Howdy,
So im having a good night shift, couple drunks to stitch up, febrile kiddies.
Then our beige phone goes, You may have a red phone, ours is beige, the colour of terror.
70 y/o female, poorly responsive, D+V, pulse 20 bpm. ETA 5 minutes, unable to get IV access. call back but no response. Crap, As im flying solo on nights and this sounds like a bit of help would be appreciated I get the switch to call the boss in. (Go ahead, shoot me)
So pt comes in, shes big, really big. GCS 13-14 more drowsy than anything. “I feel like im going to die” The night nurse bless her goes “I hope your wrong” Pt was cool to the touch, couldnt get a temp. Unable to get a BP, P 20-25 sats 91% on RA. Denies chest pain. but not exactly with the programme.
She has no veins, none. ambos had 4-5 goes nada.
So I think, going to take a while to get access and she need some rate. #ATROPINE IM, not cause ive read anything but cause makes sense to get something on board. moment of humour and as nurse draws back first before injecting, then goes “bugger no blood”
ECG comes back its a bit unclear, not a stonking inferior MI. Were now about 5 mins down the line of me trying to get access.
So I finally manage to get a tiny canula into her wrist (read paeds 24g) and give a IV dose of atropine, some response pulse up to 40, can get a BP now on NIBP 70/35. Reception has found her on the computer. and god bless the GP they have a summary on our new Health pathways info. it reads:
Type 2 Diabetic, very poorly compliant, HTN, very poorly compliant. (at which point i wondered what ”very” poorly compliant meant..) Chronic Renal Impairment. has date of last meds collected, was yesterday…So shes prob had according to computer, 190mg metoprolol(Betaloc), Diltiazem 180mg daily, Inhibace plus, Metformin 1g TDS.
Boss arrives and continues the search for a line, brief discussion re:IO. goes, “do you think IO is an option?” “maybe but were not going to do that”
At this point delving for better access i manage to feel a good radial pulse, so bugger it. pop a cannula in and get bloods off.More atropine and really not getting any BP with it despite pulse coming up. so calls made to place a pacing wire.
Labs are back:
| pH | 7.07 L | 7.35 – 7.45 | |||
| pCO2 | 32 L | 34 – 45 | mm Hg | ||
| pO2 | 139 H | 80 – 100 | mm Hg | ||
| Base Excess | -21 L | -3 – +3 | mmol/L | ||
| Actual Bicarbonate | 9 L | 23 – 29 | mmol/L | ||
| Oxygen Saturation | 98 |
| Sodium | 136 | 135 – 145 | mmol/L | |||||
| Potassium | 6.2 H | 3.5 – 5.2 | mmol/L | |||||
| Chloride | 114 H | 95 – 110 | mmol/L | |||||
| Total CO2 | 9 L | 25 – 33 | mmol/L | |||||
| Anion gap | 20 | 10 – 20 | mmol/L | |||||
| Urea | 16.4 H | 3.2 – 7.7 | mmol/L | |||||
| Creatinine | 251 H | 45 – 90 | umol/L | |||||
| Glucose | 15.4 H |
Nothing too exciting, her renal function is better than when last tested, not too sure about the potassium as might be haemolysed some but not high enough to jump on it. Gas was thought to be from poor tissue perfusion rather than DKA and her sugar aint too elevated. but getting rate up and getting some perfusion is prob first task whatever the cause.
So we wander to radiology and the boss goes, “done a pacing wire?” “uh, no”(im very articulate on nights)”you will have in about 20 minutes” I do the worlds fastest reading of the procedure. and away we go.
Gown, Glove, prep and go. Get excellent flashback and im in. wire goes in nice. Feed, curls, #Sweat feed twists, #SweatSomeMore. Wonder about how hot it is all of a sudden and that lead is bloody heavy and hot. So after a bit more work get a good position but with a pretty curl in the artium. nice response without too much voltage. Boss joins in to improve it but cant help the kink and decides he will just leave it.
Then for central line. So same but on the other side except advace introducer to maximum depth get little blood but can’t hold the bloody thing down enough to get the guidewire in. discretion being the better part of valor I give up. quick CXR to show my handiwork and no pneumo and off to HDU.
Gas-man arrives, read wonderful scottish anestetist with a great sense of humour. “Boy if you couldnt get it in there you better learn how real men put in central lines” So Uss guided jugular goes smoothly. Hes happy she has an art line in and even gets a good trace #stoked.
patients Bp still not cutting it despite rate of 90. so we started a dopamine infusion to which she responded well. decided with the metformin on board and bad perfusion not for noradrenaline. Also started cefuroxime.
<—- My Handiwork!
And today i come to work shes doing well still brady when pacer is dropped back but less so 40-50. weaned off the inotropes. troponins didnt rise any higher so it looks like was drug related.
So questions for anyone reading do you remember your first pacing wire, art line, or central line? how did it go? or was it so long ago that the dementia has already claimed it? What would you do different? (its ok my goal is to learn)
Great job! Patients doing well, so what more could you ask for!?
If we are doing the whole ‘debrief/resus course style/what would I do differently next time’ thing there are a few MINOR things that crossed my mind:
Definitely IO in quick-> atropine +-push dose adrenaline.
Tried glucagon for b-blocker toxicity? I used it for the the first time recently and surprisingly it did work, for a bit!! I appreciate in this case she is already hyperglycaemic!
Was transcutaneous pacing considered as a temporising measure until TPW could be sited?
TTE and rt sided ecg looking for RV infarct and then consideration of fluid challenge.
As for the TPW excellent work. I’ve only placed two of the J wire types before and even the most recent one was many years ago. However, I’m surprised on the choice of access, LSCV? More direct/easier route from the RIJV/RSCV and easier to negotiate the tricuspid. Tricuspid can be a real arse (I’m led to believe), however, my experience of this stems more from when i used to place PACs. When I’ve put them in from the left I’ve sometimes struggled to get a smooth transition/good position and that’s with a floatation balloon.
Anyway excellent work and blogging. Hope these comments were constructive/helpful and not negative, as I thought you did an excellent job.
Hey thanks for the thoughts,
Yeah im still not sure why boss wasnt keen on the IO.
Its interesting to look back on these things, Im pretty sure boss was more worried about possible lactic acidosis from the metformin and not keen to drop her tissue perfusion. (Hes not huge on talking)
Discussed trans-cut pacing at the time but its literally 5 metres down the corridor to rad and as not too hypotensive felt just get def management. (also as we found rate didnt equal decent output)
Yeah boss told me right and i just went from there, not 100% sure why to be honest. (will ask)
Thanks for the comments, its ok i have a tough hide.
Keeweedoc
Thanks for the reply. Thick skin is essential to survival in medicine!
I just realised I wasn’t very clear on the TPW/access comment. I was wondering why you decided on the left subclavian vein for the sheath and TPW over a right sided scv or ijv approach? As above, I understand personally and from others negotiating the tricuspid can be difficult from the left, as it is a less direct route.
The IJ was out as my boss never learnt to do them (hence the anestetic comments)
And left vs right I honestly dont know why.(Promise to ask and get back to you)
Great case. IO aside (so long as bone isn’t shattered, no reason not to IO, esp a sick patient):
For the wire, R IJ is a straight shot down. I my “extensive” personal experience, it worked very well for both. With US, easiest site to go for. Your X-ray shows the nice straight shot.
L SC allegedly has a good “curve) to get the wire in – hold the wire in the round holder up to your chest next time you have one- but make sure you’re pointing it in the right direction.
L IJ and R SC both have to make 2 turns (a flat Z) so should be tougher.
If any delay in access in a sick patient, I say IO then US guided fem stick for labs, then do what you need to do. Or drop the central line in fast (but clean!) with US
hey seth,
totally agree with IO.
with regards to wire and central lines: My boss never learnt to do IJ lines. (he learnt SC in senior registrar year when it was “new” shows his vintage) so it was always going to be a bilateral subclavian attack. he said today he doesnt think the difficulty is too much to overcome from left. He wanted right for his central line.
was wondering if many femoral lines placed? I saw quite a few in Christchurch ED. My understanding is its kind of a downstairs standard. That is noone will fault you if you have to.
cheers again.
Andre
mate, nice work. I would have IO in but its good practice in legitimate case for CVC and pacing wire placement. One suggestion if you were thinking of probable beta blocker and calcium channel blocker related bradyarrhythmia and toxicity, is high dose insulin glucose therapy. works well in selected cases of toxicity and can be started with peripheral access. reference here http://www.ncbi.nlm.nih.gov/pubmed/21563902
You can get it going via your 24G PIV you got in, whilst setting up for your CVC and pacing wire..and hopefully by the time you got CVC access and are ready to place the wire, pulse rate improves and perfusion is better. Or you can IO right away , start the insulin dextrose infusion, and get things ready for CVC insertion etc.
Femoral lines can be used temporarily but if you got IO gear for rapid access, not much point in femoral access..unless that is the only site you can get CVC access to place a pacing wire. I agree with others, pacing wire is usually easier via RIJV approach, but you did fine and had fluoro guidance.
nice blog too
Minh
hi mihn, insulin/dex could have been a good idea. its interesting working with physicians/internists in ED.
Def will push for IO in future.
Thanks for your thoughts
Keeweedoc
Ah, I remember my first pacing wire…a scary moment. Big sheath, RIJ and go from there….
Also used glucagon with effect. Faced with the same today? Well, no access to a wire so it would be transcutaneous pacing and maybe isoprenaline.
IO – yeah, why the hell not if no other option?
You did good, well done.
Your boss needs to “learn” how to do IJ lines…although nowadays everyone’s using darn ultrasound, which takes away the ‘oops, that’s the thyroid I’ve biopsied’ moments, which were kind of exciting
Still, have heard of one hapless registrar (not me) managing to pop the cuff on an ET tube whilst doing an IJ line. Not sure if that’s urban legend…or not.
Meanwhile, good blog.
we did think glucagon but in acidotic diabetic with bsl 15 decided against it. (not sure bout the call, but that was the thinking)
Boss is physician who does overnight call (no emergency docs overnight) anestetics on call too so could have gone IJ sooner.
prob biggest learning for me is how long things take.
less haste, more speed.
thanks for the comments, tim?
regards
keeweedoc
Just remember : you can’t pace meatloaf. Pacing doesn’t work (& hurts) in tox brady
cheers seth. Ill see about that later my missus makes a pretty solid meatloaf, try it with a 9v im sure it will have good MO (meatloaf output)
Hey guys,
got the boss for a coffee and had a chat about putting the wire in subclavian.
So here goes.
He uses the Left subclavian because the natural curve of the wire tends to follow nicely around from the left sub-clavian (long gentle curve) same as the Right IJ (straight down and then curve) . As it comes coiled in the spiral in the pack.
Struggles often come from the Left IJ and Right subclavian as the wire needs to be rotated or change direction and makes a Z shape then.
Hope that makes some sense.
Keeweedoc