Shot through the Spinal Cord

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Yangkower

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So I had a case as CA1 that continues to bug me when I think about it. A young healthy kid pisses off some cops (probably because he is trying to attack them) so they shoot him through the neck. Complete C2-C4 spinal cord injury and now a quad (also handcuffed to the bed with a guard standing by). I'm on call at night and the patient has episodes of bradycardia to the 20s and sometimes complete cardiac arrest that occur when the nurse moves him. Episode last for less than a minute each time and resolve when he is left alone, but patient becomes hypotensive. Nurse responds by starting dopamine (without my knowledge). I tell the nurse to stop moving the patient and stop the dopamine and have a defibrillator (for transcutaneous pacing) and atropine ready at the bedside for the next event and start ACLS if he loses a pulse. Nurse and nursing supervisor override me and continue the dopamine. Patient becomes hypertensive and tachycardic until they wean it off. So what bugs me about this is they are sure that dopamine is the right drug and their "years" of experience tells them it is right. Am I missing something? I can't think of any reason why dopamine is appropriate in this case? In fact, I can't really think of any reason to ever use dopamine.

P.S. The fact that they ignored me is a completely separate issue and won't be resolved because in this particular ICU the attendings are eunuchs.
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Yangkower said:
So I had a case as CA1 that continues to bug me when I think about it. A young healthy kid pisses off some cops (probably because he is trying to attack them) so they shoot him through the neck. Complete C2-C4 spinal cord injury and now a quad (also handcuffed to the bed with a guard standing by). I'm on call at night and the patient has episodes of bradycardia to the 20s and sometimes complete cardiac arrest that occur when the nurse moves him. Episode last for less than a minute each time and resolve when he is left alone, but patient becomes hypotensive. Nurse responds by starting dopamine (without my knowledge). I tell the nurse to stop moving the patient and stop the dopamine and have a defibrillator (for transcutaneous pacing) and atropine ready at the bedside for the next event and start ACLS if he loses a pulse. Nurse and nursing supervisor override me and continue the dopamine. Patient becomes hypertensive and tachycardic until they wean it off. So what bugs me about this is they are sure that dopamine is the right drug and their "years" of experience tells them it is right. Am I missing something? I can't think of any reason why dopamine is appropriate in this case? In fact, I can't really think of any reason to ever use dopamine.

P.S. The fact that they ignored me is a completely separate issue and won't be resolved because in this particular ICU the attendings are eunuchs.
Click to expand...

Most attendings I know have little respect for the clinical utility of dopamine.

Now, what about dobutamine? Bradycardic and hypotensive? What about a low dose epi infusion? Doesn't seem like a terrible choice but your plan also sounds reasonable.
 
I my mind this was not really a primary heart problem (just a strong vagal reflex) so the use of an ionotrope or chronotrope didn't make sense.Of course epinephrine would be given if we ever got to the point of doing ACLS which we didn't (at least that night).
 
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is this patient in neurogenic shock? dopamine is certainly a reasonable drug to consider in that case. it has its fair share of problems but its still used around the world on a daily basis for many different things. if this is a transient thing, then a dose of atropine would work, but you will get diminished effects over time with repeat atropine dosing. i wouldnt have a problem with dopamine at 5 mcg/kg/min in a patient with neurogenic shock who was persistently bradycardic.

pacing pads and bedside atropine for transient episodes of bradycardia/asystole is fine as well, but if its happening more frequently, you should probably be more aggressive about treating it.

were you on call in the unit or wwere you dropping the patient off? id be very upset if i were on call in the unit and a nurse was overriding my medical deicsions, but if it wasnt your unit at the time, it becomes a little murkier. ultimately, a physician should be deciding pressor/inotrope use and dosing.
 
Idiopathic said:
is this patient in neurogenic shock? dopamine is certainly a reasonable drug to consider in that case. it has its fair share of problems but its still used around the world on a daily basis for many different things. if this is a transient thing, then a dose of atropine would work, but you will get diminished effects over time with repeat atropine dosing. i wouldnt have a problem with dopamine at 5 mcg/kg/min in a patient with neurogenic shock who was persistently bradycardic.

pacing pads and bedside atropine for transient episodes of bradycardia/asystole is fine as well, but if its happening more frequently, you should probably be more aggressive about treating it.

were you on call in the unit or wwere you dropping the patient off? id be very upset if i were on call in the unit and a nurse was overriding my medical deicsions, but if it wasnt your unit at the time, it becomes a little murkier. ultimately, a physician should be deciding pressor/inotrope use and dosing.
Click to expand...

Most of our cardiac attendings (one dual CCM trained) dislike dopamine. They say it lacks efficacy as a pressor and it's dosing is highly unpredictable with the low, medium, and high dose gtt's being more theoretical in terms of it's actual effects. (I'm hanging on their experience not my own).

I don't have much experience with dopamine yet, and I'm not sure we even use it in our heart rooms (in fact I'm sure we don't at least on a regular basis).

According to this, renal dose dopamine isn't holding up despite it's persistent/continued use in the ICU.

http://www.ncbi.nlm.nih.gov/pubmed/16061903

Also, how would neurogenic shock warrant dopamine over another pressor or inotrope?
 
I didn't feel the patient was in neurogenic shock. The BP as on the low side but the real issue was transient episodes of extreme bradycardia with hypotension (that seem to be positional). No, I was on call in the ICU. The conversation went like this:

Nurse: "this patient keeps bradying and I'll never get my charting done if I have to keep dealing with it so I started dopamine"
Me: "I don't think dopamine is appropriate since this is likely a vagal reaction, have atropine and a defibrillator ready at bedside and wean off the dopamine as the patient's heart rate is now 150 and his BP is 170/100"
Nurse: "I've already talked to the the nursing supervisor and he agrees with me"
Me: "ok I'm going to bed, page me when you need me to sign the dealth certificate"

Kidding about the last line, but the only recourse I had at that point was to page my attending in the middle of the night and I already knew how that conversation would go so I figured it probably wasn't going to kill the patient so I would drop it. The next day after a discussion with the attending he was like " you realize I have no testicles so please don't bother me with this as I am incapable of mounting a vigorous response".
 
Yangkower said:
I didn't feel the patient was in neurogenic shock. The BP as on the low side but the real issue was transient episodes of extreme bradycardia with hypotension (that seem to be positional). No, I was on call in the ICU. The conversation went like this:

Nurse: "this patient keeps bradying and I'll never get my charting done if I have to keep dealing with it so I started dopamine"
Me: "I don't think dopamine is appropriate since this is likely a vagal reaction, have atropine and a defibrillator ready at bedside and wean off the dopamine as the patient's heart rate is now 150 and his BP is 170/100"
Nurse: "I've already talked to the the nursing supervisor and he agrees with me"
Me: "ok I'm going to bed, page me when you need me to sign the dealth certificate"

Kidding about the last line, but the only recourse I had at that point was to page my attending in the middle of the night and I already knew how that conversation would go so I figured it probably wasn't going to kill the patient so I would drop it. The next day after a discussion with the attending he was like " you realize I have no testicles so please don't bother me with this as I am incapable of mounting a vigorous response".
Click to expand...

:laugh::laugh: We have too many eunichs in this world. Seriously, wtf is wrong with some people...
 
KCBarbarossa said:
Most of our cardiac attendings (one dual CCM trained) dislike dopamine. They say it lacks efficacy as a pressor and it's dosing is highly unpredictable with the low, medium, and high dose gtt's being more theoretical in terms of it's actual effects. (I'm hanging on their experience not my own).

I don't have much experience with dopamine yet, and I'm not sure we even use it in our heart rooms (in fact I'm sure we don't at least on a regular basis).

According to this, renal dose dopamine isn't holding up despite it's persistent/continued use in the ICU.

http://www.ncbi.nlm.nih.gov/pubmed/16061903

Also, how would neurogenic shock warrant dopamine over another pressor or inotrope?
Click to expand...

yeah, you really never use it in the heart room, but it still has a place in the treatment of shock states, although it may not in 10 years. i agree people dislike it, but that doesnt mean it doesnt work or that it isnt the right drug for certain people. renal dose dopamine does not protect the kidneys (dopamine is a diuretic, actually, so it wouldnt be expected to)

if your neurogenic shock is manifested by bradycardia, any chronotrope should work. if you have vasoplegia in addition, then you may want to avoid dobutamine until you can volume expand the patient. norepi actually isnt the best drug when you want to raise CO through rate-response, in my opinion. i think that this patient was probably hypertensive, and thats why the nurse chose DA. i do not think it was right for the patient you describe, but it is definitely in the treatment algorithm for cases like this.
 
Seems like neurogenic shock...

Consequence being no sympathetic outflow from the hypothalamus and leading to:

1) unopposed parasympathetic cardiac stimulation causing bradycardia
2) decreased catecholamines in circulation causing peripheral vasodilatation.

Seems like acute management could be done by either a norepi drip or atropine along with some phenylephrine and fluids. Seems like a transvenous pacer would be in order as well to replace the atropine.

Are either of these two plans objectionable?

Seems like dopamine would be just a knee-jerk reaction to a patient in undefined shock.
 
scudrunner said:
Seems like dopamine would be just a knee-jerk reaction to a patient in undefined shock.
Click to expand...

In defense of the ICU nurse (god I feel dirty writing that), a dopamine infusion is part of the ACLS algorithm for bradycardia ...

Maybe not what most of us would reach for first, but from a protocol followin' nurse's perspective, totally reasonable for a patient with a HR of 20 after a cervical transection.


chrtbrad.gif
 
I agree neurogenic shock seem obvious, except these were very transient (<1minute) episodes that were associated with movement of the patient. I don't disagree with a pressor necessarily. I like levophed and phenylephrine. To me, in general (not for this case) using dopamine is like using a CD player. Sure it works and it used to be cool but why still do it?

There are no ICUs where nurses (other than ARNPs) are allowed to start pressors that I know of. This is a case of F***Y**, I do what I want because no-one has the huevos to stop me.




Ahh you posted to quick: Dopamine is part of the bradycardia algorithm, however, it is still after atropine (which was never given) and the nurse was using it as prophylaxis not treatment of another episode so he wouldn't be bothered while charting (his words). Except for the few episodes of extreme bradycardia the patient was actually with a HR in the 80-90s (off dopamine and in the 130s on dopamine).
 
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pgg said:
In defense of the ICU nurse (god I feel dirty writing that), a dopamine infusion is part of the ACLS algorithm for bradycardia ...

Maybe not what most of us would reach for first, but from a protocol followin' nurse's perspective, totally reasonable for a patient with a HR of 20 after a cervical transection.
Click to expand...

Yes, it's in the algorithm and it does the job... kinda.
 
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Yangkower said:
I agree neurogenic shock seem obvious, except these were very transient (<1minute) episodes that were associated with movement of the patient. I don't disagree with a pressor necessarily. I like levophed and phenylephrine. To me, in general (not for this case) using dopamine is like using a CD player. Sure it works and it used to be cool but why still do it?

There are no ICUs where nurses (other than ARNPs) are allowed to start pressors that I know of. This is a case of F***Y**, I do what I want because no-one has the huevos to stop me.




Ahh you posted to quick: Dopamine is part of the bradycardia algorithm, however, it is still after atropine (which was never given) and the nurse was using it as prophylaxis not treatment of another episode so he wouldn't be bothered while charting (his words). Except for the few episodes of extreme bradycardia the patient was actually with a HR in the 80-90s (off dopamine and in the 130s on dopamine).
Click to expand...

its clearly not the right therapy for the situation you are describing, but it is a therapy for persistent bradycardia, especially if you would be giving multiple doses of anticholinergic, which would have limited efficacy.

you say you dont disagree with a pressor...you should in this case, because the patient didnt seem to need a pressor. he did need a chronotrope/inotrope. how many times have you used dopamine in your 2 years of being a physician? you and i both suffer from other people telling us things arent any good, but yet they still end up in algorithms and still are useful in certain situations, so I dont know, I think if you are confronted with the situation of hypotension and bradycardia and decreased cardiac output as a result, you will end up considering dopamine quite a bit in those situations. epi/norepi may worsen your tissue perfusion, phenylephrine certainly wont help, dobutamine may help if you are in cardiogenic shock but probably not if the heart is empty, and it will lead to some vasodilation - so while you are volume resuscitating the shock patient dopamine is not a terrible choice.
 
I still don't like/understand the idea of dopamine (vs. other drugs) in this situation...

Few more questions:

Don't patients develop a tolerance to dopamine fairly quickly?

Why would you hang a drip for predictably inducible episodes of hypotension and bradycardia?

In cases of resuscitation, aren't you using dopamine for its adrenergic (alpha and beta agonist) effects? So why not use the specific agonists? What does dopamine bring to the table?
 
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I'm not an intensivist, so please educate me, but doesn't presence or absence of central access bear somewhat on the decision for what to infuse?
 
http://www.nature.com/sc/journal/v48/n5/abs/sc2009150a.html

http://www.springerlink.com/content/l510078783702782/

First and foremost r/o hemorrhagic shock.
For neurogenic shock, no gold standard. There really is no perfect drug. Dopamine and norepi commonly used. Dobutamine has been used with success. Vasopressin has been used. Atropine to increase heart rate. Transcutanous pads on standby if you get into trouble. The problem is unopposed parasympathetic activity due to damaged sympathetics. With a transection that high, you can almost guarantee neurogenic shock for the first couple weeks. Low SVR is the cause of hypotension. Treat the MAP like you would for septic shock.
 
scudrunner said:
I still don't like/understand the idea of dopamine (vs. other drugs) in this situation...

Few more questions:

Don't patients develop a tolerance to dopamine fairly quickly?

Why would you hang a drip for predictably inducible episodes of hypotension and bradycardia?

In cases of resuscitation, aren't you using dopamine for its adrenergic (alpha and beta agonist) effects? So why not use the specific agonists? What does dopamine bring to the table?
Click to expand...

i think we have beaten this particular situation to death. it appears that it isnt the typical scenario where you would break out an infusion of either a pressor or inotrope.
 
imfrankie said:
I'm not an intensivist, so please educate me, but doesn't presence or absence of central access bear somewhat on the decision for what to infuse?
Click to expand...

not really. give what they need. if you need norepi, put in a line. i wouldnt feel comfortable infusing DA/DBT/NE/EPI/VP without a central line in place, or it can go through a PIV while im placing a line.

if you cant get a line in anywhere, infuse what you need through the biggest IV you can, ultimately, all of these will be bad if the IV goes sour.
 
Well, it sounds like I'm going to have a dissenting opinion here, but it sounds like the OP and a few others are missing a few things.

You have a previously healthy young adult with a complete C-spine injury. So you take a patient with baseline high vagal tone (likely) and now add neurogenic shock: take away ALL the cardiac accelerator fibers and ALL the sympathetically-mediated tone to the entire splanchnic circulation. And you're surprised that the patient has severe bradycardia and occasional sinus arrest with stimulation? You're upset that the ICU staff want to prophylax against cardiac arrest? I agree with pacer pads and atropine at the bedside of course.

There are a couple of questions here. The first is, "is dopamine appropriate for symptomatic bradycardia and/or neurogenic shock?" Certainly, as-needed atropine boluses can treat symptomatic bradycardia. However, neurogenic shock persists for days to weeks following cord injury. Treating empirically with a chronotrope+pressor is totally reasonable. I can think of only dopamine, epi, norepi, and MAYBE isoproterenol that fit the bill.

The next question: "Is dopamine a 'good' drug?" Depends on your viewpoint. If you want to know, "does it WORK as a chronotrope and pressor?" then the answer is YES. If you want to know, "does it cause diuresis" then the answer is HELL YES. But the various effects at various doses vs. side effects like PACs/PVCs/tachyarrhythmias are really unpredictable. How much DA vs. B1 vs. a1 agonism you get at a certain dose is very variable. So, titrate to effect. Clearly, the ICU nurses didn't do that, went a little overboard with the dopamine, and got the HR to 150. That's a separate issue.

The next question: "Does 'renal-dose' dopamine work?" Again, it depends. Dopamine somehow now has a bad rap for "renal dose," but what we really know about "renal dose" is that low-dose dopamine does not improve outcomes in patients with oliguric AKI. Limit your hate on dopamine to that statement and its known/obvious side effects. However, keep in mind that it DOES work as a diuretic, but increasesr renal medullary oxygen consumption without really improving medullary oxygen delivery, so be careful in borderline kidneys.
 
There have been several helpful posts about situations where dopamine could be used. I still contend the unpredictable dosing and side affects make it a drug I wouldn't be inclined to reach for. But I am definitely softening my stance on it. Which is why I posed the question.

In this case prophylaxis against 30-60 seconds of bradycardia and hypotension that occur 1-3 times per shift when you are moving a patient does not seem reasonable. Especially when the rest of the time the patient is hypertensive and tachycardic on the med. I don't think you can easily titrate a drug to prevent a sudden and episodic event.

But who knows maybe I'll give it a try next time.
 
Well you can decide that HR of 120 and some hypertension, especially in the setting of a partial SCI is more beneficial than any bradycardia
 
I just want to know how the nurse is starting an infusion for a drug without an order for it. That's enough for serious writeup and possible job loss at our hospita I mean it's either ordered by the doc or it isn't. If she pretends she had a verbal order from the attending, somebody still has to sign the verbal order.
 
Mman said:
I just want to know how the nurse is starting an infusion for a drug without an order for it. That's enough for serious writeup and possible job loss at our hospita I mean it's either ordered by the doc or it isn't. If she pretends she had a verbal order from the attending, somebody still has to sign the verbal order.
Click to expand...

i would imagine there is more to that story
 
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