how would you treat a leathal injection

[Perrotfish]

---

Members do not see this ad.

So since I matched I've been thinking about worst case scenarios for residency, and one in particular keeps popping up in my mind: the accidental administration of KCL IV push. I remember in particular seeing a news story when a nurse administered a vial of KCL during a pediatric code (she was driven out of the profession), and reading in a student doctor thread about how a resident wrote for KCL push from a drop down menu. So, if someone accidentally administers a large quantity to KCL IV, and you know it, is there anything you can do to salvage the situation? Fluids? Insulin and glucose? Rush the patient to dialysis? What would/could you do?

 

[Rendar5]

Just throw the whole hyper-K sink at them:

Calcium Gluconate boluses to stabilize the EKG (you're looking for more than just QRS widening, hypotension and any bradycardic rhythm are also staple rhythms of the hyperK patient).

Throw albuterol, lasix, IV insulin + D50, and bicarb at them. And call for emergent HD.

Honestly though, I'm curious how high the potassium would go, and if it's a very transient effect. If it is, you may not need HD, as it will redistribute, and the patient should have normal kidneys.

Kayexalate may not work, depends who you ask and how much they believe in that dogma. Of course, you'd give it though, because there would be plenty of "expert witnesses" who would hang you for departing from "standard of care", even though this is a potentially unsalvagable patient.

 

[NotAProgDirector]

The honest truth is this:

1. There is probably nothing you could do. The patient's heart will go into cardiac standstill. A code will be called, but it will be unsuccessful.

2. Any good system will have multiple systems in place to avoid this. For example, KCl should not even be on the floor in any vial or way to draw it up in the first place. All of our K containing IV fluids are mixed in pharmacy. No K on the floor. Can't happen.

Of course, this doesn't stop errors from happening that you haven't thought of.

 

[docB]

Agree with aProgDirector. It would be pretty hard to find concentrated KCl outside the pharmacy because this is a known high risk error. Same as how insulin, heparin and so on now have tight controls in place.

As an example I recently discovered that in my hospital to put a patient on D5 1/2 NS with 20 meq KCl, i.e. just basic replacement fluid, I would have to place them on telemetry as I was giving them IV potassium.

 

[BADMD]

As mentioned previously, this is unlikely to happen accidentally these days.

As there is not structural lesion causing the issue and the KCl will be redistributed, prolonged CPR would be in order. I would also be on the horn with cardiothoracics ASAP for bypass.

 

[PMPMD]

Throw some ice on their head/axillae/groin too if you want them to have CNS function after CPB.

 

[PMPMD]

According to Dr. Wikipedia, the usual lethal injection K dose is "only" 100 mEq. I was surprised it was that low, because they grossly overdose the pentothal and pancuronium components.

FYI a true lethal injection for the death penalty is pentothal 2-5GM (IV induction agent, usual general anesthesia induction dose is 3-5mg/kg) and pancuronium 100mg (nondepolarizing neuromuscular blocker AKA paralytic, usual anesthesia dose 0.1-0.2 mg/kg).

 

[Law2Doc]

So since I matched I've been thinking about worst case scenarios for residency, and one in particular keeps popping up in my mind: the accidental administration of KCL IV push. I remember in particular seeing a news story when a nurse administered a vial of KCL during a pediatric code (she was driven out of the profession), and reading in a student doctor thread about how a resident wrote for KCL push from a drop down menu. So, if someone accidentally administers a large quantity to KCL IV, and you know it, is there anything you can do to salvage the situation? Fluids? Insulin and glucose? Rush the patient to dialysis? What would/could you do?

Wipe your fingerprints off the syringe, cross out the order, and run for the border.

 

[Mattchiavelli]

According to Dr. Wikipedia, the usual lethal injection K dose is "only" 100 mEq. I was surprised it was that low, because they grossly overdose the pentothal and pancuronium components.

FYI a true lethal injection for the death penalty is pentothal 2-5GM (IV induction agent, usual general anesthesia induction dose is 3-5mg/kg) and pancuronium 100mg (nondepolarizing neuromuscular blocker AKA paralytic, usual anesthesia dose 0.1-0.2 mg/kg).

You'd think they would use a depolarizing agent because hey, don't have to worry about the hyperkalemia! Or will you not get good polarization with all the extracellular K+ rom KCl?

The fact you know all the lethal injection meds and have your avatar as the chick from Audition is .... interesting

 

[PMPMD]

You'd think they would use a depolarizing agent because hey, don't have to worry about the hyperkalemia! Or will you not get good polarization with all the extracellular K+ rom KCl?

Yeah they probably want to avoid the fasciculations which would make onlookers uncomfortable. They give the NMB before KCl so they wouldn't be hyperkalemic yet.

The fact you know all the lethal injection meds and have your avatar as the chick from Audition is .... interesting

😉

 

[Xerxes1729]

Clearly, it's not the amount of potassium that is lethal, but the rate at which it is given. Kayexelate and dialysis therefore have no role to play since the problem is a transiently high serum potassium concentration, rather than total-body potassium overload. Your best bet would probably be CPR for the cardiac arrest, if any, and then calcium and albuterol. If you can maintain perfusion with quality CPR long enough for the patient's cells to take up some of that potassium, he might live.

 

[45408]

Probably nothing. There's a reason it's the lethal injection.

 

[logos]

Clearly, it's not the amount of potassium that is lethal, but the rate at which it is given. Kayexelate and dialysis therefore have no role to play since the problem is a transiently high serum potassium concentration, rather than total-body potassium overload. Your best bet would probably be CPR for the cardiac arrest, if any, and then calcium and albuterol. If you can maintain perfusion with quality CPR long enough for the patient's cells to take up some of that potassium, he might live.

Albuterol is probably the slowest option other than bicarb, about which there is some question weather it works at all unless the patient is acidotic to start with.

 

[neusu]

Just throw the whole hyper-K sink at them:

Calcium Gluconate boluses to stabilize the EKG (you're looking for more than just QRS widening, hypotension and any bradycardic rhythm are also staple rhythms of the hyperK patient).

Throw albuterol, lasix, IV insulin + D50, and bicarb at them. And call for emergent HD.

Honestly though, I'm curious how high the potassium would go, and if it's a very transient effect. If it is, you may not need HD, as it will redistribute, and the patient should have normal kidneys.

Kayexalate may not work, depends who you ask and how much they believe in that dogma. Of course, you'd give it though, because there would be plenty of "expert witnesses" who would hang you for departing from "standard of care", even though this is a potentially unsalvagable patient.

Crack the chest and manual cardiac massage so the meds circulate. Wait long enough for them to take effect.

 

[Arcan57]

Crack the chest and manual cardiac massage so the meds circulate.

No.

 

[Perrotfish]

I think the diversity of answers here is fascinating. I've gotten CPR, albuterol, diyalysis, lasix d51/2, kayexelate, calcium carbonate, insulin and glucose, cardiopulmonary bypass, total body cooling and even a cracked chest. It seems like everyone agrees they would call for help (other than those who would hide the body), but not who 'help' is. Some quesetions:

1) Does anyone know how you dose Insulin and glucose for potassium overload? I've never heard of it actually being done. What about albuterol?

2) The ACLS guidelines don't call for cooling until a patient has a normal heart rhythm again. Would you wait until the patient's heart stopped and started again, or just pack him in ice as soon as he became arrhythmic?

3) How fast would you give fluids in this case and how much would you give? 20 mL/kg as fast as you can through 2 large bore IVs?

4) Is there really such a thing as emergent cardiopulmonary bypass? What kind of access would you need to make it happen? If I was thinking of making this happen do I need to Intubate the patient.

5) For CPR, I know the EMTs have CPR machines that are much more efficient that human CPR. Do those things exist in the hospital?

As mentioned previously, this is unlikely to happen accidentally these days.

As Douglas Adams once said: "A common mistake people make when trying to design something completely foolproof is to underestimate the ingenuity of complete fools."

 

[NotAProgDirector]

1) Does anyone know how you dose Insulin and glucose for potassium overload? I've never heard of it actually being done. What about albuterol?

10 units of regular insulin IV, and 1 amp of D50. Always give the D50 first. Nothing more embarrassing than giving the insulin first and then losing the IV access / finding out you don't have an amp of D50 handy and you've made a bad situation worse.

2) The ACLS guidelines don't call for cooling until a patient has a normal heart rhythm again. Would you wait until the patient's heart stopped and started again, or just pack him in ice as soon as he became arrhythmic?

It would be completely impractical to cool a patient while you're trying to code them. Cooling involves preventing shivering (usually with neuromuscular blockade), and creates a million new problems (but works really well). Plus, most use a cooling system (like the Artic Sun) rather than ice. So, get the rhythm back first, then worry about cooling.

3) How fast would you give fluids in this case and how much would you give? 20 mL/kg as fast as you can through 2 large bore IVs?

Whatever IV access you have, you're running wide open. On a pump, you usually would just enter 1000 cc/hr. Most codes end (if unsuccessful) at 15 minutes, so you're only going to get 250 cc in. Unless you have an introducer sheath in -- then you can really run the fluids.

4) Is there really such a thing as emergent cardiopulmonary bypass? What kind of access would you need to make it happen? If I was thinking of making this happen do I need to Intubate the patient.

Patient not breathing = intubated, so that should have already happened. And, no, you're almost never going to do emergency bypass. The equipment is never where you would want it, much too complicated to use (or you need someone who specifically knows how to use it). Maybe if you're in the CTICU.

5) For CPR, I know the EMTs have CPR machines that are much more efficient that human CPR. Do those things exist in the hospital?

Sometimes -- depends on the hospital.

 

[BADMD]

Patient not breathing = intubated, so that should have already happened. And, no, you're almost never going to do emergency bypass. The equipment is never where you would want it, much too complicated to use (or you need someone who specifically knows how to use it). Maybe if you're in the CTICU

This will be highly system dependent. We have had hypothermic arrests come in that we got onto bypass out of the ED. While I'm sure there is a certain amount of the stars aligning, in the case of an extraordinary iatrogenic screw up, there will be an extraordinary system response.

 

[dpmd]

Whatever IV access you have, you're running wide open. On a pump, you usually would just enter 1000 cc/hr. Most codes end (if unsuccessful) at 15 minutes, so you're only going to get 250 cc in. Unless you have an introducer sheath in -- then you can really run the fluids.

While I won't argue that the nurses won't do this, entering 999 on the pump is not a bolus. If your facility has some crazy tubing that won't flow unless it is on a pump, just grab some secondary tubing and hook it as close as possible to the line, then hang it high and open the stopcock. Will run much faster than the pump in most IV sizes that people will have in the hospital. Have a student or someone else squeeze the bag and you can get even more. In this particular situation make sure you aren't running D5 1/2 NS with 20 KCL wide open.

 

[PMPMD]

While I won't argue that the nurses won't do this, entering 999 on the pump is not a bolus. If your facility has some crazy tubing that won't flow unless it is on a pump, just grab some secondary tubing and hook it as close as possible to the line, then hang it high and open the stopcock. Will run much faster than the pump in most IV sizes that people will have in the hospital. Have a student or someone else squeeze the bag and you can get even more. In this particular situation make sure you aren't running D5 1/2 NS with 20 KCL wide open.

Pressure bag?

 

[gutonc]

Pressure bag?

Is the right answer. But often hard to come by outside of the OR/ED/ICU.

 

[gutonc]

I think the diversity of answers here is fascinating. I've gotten CPR, albuterol, diyalysis, lasix d51/2, kayexelate, calcium carbonate, insulin and glucose, cardiopulmonary bypass, total body cooling and even a cracked chest. It seems like everyone agrees they would call for help (other than those who would hide the body), but not who 'help' is. Some quesetions:

1) Does anyone know how you dose Insulin and glucose for potassium overload? I've never heard of it actually being done. What about albuterol?

Doses are easy, 10U and 1 amp D50. But have you never really heard of this treatment for HyperK?

5) For CPR, I know the EMTs have CPR machines that are much more efficient that human CPR. Do those things exist in the hospital?

Sort of...although they're not as efficient as the ones that trucks carry. They're called interns.

 

[45408]

Pressure bag?

Or a rapid infuser.

 

[dpmd]

Or a rapid infuser.

Both good options but take time for someone to go get them (although you think it would be simple to place a pressure bag in the code cart). There is almost always at least 5 people at a code who aren't doing anything, so having them squeeze an IV bag gives them something to do and keeps them out of the way.

 

[Perrotfish]

Doses are easy, 10U and 1 amp D50. But have you never really heard of this treatment for HyperK?
.

Never seen it done. The only treatments I've ever seen for hyper K are

1) take the K out of the fluids and wait

or

2) Dialysis.

The rest I've never seen in action.

 

[gutonc]

Never seen it done. The only treatments I've ever seen for hyper K are

1) take the K out of the fluids and wait

or

2) Dialysis.

The rest I've never seen in action.

Gonna be a rough year for you next year.

 

[dpmd]

Gonna be a rough year for you next year.

Depends on what he/she is going in to. In surgery I think I have maybe busted out the D50/insulin thing a handful of times. Usually I'm not dealing with a ridiculous K number, or the number doesn't match the patient and it turns out it was a bad lab draw (or fleetingly transient I guess). I don't remember if I knew the doses coming in as an intern. Knowing that it is one of the treatments and having something you can look up the dose in rapidly is usually good enough.

 

[Perrotfish]

Gonna be a rough year for you next year.

It's not like I've never heard of it, but most of the patients I saw get really get dangerously hyperkalemic were kideny patients, and the feeling was that treating them with anything other than dialysis was missing the point. Everyone who was mildly hyperkalemic, on the other hand, seemed to respond very well to conservative management, taking the K out of the bag, and maybe some medication changes (remove spironolactone, add lasix).

The feeling on my medicine rotation seemed to be that if you were using albuterol, insulin and glucose, or kayexelate to control potassium levels you we either doing too much or too little. I'm not sure what the exception to that rule would be, especially on Peds. Tumor lysis syndrome, I guess, but even those were mostly managed with fluids and patience where I rotated.

I don't remember if I knew the doses coming in as an intern. Knowing that it is
one of the treatments and having something you can look up the dose in rapidly
is usually good enough.

Knowing doses is getting to be a pretty rare skill. EMR + ever increasing legal concerns means fewer and fewer students have really written orders before Intern year.

 

[docB]

The feeling on my medicine rotation seemed to be that if you were using albuterol, insulin and glucose, or kayexelate to control potassium levels you we either doing too much or too little.

This is true but these therapies are mainly temporizing measures to keep the patient alive until dialysis can be arranged. In my area "stat" dialysis is at best 3 to 4 hours away and way more if they need vascular access, a common issue.

 

[BigRedBeta]

4) Is there really such a thing as emergent cardiopulmonary bypass? What kind of access would you need to make it happen? If I was thinking of making this happen do I need to Intubate the patient.

You could argue over the definition of "emergent" but E-CPR (cannulating for ECMO while doing chest compressions concurrently) at many of the major ECMO centers gets patients on the pumps within an hour. At the places that are doing it, whenever there's a code, the question has to be asked "are they coding because of something that's reversible" and in this situation, the consensus is yes.

I was just at the Pediatric Academic Societies meeting last week and there was a presentation on E-CPR and the accumulated data in the ELSO database shows that prolonged duration of CPR prior to cannulation was not associated with increased mortality. High quality CPR will always be the bedrock of surviving cardiac arrest.

ECMO cannulas are specialized and need to be placed by surgeons (who does that - whether cardiothoracic or general will vary by institution - I do know that, for example, pediatric surgery fellows have a minimum number of cannulations they're supposed to have completed during fellowship). During CPR you likely would have intubated, and once on ECMO, patients are put on generally low support "rest" vent settings. However, depending on the level of sedation and with presumably otherwise healthy lungs, it's not unheard of to extubate while on ECMO (on the flip side, when the lungs are so completely trashed and noncontributing to the point that the patient is going to get a lung transplant, I've also seen a patient get extubated while on ECMO).

 

[turkeyjerky]

Is the right answer. But often hard to come by outside of the OR/ED/ICU.

If you have a manual BP cuff, you can just wrap that around the bag and inflate it above 200 mmhg.

 

[Nellyakgo]

When I was in med school one of our IM attendings (a super nice guy) went to the ER and convinced one of the nurses that he had a medical necessity for K and made the nurse inject him with KCl. It seems he wanted to commit suicide that way. Of course he arrested and immediately had the attention of everyone at the ER, they did extended CPR (and I don't know what else) and could not save him. This was many years ago and I wasn't there so my information (other than persoanlly knowing the guy) is second hand. It was very sad and weird.

 

[Xerxes1729]

ECMO cannulas are specialized and need to be placed by surgeons (who does that - whether cardiothoracic or general will vary by institution - I do know that, for example, pediatric surgery fellows have a minimum number of cannulations they're supposed to have completed during fellowship).

Not everywhere. There's one hospital in San Diego where the ED docs will get someone onto ECMO themselves, then get the rest of the necessary personel involved.
http://emcrit.org/podcasts/ecmo/

 

[SurfingDoctor]

During CPR you likely would have intubated, and once on ECMO, patients are put on generally low support "rest" vent settings. However, depending on the level of sedation and with presumably otherwise healthy lungs, it's not unheard of to extubate while on ECMO (on the flip side, when the lungs are so completely trashed and noncontributing to the point that the patient is going to get a lung transplant, I've also seen a patient get extubated while on ECMO).

I don't practice at a place that does E-CPR (very few pediatric hosiptals do). The issues with lung "rest" settings typically only apply to patients with a cardiac and pulmonary reason for ECMO (ie sepsis). While cardiac arrests are usually secondary to respiratory arrests in children, someone with profound or prolonged hypoxia that causes cardiac arrest would not be a good E-CPR candidate (given the poor neurologic prognosis). Instead, E-CPR is more useful in a cardiac-related arrest solely, in which the ECMO works more like a VAD. In this setting, lung rest is not ideal as you want to either decannulate after myocardial function recovers in several days (at the neurologic exam is tolerable) or you plan to transition to a VAD. Granted I've only seen 1 instance of VA ECMO after cardiac arrest in a transplant patient, but his lungs were healthy (or relatively, he did have some pulmonary edema after the CPR).

As far as lung transplants, at least in pediatrics, ECMO is a general contraindication for eligiblity to receive lung transplants, meaning using ECMO as a bridge (though I think for a few centers, this is not the case).
http://jtcs.ctsnetjournals.org/cgi/content/abstract/140/2/427
Usually the adage for any transplant candidate is that you have to be sick... but not too sick

 

[Mattchiavelli]

you can always take a look at an EKG and see if the T waves are peaking and decide based on that- not everyone's myocardium is going to act the same way at the same K and there are some good images of the progression of peaked T waves to V-tach that you can google.

The reason you don't ice a patient that is coding is because there are already 3261 people there bc "OMG Code!!!" and it's confusing enough. Most people don't make it to that point either. Get your ABCs down and you can do
gather info -> make plan -> enact plan -> gather info -> refine plan
in a loop until the patient is stable and you can write your note (and ice) or everything reasonable is exhausted, you call the time, and you write your note

 

[BigRedBeta]

I don't practice at a place that does E-CPR (very few pediatric hosiptals do). The issues with lung "rest" settings typically only apply to patients with a cardiac and pulmonary reason for ECMO (ie sepsis). While cardiac arrests are usually secondary to respiratory arrests in children, someone with profound or prolonged hypoxia that causes cardiac arrest would not be a good E-CPR candidate (given the poor neurologic prognosis). Instead, E-CPR is more useful in a cardiac-related arrest solely, in which the ECMO works more like a VAD. In this setting, lung rest is not ideal as you want to either decannulate after myocardial function recovers in several days (at the neurologic exam is tolerable) or you plan to transition to a VAD. Granted I've only seen 1 instance of VA ECMO after cardiac arrest in a transplant patient, but his lungs were healthy (or relatively, he did have some pulmonary edema after the CPR).

As far as lung transplants, at least in pediatrics, ECMO is a general contraindication for eligiblity to receive lung transplants, meaning using ECMO as a bridge (though I think for a few centers, this is not the case).
http://jtcs.ctsnetjournals.org/cgi/content/abstract/140/2/427
Usually the adage for any transplant candidate is that you have to be sick... but not too sick

Of course, in this instance, ECMO could be considered, kind of, in a way, a sort of surrogate for VAD, but I'm unaware of any of discussion of "emergent" VAD placements - at least on the peds side of things. I'm at center with a significant amount of pediatric VAD experience and have never heard anything other than discussions about crashing to ECMO.

I didn't make it clear, but E-CPR is reserved for in-hospital arrests, hopefully avoiding much of the prolonged hypoxia issue. Certainly in the hypothetical example that triggered this post, you could presume as much.

One could easily argue the definition of "rest" settings, which is what I think we're doing. In a situation where you had otherwise healthy lungs they wouldn't look much different than very low levels of support in a patient who was requiring high levels of support. Perhaps it would be more accurate in the setting of sepsis and the like, to define "rest" settings as those that don't provide the level of support required prior to the initiation of ECMO and will avoid causing acute lung injury. Again, I left a lot of specifics out of my post, but depending on how things played out, you might be able to get by on fairly low flow that allowed significant contribution of the healthy lungs. It'd obviously be dependent on the degree of myocardial function and how quickly you wanted to push the heart to do the work. But if you sustained massive myocardial damage and the heart function was essentially nil...you'd be still be on "rest" settings and in the event of bubbles in the circuit or some other emergency, you'd still jump to rescue vent settings - would you not? - to really push the oxygenation while you're doing compressions...maybe I'm wrong, but that'd be the first thing I'd do in that situation.

Lastly, I'll admit I have zero experience with lung transplants, but the abstract you linked isn't evidence that ECMO is contraindicated as a bridge to transplant. While the abstract shows a distinctive difference between ECMO and non-ECMO lung transplant recipients (non-ECMO patients overall seem to have about a 80% 1-year survival post transplant: http://www.ncbi.nlm.nih.gov/pubmed/21309962), I'd argue that the real comparison should be made against all patients who have pulmonary failure, of which survival with the use of ECMO is less than 60% to begin with (http://www.ncbi.nlm.nih.gov/pubmed/20959787) and with the small sample size in the abstract you linked, that's unlikely to be statistically significant.

 

[SurfingDoctor]

I will agree that "rest" is very vague and that no center uses the same settings. The idea is high-ish PEEP, low tidal volumes, low respiratory rates (or even extubate as you elluded to). The idea is prevent the lungs from collapsing, but they do not typically provide adequate oxygenation or ventilation, which is what your saying. In the case of a solely cardiac arrest getting E-CPR, while you not want to beat on the lung with high vent settings, getting a sense of how they operate is imperative because if you have poor heart function and your lungs are trashed, your survival is almost zero and you cease to be a ECMO or VAD candidate. Like I said, I don't have much experience with E-CPR patients, but the 1 or 2 heart transplant patients who arrested on ECMO (which is sort of the same thing) had more "normal" vs "rest" ventilator settings.

Yep, the sample size was small in that article, but by nature of the fact that lung transplants are, along with hearts, the least common type of pediatric transplants (well I guess small bowel is the least common), that's not surprising. But this is what I was pointing to in the article:
"Survival to discharge was higher among patients weaned before lung transplant (4/6, 66% vs 2/9, 22%)"

Yep that's a small sample size, but the number of donors available for the number of recepients is huge. If you have a donor lung and 2 patients, one on ECMO and one not on ECMO, you are going to give it to the person who is more likely to survive, ie the non-ECMO person (which according to that article was 66% chance as opposed to a 22% chance). It's not an absolute contraindication, but it is a relative one at most pediatric transplant centers.

The 80% non-ECMO statistic you quoted is in relation to all solid organs (which a majority are kidney and liver) and are as you stated, non-ECMO recepients, so I'm not sure how that specifically relates to peri-operative ECMO in lung transplants. And comparing a peri-operative lung transplant candidate on ECMO to your standard respiratory failure ECMO is quite different (VV vs VA, no assoicated right-sided heart failure, reversible vs irreversible process, all of which will effect survival)

Yikes, we got way off topic on this discussion.