MRI Critical Care Teaching - PBL Case 1 Luka Randic

Case 1  Week 1:  Scenario 1  Questions  Week 2:  Answers to Scenario 1  Scenario 2  Week 1:  Scenario 1  Questions  Week 2:  Answers to Scenario 1  Scenario 2

Case 1  You’re on call for critical care and are called to resus to help manage a 72 year old man called Charles.  Sexy Suze, the A&E sister has just finished eating her coleslaw salad with chocolate biscuits and tells you Charles was brought in from his residential home 1.5 hours ago after ingestion of 40x75mg Dothiepin.  As you are starring at a piece of coleslaw on her chin, you politely ask where the A&E reg and consultant are. She tells you they have both been sacked due to failing their ANTT assessments and you have to look after the patient.  You’re on call for critical care and are called to resus to help manage a 72 year old man called Charles.  Sexy Suze, the A&E sister has just finished eating her coleslaw salad with chocolate biscuits and tells you Charles was brought in from his residential home 1.5 hours ago after ingestion of 40x75mg Dothiepin.  As you are starring at a piece of coleslaw on her chin, you politely ask where the A&E reg and consultant are. She tells you they have both been sacked due to failing their ANTT assessments and you have to look after the patient.

Case 1  Suze tells you his HR is 120 and BP 100/60 and has warm dry skin with dilated pupils. His GCS is E3, M6, V3.  What would you do?  What investigations would you do?  Can you stratify the risk of toxicity?  Suze tells you his HR is 120 and BP 100/60 and has warm dry skin with dilated pupils. His GCS is E3, M6, V3.  What would you do?  What investigations would you do?  Can you stratify the risk of toxicity?

Case 1  12 lead ECG:  SR120, normal QRS & QTc.  ABG:  pH 7.38, p , pC02 4.1, HC03 20, BE -7  U&E:  Na 139, K 4.1, Ur 6.2, Cr 94  12 lead ECG:  SR120, normal QRS & QTc.  ABG:  pH 7.38, p , pC02 4.1, HC03 20, BE -7  U&E:  Na 139, K 4.1, Ur 6.2, Cr 94

Case 1  Shortly after your assessment he becomes increasingly drowsy with a GCS E1, M5, V2.  Cardiac monitor shows QRS prolongation and a 12 lead ECG shows a QRS of 0.2s and a PR of 0.24s  What is this patient at risk of?  How does the QRS correlate to clinical risk?  What would you do now?  What other management would you consider?  Shortly after your assessment he becomes increasingly drowsy with a GCS E1, M5, V2.  Cardiac monitor shows QRS prolongation and a 12 lead ECG shows a QRS of 0.2s and a PR of 0.24s  What is this patient at risk of?  How does the QRS correlate to clinical risk?  What would you do now?  What other management would you consider?

Case 1  1-2ml/kg of 8.4% NaHC03  Intubate and ventilate - Why?  What agent would you use for induction? Why?  Cardiac monitor back to SR 120 with normal PR/QRS/QTc.  1-2ml/kg of 8.4% NaHC03  Intubate and ventilate - Why?  What agent would you use for induction? Why?  Cardiac monitor back to SR 120 with normal PR/QRS/QTc.

Case 1  You decide to transfer him to ICU.  What do you need for a safe transfer?  He is transferred to ICU. What other management would you consider?  Activated Charcoal - Even though now 2h post ingestion, TCA’s slow gastric emptying and some degree of enterohepatic circulation (intubated so airway protected).  You decide to transfer him to ICU.  What do you need for a safe transfer?  He is transferred to ICU. What other management would you consider?  Activated Charcoal - Even though now 2h post ingestion, TCA’s slow gastric emptying and some degree of enterohepatic circulation (intubated so airway protected).

Case 1  As you settle him in the ICU bed the cardiac monitor changes - broad complex tachycardia - VT.  How would you manage this?  NaHC03? Antiarrythmics? Proconvulsants?  Management of VT in a patient who has been adequately alkalinised - phenytoin or overdrive pacing.  As you settle him in the ICU bed the cardiac monitor changes - broad complex tachycardia - VT.  How would you manage this?  NaHC03? Antiarrythmics? Proconvulsants?  Management of VT in a patient who has been adequately alkalinised - phenytoin or overdrive pacing.

Case 1  He then has a grand mal seizure.  What would you do?  Check BM  Treat with iv diazemuls, then phenytoin then intubate/ventilate if not already.  He then has a grand mal seizure.  What would you do?  Check BM  Treat with iv diazemuls, then phenytoin then intubate/ventilate if not already.

Case 1  His BP drops to 70/40.  Cardiac monitor shows SR 120.  How would you manage this?  Ensure well filled.. Then:  Hypotension may be due to -  Alpha blockade & vasodilation - Rx NA  Direct myocardial suppression - ionotropes after fluid challenge.  May need PAFC to optimise treatment - consider Glucagon 10mg if resistant hypotension.  His BP drops to 70/40.  Cardiac monitor shows SR 120.  How would you manage this?  Ensure well filled.. Then:  Hypotension may be due to -  Alpha blockade & vasodilation - Rx NA  Direct myocardial suppression - ionotropes after fluid challenge.  May need PAFC to optimise treatment - consider Glucagon 10mg if resistant hypotension.

Case 1  8am suddenly appears, patient is stable, you are tired and your bleep goes off again..  You’ve never been so glad to hand over but the morning consultant is surprised you haven’t updated the handover sheet…. :-)  You’re off to bed remembering you still need to do your PBL homework…  8am suddenly appears, patient is stable, you are tired and your bleep goes off again..  You’ve never been so glad to hand over but the morning consultant is surprised you haven’t updated the handover sheet…. :-)  You’re off to bed remembering you still need to do your PBL homework…

TCA OD case group learning points? General OD mangment ED management Transfers ICU managment TCA OD case group learning points? General OD mangment ED management Transfers ICU managment

TCA learning points  Toxicity with >5mg/kg, severe toxicity with mg/kg.  All paitents should have a 12 lead ECG (QRS) and observed for a minimum of 6h with cardiac monitoring.  QRS >100ms is a marker of risk of seizures & arrythmias (esp is QRS >160).  Patients with arrythmias are at risk of seizures and vice- versa.  NaHC03 is the Rx of choice for arrythmias - AVOID antiarrythmics.  Indications for bicarb?  Hypotension may also be due to vasodilation and myocardial suppression.  Toxicity with >5mg/kg, severe toxicity with mg/kg.  All paitents should have a 12 lead ECG (QRS) and observed for a minimum of 6h with cardiac monitoring.  QRS >100ms is a marker of risk of seizures & arrythmias (esp is QRS >160).  Patients with arrythmias are at risk of seizures and vice- versa.  NaHC03 is the Rx of choice for arrythmias - AVOID antiarrythmics.  Indications for bicarb?  Hypotension may also be due to vasodilation and myocardial suppression.