He simply looks sick…

aka Ruling the Resus Room 001

A 60 year-old man is brought into the emergency department because he has felt unwell the past 5 hours. He is awake, diaphoretic and ‘looks sick’. He is mildly tachycardic, mildly tachypneic and afebrile with a blood pressure of 100/60 mmHg. His blood glucose is normal. There is no history of trauma.

Clearly this man needs a bit of work — he looks sick with abnormal vital signs. So… Now what?

Inspired by a talk by Amal Mattu on ‘The Crashing Patient


Questions

Q1. What are your initial actions?

Answer and interpretation

Initial actions, after assessing the ABCs, should include:

  • Manage in a resuscitation area
  • Get help
  • Administer high-low oxygen via a non-rebreather mask
  • Attach monitoring/ defibrillator — SpO2, RR, ECG, BP
  • Obtain large bore IV access (2 big peripheral lines) and take bloods
  • Perform a 12-lead ECG

Blood glucose has already been checked.

“Somewhere between ABC and CBC, [there’s scope to] lose a lot of patients…”
— Amal Mattu


The ECG shows a mild sinus tachycardia and ‘non-specific’ T wave changes. The patient still looks sick. A bag of normal saline is hanging. Nothing much has changed.


Q2. What is most useful thing you can do at the bedside do figure out what to do next?

Answer and interpretation

Perform bedside ultrasound.

In particular look for a pericardial effusion and check for an aortic aneurysm. About half of aortic emergencies present without chest or back pain and simply ‘look sick’. Abdominal ultrasound can often easily identify an abdominal aortic aneurysm and pericardial tamponade is a common mechanism of death in aortic dissection. Ultrasound can also diagnose tension pneumothorax, potential causes of hypovolemia, effusions and cardiac failure.

“’Classic presentation’ means it occurs 15% of the time.”
— Amal Mattu


Unfortunately, while you are thinking about Q2, the patient has a PEA arrest.


Q3. What is the resuscitation algorithm for a PEA arrest?

Answer and interpretation

Pulseless electrical activity is a non-shockable rhythm. This is the Australian/ New Zealand Resuscitation Council’s algorithm for adult cardiorespiratory arrest:

anzcor-adult-cardiorespiratory-arrest-flowchart-jan-2016

Q4. Should you thrombolyse this patient?

Answer and interpretation

Thrombolysis is often suggested as myocardial infarction and pulmonary embolism are common causes of a PEA arrest.

By all means, get ready to administer thrombolytics but consider other causes of PEA arrest first. As part of this do the bedside ultrasound — arrests from aortic emergencies also commonly result in PEA. Needless to say, thrombolysis won’t do these patients any favours…


Q5. What are the causes of PEA?

Answer and interpretation

Remember the 6Hs:

  • Hypovolemia
  • Hypoxia
  • Hydrogen ions (acidosis)
  • Hyperkalemia or hypokalemia
  • Hypoglycemia
  • Hypothermia

and the 6Ts:

  • Tablets and toxins
  • Tamponade (cardiac)
  • Tension pneumothorax
  • Thrombosis (myocardial infarction)
  • Thrombosis (pulmonary embolism)
  • Trauma

Note that this commonly used memory aid doesn’t include:

In this case, bedside ultrasound shows a pericardial effusion and a dilated aortic root.

“Every time you see a sick patient, perform bedside ultrasound. Look at the heart, look at the belly. You will save lives.”
— Amal Mattu


Q6. Based on the answer to Q5, what should you do next?

Answer and interpretation

Put simply, the next steps are:

  • Continue effective CPR — don’t stop!
  • Urgently notify the on-call cardiothoracic surgeon, or arrange transfer to an appropriate center.
  • Emergency drainage of the pericardial effusion to correct the pericardial tamponade (preferably ultrasound guided).
  • If there is ‘return of spontaneous circulation’, initiate post-resuscitation care.

Don’t let the patient die like a King.

“The aorta is a ticking bomb, a grenade waiting to go off.”
— Amal Mattu


References
  • Kurimoto Y, Morishita K, Narimatsu E, Asai Y, Abe T. Satisfactory recovery after 45 minutes of resuscitation in acute aortic dissection. Crit Care Med. 2002 Sep;30(9):2030-1. PMID: 12352036.
  • Mattu, A. ‘The Crashing patient‘ — Free Emergency Medicine Talks.
  • Meron G, Kürkciyan I, Sterz F, Tobler K, Losert H, Sedivy R, Laggner AN, Domanovits H. Non-traumatic aortic dissection or rupture as cause of cardiac arrest: presentation and outcome. Resuscitation. 2004 Feb;60(2):143-50. PMID: 15036731.

Ruling the Resus Room 700

CLINICAL CASES

Resus Room Reflection

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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