Train wreck from last night

[Bougie]

Paged at 2AM to the cardiac ICU:

68 YO 152 kg male with known history of severe AS, CAD, DM, COPD, OSA, renal insufficiency (Cr 1.68) admitted from an outside hospital where he presented with fever, dyspnea, chest pain. Cath at OSH showed severe left main disease and LCX disease. CXR shows possible LLL consolidation. Vfib arrest at OSH resolved immediately with 1 minute of chest compressions and 300J shock (not intubated). Transferred to our facility. Surface echo at midnight shows an aortic valve area of 0.91 cm2 with "small pericardial effusion with very minimal tamponade effect." Scheduled for 0700 CAB and AVR.

Progressively more obtunded and dyspneic over next 2 hours. VS: BP 85/49, HR 119, SpO2 89% on NRB, PAP: 57/14, PCWP 15, CVP 13. ABG: 7.21/69/98. Mallampati 4, thyromental distance 3cm.

Your plan?

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[deleted126335]

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[Planktonmd]

Paged at 2AM to the cardiac ICU:

68 YO 152 kg male with known history of severe AS, CAD, DM, COPD, OSA, renal insufficiency (Cr 1.68) admitted from an outside hospital where he presented with fever, dyspnea, chest pain. Cath at OSH showed severe left main disease and LCX disease. CXR shows possible LLL consolidation. Vfib arrest at OSH resolved immediately with 1 minute of chest compressions and 300J shock (not intubated). Transferred to our facility. Surface echo at midnight shows an aortic valve area of 0.91 cm2 with "small pericardial effusion with very minimal tamponade effect." Scheduled for 0700 CAB and AVR.

Progressively more obtunded and dyspneic over next 2 hours. VS: BP 85/49, HR 119, SpO2 89% on NRB, PAP: 57/14, PCWP 15, CVP 13. ABG: 7.21/69/98. Mallampati 4, thyromental distance 3cm.

Your plan?

1- Secure the airway with awake fiberoptic intubation after good topicalization + transtracheal block and with some Midazolam/ Fentanyl (This should have been done earlier since the guy already had a cardiac arrest once and there is no reason for this not to happen again).
2- Try to figure out why he is deteriorating:
The pericardial effusion could have increased especially that Diastolic PAP, CVP and PCWP are almost equal so repeat echo or do TEE.
If the effusion had increased then you need to get that fluid out.
The numbers don't indicate severe LV failure but the PA pressure is pretty high, it might improve once you are able to oxygenate him better.
He could be infarcting acutely as well and the TEE could help make that diagnosis.
If there is new wall motion abnormality then he might benefit from IABP.
Don't forget to repeat the CXR to make sure that you are not missing a pneumothorax caused by the CPR earlier.
Even if he makes it to surgery he will have a tough time getting off bypass with his ongoing pneumonia.

 

[Noyac]

If he has a good TM distance, good cervical ROM, and I can get a big blade in his mouth like a MAC 4, then RSI. If he looks difficult to me then I go some other route. MP4 means very little to me without the other information.

By the way, he doesn't have severe AS.

The numbers don't look so bad to me.

He is failing do to resp failure. What meds has he received. Can they be reversed. Does it matter if you can reverse them, I say no. Tube him and bring him to the OR in the morning.

 

[urge]

Would they do an AVR with concurrent pneumonia? Seems like a setup for endocarditis. Awake fiberopric fo' shoe. Plenty of local. I might be tempted to give some ketamine if my first attempt does not go so smoothly. IABP is probably warranted. Slow down the rate and increase the MAP. Pray for the best.

 

[militarymd]

Paged at 2AM to the cardiac ICU:

68 YO 152 kg male with known history of severe AS, CAD, DM, COPD, OSA, renal insufficiency (Cr 1.68) admitted from an outside hospital where he presented with fever, dyspnea, chest pain. Cath at OSH showed severe left main disease and LCX disease. CXR shows possible LLL consolidation. Vfib arrest at OSH resolved immediately with 1 minute of chest compressions and 300J shock (not intubated). Transferred to our facility. Surface echo at midnight shows an aortic valve area of 0.91 cm2 with "small pericardial effusion with very minimal tamponade effect." Scheduled for 0700 CAB and AVR.

Progressively more obtunded and dyspneic over next 2 hours. VS: BP 85/49, HR 119, SpO2 89% on NRB, PAP: 57/14, PCWP 15, CVP 13. ABG: 7.21/69/98. Mallampati 4, thyromental distance 3cm.

Your plan?

Does cx dz matter after you have severe L main dz?

I would slap a surface echo probe on him immediately and take a quick look

 

[Jeff05]

1. airway - you've described an oral boards difficult airway, he buys an awake fiberoptic. (i would topicalize him to decrease response to laryngoscopy give him 40 of succ and take a look with a glidescope - worse comes to worst he'll be breathing again in 3 minutes) his PAP will go down some after he's tubed and not hypoxic and hypercarbic/acidotic. keep him paralyzed to decrease o2 demand and ensure compliance with vent.
but, i'm sure he has a component of chronic PAH 2/2 OSA...

2. hypotension - he's tachy with AS and possibly septic. i would try to slow him down with esmolol and tighten up his SVR with phenylephrine if needed. a new infarct is a possibility - send troponins (if he's infarcting - OR stat). antibiotics.

3. CAD - as before, beta blockade is a good thing. a reasonable diastolic BP is a good thing. keep him on 100% o2 and hct about 30.

he buys a swan for PAP management and an echo to look at WM, fluid status, r/o tamponade, r/o PTX (lung sliding).

asa 5 for high risk procedure...if he ever leaves the hospital you'll be a hero.

avoid aprotinin on pump as his kidneys are already compromised.

 

[VentdependenT]

Paged at 2AM to the cardiac ICU:

68 YO 152 kg male with known history of severe AS, CAD, DM, COPD, OSA, renal insufficiency (Cr 1.68) admitted from an outside hospital where he presented with fever, dyspnea, chest pain. Cath at OSH showed severe left main disease and LCX disease. CXR shows possible LLL consolidation. Vfib arrest at OSH resolved immediately with 1 minute of chest compressions and 300J shock (not intubated). Transferred to our facility. Surface echo at midnight shows an aortic valve area of 0.91 cm2 with "small pericardial effusion with very minimal tamponade effect." Scheduled for 0700 CAB and AVR.

Progressively more obtunded and dyspneic over next 2 hours. VS: BP 85/49, HR 119, SpO2 89% on NRB, PAP: 57/14, PCWP 15, CVP 13. ABG: 7.21/69/98. Mallampati 4, thyromental distance 3cm.

Your plan?

This guy's gonna do GREAT!

Sounds like sepsis with CHF developing.

1. Airway first. Do what you gotta do.
2. Next gotta do something about that pressure. Get the SVR up. Give some neosynephrine and see what that does. If it doesn't do anything then give a bigger dose. Neo should help with those cornaries and the MAP, considering the decreased SV. Your boy may be heading towards Levo-country. Thats not a good place to be.
3. Ahh, now what about fluids...CVP hi, PCWP normalishy, PAP high. Ok so we got OSA and hypercarbia, yeah that'll drive up the PAP, really piss of the RV. Maybe get it all nice n' stiff and jack up your CVP, even though he may be "low on fluids." So what do I do, give him fluids. See what it does. If he's developing sepsis then he's gonna need em. His kidneys not worken so well? Give him fluids. Fluids fix everything ya know. Once you flood him then you can slam him with lasix.
4. Ok, now we can get all our other crap in order.
- CXR. Like the pneumo thing. May not have caused this but its gonna get worse with invasive PPV. Maybe the dude aspirated during the code and thats why he's hypoxic. Gonna make that pneumonia worse.
- Like what Mil said. Get somebody over there who can do an echo stat. If you got one handy drop a probe down there and do a quick n' dirty exam. Should help you in some way to guide your therapy (fluids vs pressors/inotropes).
- order your lab set with LFT's, Cardiac Enzymes, Lactic acid level, lytes, CBC.
- EKG is easy to do. Get one.
- Now would be a good time to hang some antibiotics....what do we do now a-days...Vanc and Zosyn? Sounds good.


-Maybe the dude flipped a PE. Get him stablized and get him to the scanner. Your A-a gradient is gonna be jacked for multiple reasons. Just another reason to get a CT scan.

-SPo2 seems a bit low for a Pa02 of 98%. Your Pa02 looks like *** with a dude on 100% NRB...or 80% Face Mask. EIther way you got some shunt runnin yo' way.

 

[VentdependenT]

Oh yeah, and don't forget to thank those F*#Kers at the notorious OSH for this "interesting consult."

Bastards.

 

[VentdependenT]

Oh man, don't forget all those medical consults!
-nephrology (hey at least his creatnine was less than two before I started that levo drip)
-cardiology
-ID (why the hell not)
-Nutrition (haha, my fav)
-PT (its always good to get those guys worked up)
-Pulmonary (get those continuous nebs runnen!)
-endocrine (diabetes and obesity! Oh yeah, get a CORTISOL LEVEL! WHOOHHHAHA)
-ENT maybe he'll need a palatoplasty after his big cardiac surgery!
- Neurology (for the hypoxic brain injury which is sure to develop during bypass)
- Who else am I forgetting.....who do we never consult....hmmm.....RAD-ONC!

-get your Nitric-Oxide ready for the ride to the OR. Somebody is going to want to treat that PAP number. Gotta make it look normal ya know.

While your at it PAN-CULTURE the guy!

 

[urge]

Bougie,

How did it go?

 

[SexPanther]

Does cx dz matter after you have severe L main dz?

I would slap a surface echo probe on him immediately and take a quick look

I'm wondering, is this new disease or stable severe disease that has been deemed unfit for PTCA/CABG and warrants medical management only?

Does this guy need an AVR? Yeah, at some point. Is that point now? From my intern perspective (which means nothing), I would say no. I'm more concerned about the possibility of tamponade, etc. brought up by all the studs already.

My hunch is he's in septic shock and heading for severe sepsis...fast. Intubate, get on low Vt ventilation protocol, fluid resuscitate aggressively, get that echo Mil mentioned (and tap the pericardium if he does in fact have an effusion causing tamponade). He's gonna be on pressors, which will aggravate his AS but we've got to get the tissues their damn oxygen. If he's not lined up, he will be soon. I agree that a Swan is justified here due to his valvular problems and the possibility that he could have a component of cardiogenic shock. Let's get a mixed venous O2, I want to know what his O2 extraction is to help guide my therapy. Lab him up/EKG/CXR like Venty wanted, and yeah I would cort stim this guy too. Troponins will be difficult to interpret in this setting as they can be elevated in tachycardia, strain from AS, pulm HTN etc., but I think you have to do it. I'm starting some big gun, broad spectrum Abx ASAP too.

Somebody already talked about the possible cause of his pulm HTN; hopefully this may improve with removal of hypoxic vasoconstriction while vented and treatment of his pneumonia. Once he's out of the septic woods, he may need some lasix to offload his RV which could improve his LV output due to ventricular interdependence. Insulin gtt for strict hypglycemic control. PT/OT as Vent said, but the nurses will probably order it anyway.

This guy may not do well (please note the sarcasm).

 

[militarymd]

Of note.....patient is still perfusing OK based on ABG...pure resp. acidosis....not metabolic acidosis.

 

[Jeff05]

this patient has severe 2 vessel dz in the setting of dm - he buys a cabg. so while his chest is open he also buys a valve.

 

[SoCuteMD]

this patient has severe 2 vessel dz in the setting of dm - he buys a cabg. so while his chest is open he also buys a valve.

LM disease buys CABG w/ or w/out DM.

 

[Gern Blansten]

 

[Bougie]

Here's how it went down.

Called attending (rather weak but nice guy, no echo experience, lifelong in academia, you know the type), called Jr resident for learning experience, called stud cardiac surg fellow who happened to be around.

We went with the diagnosis of worsening tamponade effect confounded by his AS. Hypercarbia from pneumonia and the sedation he got from his cath didn't help either.

Preload up with LR bolus, SVR up with phenylephrine drip. SBP now 130s. Placed radial arterial line in other wrist, the existing one was overdamped. Stat CXR shows no PTX. Surface echo shows ???? beacuse the guy's fat and it's the blind leading the blind (CA-2 and surgery fellow) and my attending is teaching the Jr resident about lidocaine drips for spine cases (WTF???). Prepped chest with surgeon and pericardiocentesis kit in room. Mac 4, Miller 3, bougie, Fastrach LMA, portable FOBS on standby. Phenylephrine, vasopressin, ketamine, esmolol drawn and ready. All this takes 30 minutes, Spo2 now low 80s.

Induced with increments of ketamine and esmolol. Needed a bump with neo. Succ in.

MP4, TM3, but excellent extension and good incisor distance. DL with Mac 4, grade 3 view. Bougie in, first pass was smooth as a baby's a**. Second pass, click click click. Tube in, BP tanks with first positive pressure breath with ambu-bag. SBP 40s, STs up, frequent PVCs . Vasopressin bolus given, SBP 90s, STs still up, pericardiocentesis kit opened. Needle in chest, 90cc out, SBP 150s, STs down, NSR rate 75.

Another fluid bolus, phenyleprine gtt keeping SBP 140s. Godzilla-cillin ordered. Ordered full labs and cultures since we are in academia (even a BNP!!). Convinced attending surgeon to come in a little sooner for CAB, AVR.

Surgery went fine, extubated 14 hours postop. Eating orange jello and watching Nascar this morning. Asks me "Now who are you again, doc?"

Gotta love this job. Critique??

 

[Planktonmd]

Here's how it went down.

Called attending (rather weak but nice guy, no echo experience, lifelong in academia, you know the type), called Jr resident for learning experience, called stud cardiac surg fellow who happened to be around.

We went with the diagnosis of worsening tamponade effect confounded by his AS. Hypercarbia from pneumonia and the sedation he got from his cath didn't help either.

Preload up with LR bolus, SVR up with phenylephrine drip. SBP now 130s. Placed radial arterial line in other wrist, the existing one was overdamped. Stat CXR shows no PTX. Surface echo shows ???? beacuse the guy's fat and it's the blind leading the blind (CA-2 and surgery fellow) and my attending is teaching the Jr resident about lidocaine drips for spine cases (WTF???). Prepped chest with surgeon and pericardiocentesis kit in room. Mac 4, Miller 3, bougie, Fastrach LMA, portable FOBS on standby. Phenylephrine, vasopressin, ketamine, esmolol drawn and ready. All this takes 30 minutes, Spo2 now low 80s.

Induced with increments of ketamine and esmolol. Needed a bump with neo. Succ in.

MP4, TM3, but excellent extension and good incisor distance. DL with Mac 4, grade 3 view. Bougie in, first pass was smooth as a baby's a**. Second pass, click click click. Tube in, BP tanks with first positive pressure breath with ambu-bag. SBP 40s, STs up, frequent PVCs . Vasopressin bolus given, SBP 90s, STs still up, pericardiocentesis kit opened. Needle in chest, 90cc out, SBP 150s, STs down, NSR rate 75.

Another fluid bolus, phenyleprine gtt keeping SBP 140s. Godzilla-cillin ordered. Ordered full labs and cultures since we are in academia (even a BNP!!). Convinced attending surgeon to come in a little sooner for CAB, AVR.

Surgery went fine, extubated 14 hours postop. Eating orange jello and watching Nascar this morning. Asks me "Now who are you again, doc?"

Gotta love this job. Critique??

Nice work.

 

[urge]

You got away with it, but I wouldn't have done it that way.









I'm BS. Good job.

 

[Gern Blansten]

I need to hear more about the lidocaine drips for spine surgery.

 

[Ferdie]

What a great thread!

Being post-call right now after an exhausting night of medicine cross-cover, with a few real sick patients (none like in this thread though!) keeping us running in circles all night long, I'm wondering how the he11 I'm going to be able to do this for real come July when I'm an intern. I can't wait until I'm ultra smooth, like you guys

Seriously, threads like this are awesome - they get me thinking about what I would do, and analyzing and learning from what other people would do, so that hopefully next year when people inevitably krunk while I'm on call I can keep a cool head about myself. Well, a cool-er head, at least!