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Case #17: The Princess and the PEA


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You, the intrepid on-call surgical PA, are taking call from the best place possible- your living room couch. About an hour after arriving home, you are called about one of your ICU patients.

70 yo F, POD#2 CABGx2. Preoperatively the patient had just initiated hemodialysis for CKD (diabetic/hypertensive nephropathy). She underwent her first postop HD session earlier today; 2 kg fluid removed, otherwise uncomplicated.

As you sit on your couch, the covering resident tells you the patient was hypotensive to the 60s. You advise a 500 cc fluid bolus and call back if there are any further problems.

You get a text page 2 hrs later- patient is coding. You hop in the car and arrive at the bedside 15 mins later. The code team has just restored a perfusing rhythm 5 mins prior to your arrival.

“She was in PEA,” says the code leader.

OK, what you do want to know?

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Davis is breaking the PA school Rule #1 which is 90% of your dx comes from the H&P

But he's a jedi master so he gets it his way!

 

Na 132

K 4.2

Cl 98

HCO3 20

Ca 6.3

Mg 2.2

 

short, obese pt getting puffier by the second

equal BS, coarse & junky

heart tones there but tough to hear above the room noise

abd softly distended

ext cool fingers/toes, thin pulses

 

BP is all over the place; intermittently getting 50-100 mcg epi boluses so the SBP is 60-180 depending on when you look at the monitor

sat 99% RR 14

rhythm sinus 70-100 (again, the epi)

 

anuric, dialysis pt

no swan

 

PEA strip- Sinus w/ tachy and brady breaks, but narrow complex

 

NOW.......

 

students and junior PAs out there........

 

You do NOT need to know much about cardiac surgery to work this case up

This is ACLS

before I go on....

 

WHAT is rcdavis getting at with his questions?

Per ACLS, what do you need to rule in/out?

 

List you differential based on the above info and hx...... and then ask specific questions based on that

You can generate a good list based on this alone

But you will need to ask a few more questions.......

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Hey, I was called to the hospital tonight to see a status migraine gal. When I got there, she was screaming of lower abdominal pain. I finished my work up, poked around a bit on her abdomen . . . and called her PCP. I told him my ideas about her headache and then started to talk about her abdomen. He then said, in a very friendly kind of way, "Hey, you're the neck up guy. I'll get someone else to poke on her belly."

 

So as a neck up guy, and no longer ACLS cert. the first thing I would do would be order an echo (looking for a tamponade) but that's coming from a neck up guy.

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With PEA, you need to r/o the cause, so you can either use the "H & T" or the rule of "3 and 3". Ill speak about the 3 and 3. severe hypovolemia, pump failure, and obstruction to circulation: Tension Pneumo, Cardiac Tamp, or Pulm embol.

 

Is she intubated?

whats her temp?

Does she have a peri-resucitative ABG?

Given her lytes, nothing drastic, so hyper/hypokalemia can be r/o, which should be given the fact the she is a HD patient.

The pt. is becoming puffier by the second, w/ thin pulses, coarse junky BS b/l, etc. sounds like a pump problem to me, despite having ionotropes on board, it seems her heart is still floppy and inadequately pumping.

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With PEA, you need to r/o the cause, so you can either use the "H & T" or the rule of "3 and 3". Ill speak about the 3 and 3. severe hypovolemia, pump failure, and obstruction to circulation: Tension Pneumo, Cardiac Tamp, or Pulm embol.

 

Is she intubated? Yes

whats her temp? 36.5

Does she have a peri-resucitative ABG? 7.30/35/440/17.5

Given her lytes, nothing drastic, so hyper/hypokalemia can be r/o, which should be given the fact the she is a HD patient.

The pt. is becoming puffier by the second, w/ thin pulses, coarse junky BS b/l, etc. sounds like a pump problem to me, despite having ionotropes on board, it seems her heart is still floppy and inadequately pumping.

 

There is a portable ultrasound unit in the ICU. You put the probe on the chest and see some pericardial fluid and clot.

The CXR shows a widened mediastinum and good ETT placement.

 

She could have "pump failure" but that can be from different causes.

She has surgery 2 days ago.

 

What to do?

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There is a portable ultrasound unit in the ICU. You put the probe on the chest and see some pericardial fluid and clot.

The CXR shows a widened mediastinum and good ETT placement.

 

She could have "pump failure" but that can be from different causes.

She has surgery 2 days ago.

 

What to do?

 

Okay, here's the dummy speaking, but if she is so compromised I would do a pericardiocentesis and see if she doesn't suddenly increase her cardiac output.

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Given the fact the pt had surgery 2 days ago, perhaps there are post-surg complications, and the pt is still bleeding somewhere from the surg site causing tamponade. A widened mediastinum has more than 1 d/dx, but in this it seems the previous surgery is the culprit. I dont know protocol for a POD 2 cabg pt w/ tamponade. DO you attempt a pericardialcentesis? Also, what about the clot? Does the pt need to go back into surgery to release the tamponade? Is LMWH appropriate at this time?

 

Super dooper Junior PA.

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She had surgery 2 days ago; she did not have significant bleeding postop and I had removed her chest tubes POD 1. Centesis is an option and is best for thin effusions. Clot is notoriously difficult to drain with a needle/catheter.

I opened the bottom of her incision, got in the pericardium and drained out about 300 cc blood, but the pericardium did NOT seem to be under tension (as you would have w/ tamponade).

She's still getting epi boluses.

 

Now is a good time to review those H's and T's.

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Current physical exam please....(with current vs s/p pericardial drainage).

 

 

In bed, unresponsive

Coarse BS (ventilated), diminished posteriorly

heart tones unchanged

belly silent, distended

periphery cool

 

 

Im putting one of my DDx, is a graft closure.

 

troponin 1.99, POD2, renal pt

 

 

Can we explain the widened mediastinum? Is that expected following a CABG or is there any suspicion of damage to the aorta during the surgery that is now making its appearance?

 

You will generally see a subtle widening of the mediastinum after surgery, primarily irregular heart borders with vascular congestion. This looks wider than usual.

 

H and Ts... Well, this pt is also suffering from non-anion gap acidosis, and she has CKD. her ABG is in metabolic acidosis range as well. So perhaps this is a H+ ion acidosis? Is dialysis an option at this point. in the game?

 

Well, maybe a mild gap.

What do you mean by H ion acidosis? What other kind is there?

Her acidosis is not severe enough to warrant emergent dialysis given the clinical context.

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Has dialysis altered the oncotic pressure and allowed the third spacing fluids...leading to an abdominal compartment syndrome?

 

I'll answer your question with more questions:

 

How would you estimate her oncotoic pressure?

How would you dx abd compartment syndrome and what findings in this case suggest it?

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Do you have a GFR, BUN/CR? Also, (I know very little about this) Despite the fact that there is good ETT placement, where are her vent settings ? Is she being inadequately ventilated?

regarding her abdominal compartment syndrome: she has a distended abd, anuric, coarse breath sounds, POD #2; all of these along with her CKD can lead to ACS, right?

 

Maybe I need to go back to PA school...

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You will need to measure the bladder pressure to evaluate for Abdominal Compartment Syndrome. I believe a pressure greater than 12 is abd Hypertension and greater than 20 is compartment syndrome. Either way, if it is >12 I would think seriously about surgical decompression of the abd.

 

I just applied to PA school, so please forgive me if this doesn't make any sense. I have been listening to EMRAP Critical Care podcasts and they were discussing this phenomenon in relation to managing ventilated patients.

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Hypovolemia. Given 500 bolus. Any additional volume?

Hypoxemia-O2 Sat 99%

Acidotic-7.30/35/440/17.5. Bicarb is low. Replaced?

Hypokalemia- 4.2

Hyperkalemia 4.2

Hypoglycemia--?

Hypothermia-36.5

Tamponade- Drained 300cc. POD #2, Are the CTs in place or removed?

Tensio PTX- CX with wide mediastinum and good ETT placement. Any signs of PTX?

PE-Always a risk factor. Need to rule out.

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Do you have a GFR, BUN/CR? Also, (I know very little about this) Despite the fact that there is good ETT placement, where are her vent settings ? Is she being inadequately ventilated?

regarding her abdominal compartment syndrome: she has a distended abd, anuric, coarse breath sounds, POD #2; all of these along with her CKD can lead to ACS, right?

 

You don't have a GFR, nor would you need one in a code situation.

The BUN/Cr are 50/2.2 (remember she's a dialysis dependent, anuric renal pt)

Vent- A/C TV 400 RR 14 FiO2 1.0 PEEP 8.0

YOU can tell me if she's adequately ventilated based on the ABG

 

Remember - this is a PEA code case. Abd compartment syndrome 1) is not a cause of PEA 2) could not be dx by renal function given her baseline renal status

 

You will need to measure the bladder pressure to evaluate for Abdominal Compartment Syndrome. I believe a pressure greater than 12 is abd Hypertension and greater than 20 is compartment syndrome. Either way, if it is >12 I would think seriously about surgical decompression of the abd.

 

I have seen several cases over the yrs where pts are ill, have a distended belly and ACS is entertained. Bladder pressures are usually acceptable. As I recall a value of 30 or more usually results in oliguria or renal failure.

 

Hypovolemia. Given 500 bolus. Any additional volume? Getting LITERS of NS as time passes. 5-6 liters in at this point. Still unstable.

Hypoxemia-O2 Sat 99%

Acidotic-7.30/35/440/17.5. Bicarb is low. Replaced? Given 2 amps (100 meq)

Hypokalemia- 4.2

Hyperkalemia 4.2

Hypoglycemia--? glc WNL

Hypothermia-36.5

Tamponade- Drained 300cc. POD #2, Are the CTs in place or removed? Tubes are out, yesterday.

Tensio PTX- CX with wide mediastinum and good ETT placement. Any signs of PTX? No pneumo. But you put the US probe on the chest and see a fair amount of pleural fluid.

PE-Always a risk factor. Need to rule out. True, but with no significant A-a gradient it would be surprising. You need a major PE- so called saddle embolus or the like- to cause cardiac collapse. You'd expect to see more hypoxemia.

 

 

So you're standing there dumbfounded. The pericardium is open, she got volume, and you're fixing the acidosis. The CXR looks unremarkable except for the mediastinum. The pleural spaces look OK on the film but there's a big effusion on the left by US.

The surgeon's on his way in.

Last thoughts?

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What's her sugar?

 

What is she on for meds?

 

Disregard... just saw you posted her BSL is WNL.

 

Still, just curious, what is she on for meds (drips mainly... I didn't see them anywhere)? Or did I miss those too...

 

And that calcium is critically low (assuming her albumin isn't through the floor as well). How about we give her some as well...

 

G

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