complex rhythm (sine wave). Right then he went into asystole and stopped breathing. So I immediately had the tech start CPR as I intubated him and had a nurse bag the patient. We immediately started ALCS resuscitation giving him epinephrine followed by atropine...and then calcium and several amps of bicarb. The kid had an insulin pump on so I figured he was in DKA and hyperkalemic. We ended up shocking him 7 times and repeated the ACLS meds multiple times over the course of 75mins. We got him back several times but lost him again each time. We put him on multiple drips as well as some mannitol...we finally got a perfusing rhythm after 60mins. His blood sugar was 1550(he is a type 1), his pH was 6.7, his potassium was 9.7, his sodium was 105, and his lactate was 14! All numbers not compatible with life! The kid had continuous chest compressions for over an hour. We thought about calling the code several times but didnt given his age. When he left the ER his pupils were fixed and dilated. I just knew this kid was dead. Most of the nurses were crying. Apparently the kid was in his first semester at UF and had been boozing it up the past few days and just became unresponsive at home. His friends drug him in the back door of the ER. So I come into work this am and walk up to the PICU to check on him. I fully expected him to be dead or still on the vent on multiple drips. When I get up there I walk into the room where we took him the day before and some other kid was in the bed sitting up eating breakfast. Not a good sign. He must have died in the night and another kid was in his bed. I asked the nurse where the kid that we brought up yesterday was....she said, thats him in the room!!! The kid was extubated and sitting up eating breakfast! WOW...that just doesnt happen. Dead for over an hour and the next day almost back to normal. I talked to his parents and to him. He did not know the seriousness of the situation. He started crying when he learned that he was dead and we resuscitated him. At least I feel better that we saved a good kid. I told mom that they need to take him back home to south Florida and put him in a Jr college for a while. I have run many codes but have never seen such a good and full recovery after that long down. His only complaint was mild double vision when looking in certain directions....and terrible chest wall pain of course!

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[Termwean]

Amazing!

 

[Apollyon]

Just like the dialysis players that come in with the sine wave or asystole on the monitor, with the K+ of 8 or 9, that get flogged into submission, then dialyzed, and walk out of the hospital intact 2 days later. Miraculous.

 

[njac]

someone, uh very close to me, had a similar experience at 22.

Weeks and weeks of not feeling well, went to doctor about various things, but for whatever reason a chem panel was never drawn. Goes out one night, doesn't drink much, gets home and starts throwing up uncontrollably. Passes out in own vomit. Girlfriend doesn't hear from him by noon or so and calls the house, roommate looks in and says "he's just passed out". A couple hours later she calls again and the other roommate goes in and can't wake him up - EMS called, etc.

Their immediate assumption was an O/D, here was a 22 y/o 6'1" male weighing all of 137lbs (gradually lost about 50# over a couple months). They also took him to one of the crappier ERs in town so that makes me think that more... I wasn't involved at the time, I've just heard this story many times so some details might be fuzzy. Anyway, Kussmal respirations and a very slow and weak pulse. They told his mother 3 nights in a row that he wasn't going to make it and that she should make arrangements. When he woke up a couple days later and his first words were (to his mother) "what the hell are you doing here?" they decided that she would have to spoon feed him for 6 months. Nine days after going in he walked out, a newly diagnosed DM1, and returned to classes at the University of Arizona less than 2 weeks after the initial ordeal.

Like I said, I wasn't in the picture at that time so I don't know the exact numbers other than glucose >1200 when he was brought to the hospital. It's amazing how resilient the bodies of young people are, especially when you see labs like that. As far as sequelae he was on an ACE-I for a couple months afterwards but the microalbuminuria resolved, and had fuzzy vision for a couple days. But I don't think he ever coded - that is incredible that you all were able to save that kid. And I'm glad to see the kid realized the seriousness of the situation when you explained it. Wow.

 

[Big Z]

For the sake of argument.. he was probably extremely HYPOkalemic (meaning his TOTAL potassium, not his serum potassium).. His serum K was transiently high because he was extremely acidotic.. fluids and bicarb would have brought his K down nicely as his acidosis resolved. Sounds like a great case and a nice save.. good work!

 

[Arch Guillotti]

It is an absolutely unbelievable feeling to see someone alive and kicking after you have performed CPR on them. During residency I had two patients who arrested during/after procedures that I performed on them (floating a PA catheter and a subarachnoid block). Now that is a BAD feeling when CPR is being performed on a pt. who was talking to you just a couple of minutes prior. It is a good feeling to have a nice save especially after all the flogs that we all routinely see.

 

[Apollyon]

It is an absolutely unbelievable feeling to see someone alive and kicking after you have performed CPR on them. During residency I had two patients who arrested during/after procedures that I performed on them (floating a PA catheter and a subarachnoid block). Now that is a BAD feeling when CPR is being performed on a pt. who was talking to you just a couple of minutes prior. It is a good feeling to have a nice save especially after all the flogs that we all routinely see.

Had that happen in my paramedic days - guy gets shocked twice by fire before we get there. Third shock is us, and the guy converts. Then he codes again, gets shocked, and converts. Finally, codes again, gets shocked a 5th time, and converts, and I'm saying out loud, "I wonder how much this guy weighs?", and he says, "I'm 220", and I said, "Hey, I have my dose of lidocaine!" He stayed alive, too.

 

[Jeff698]

Strong work.

That's what you trained for. Not the toothache or back pain at 3am.

Savor the memory of this case, hopefully it'll carry your through many an anxious fibromyalgia patient who insists you cure them.

Take care,
Jeff

 

[kungfufishing]

great case. reading the above unfortunately just reminded me of my most recent code flog job. Havent had a save that good.

 

[WilcoWorld]

"I wonder how much this guy weighs?", and he says, "I'm 220", and I said, "Hey, I have my dose of lidocaine!"

220lbs - How nicely that math worked out for you, eh?

 

[dchristismi]

Strong work.

That's what you trained for. Not the toothache or back pain at 3am.

Savor the memory of this case, hopefully it'll carry your through many an anxious fibromyalgia patient who insists you cure them.

Take care,
Jeff

Bingo. There are not that many huge "saves*," and those which truly are deserve a special place in our memories - so they can be dusted off frequently and remind us of why we do what we do. Great case, thanks for sharing.

Strong work indeed.
Danielle


*in my book, meaning a young, healthy person who dies for whatever reason, and you not only pull them back, but you pull them back neurologically intact.

 

[leviathan]

It is an absolutely unbelievable feeling to see someone alive and kicking after you have performed CPR on them. During residency I had two patients who arrested during/after procedures that I performed on them (floating a PA catheter and a subarachnoid block). Now that is a BAD feeling when CPR is being performed on a pt. who was talking to you just a couple of minutes prior. It is a good feeling to have a nice save especially after all the flogs that we all routinely see.

Yeah it's the worst when you've been talking to them. One of the times I got really f8*$@#* up emotionally after an arrest was when I watched the dude arrest in front of me after talking to him for 10 mins. We got him back though and I saw him a few weeks later neurologically intact.

 

[fakin' the funk]

For the sake of argument.. he was probably extremely HYPOkalemic (meaning his TOTAL potassium, not his serum potassium).. His serum K was transiently high because he was extremely acidotic.. fluids and bicarb would have brought his K down nicely as his acidosis resolved. Sounds like a great case and a nice save.. good work!

For the sake of argument, he was probably extremely HYPERkalemic, as you stated - his serum K was high. I think what you were getting at is total-body-K-depletion, no?

 

[The White Coat Investor]

Nice save. Strong work. You'll remember that one for a long time. Use it for those times when you feel like you aren't doing any good.