Time to pace, no time to waste

Here is another post from one of our senior residents - Dr Gayathri Nadarajan.
It is 5am in the resuscitation room. And just when everyone was starting to space out, the nurse brings in a 18-year-old girl on a wheelchair, following a near-syncopal episode. She looked pale, diaphoretic and something didn’t seem quite right.
Presenting Complaint
Diarrhoea, vomiting  and dizziness for 2 days. No actual syncope or seizure like episodes. No fever. No HI and no headache. Has mild abdominal cramping sensation.
Past Medical History
NIL. Certain she is not pregnant
Vitals
BP 100/60     HR-45/min     Temperature- 36.7
Examination
Unremarkable. Abdomen was soft without any guarding or rebound.
ECG shows
Complete heart block
Figure-18-ECG-showing-third-degree-complete-AV-block-and-a-junctional-escape-rhythm

During the consult….
While talking to the patient, her eyes rolled upwards, her body went stiff and she appeared to have a tonic clonic seizure. I couldn’t feel a pulse and the cardiac monitor showed asystole. We immediately started chest compressions. Within a few seconds, she regained consciousness and was shocked to find all of us fussing over her.
Her heart rate was about 40-45. Hence we gave her atropine and prepared for transcutaneous pacing. While preparing for transcutaneous pacing, she had 2 more episodes of brief tonic clonic seizure following a sinus pause. Dopamine was prepared concurrently as the pacing wires were attached to the monitor.
We finally started pacing her and called for a cardiology consult.
That was not the only problem….
In view of the abdominal discomfort in a young girl with syncope, bedside FAST was done, which showed free fluid in the abdomen.
ruq1
Rapid urine HCG was done, which was negative. Hence a GS consult was called for.

Findings and progress
CT scan showed:
  • Moderate ascites
  • Mild diffuse thickening of the large bowel, which is nonspecific and could be associated with non-specific colitis.
  • Gallbladder is distended.
  • Bilateral pleural effusion with associated atelectasis/ consolidation
Troponin:
Her troponin T was 870 ng/L and CK-MB was 39.99.
FBC:
WCC was 15.4
Rest of her bloods were unremarkable and CXR was clear.

Progress
In ED, we concluded that she had symptomatic heart block and the most likely diagnosis was myocarditis. (after ruling out things like drug overdose, pregnancy)
The free fluid in the abdomen could have possibly been due to an inflammatory process such as colitis
In view of the complete heart block with syncope, she needed tranvenous pacing. Hence the cardiology team reviewed her in the ED.
Patient had the transvenous pacing wire inserted and she was admitted under the CGH cardiology team. Inpatient echo was normal. During her stay, family requested for transfer of care to NHC. She is currently recuperating there. She is currently off the transvenous wire and awaiting a pacemaker.

Learning points
  • It is important to check the pulse in patients with a seizure as the seizure could have been the result of hypoxia to the brain from a loss of cardiac output (such as VF/VT/ ventricular pause). This was probably the mechanism of her tonic clonic seizure.
  • Don’t hesitate to pace. When there is significant bradycardia / sinus pauses, indications to pace are:
    • hemodynamic instability (hypotension/ cold, clammy peripheries),
    • altered conscious level
    • syncope
  • Myocarditis can have various cardiac manifestations. Do not forget to include it in our list of differentials.
  • Free fluid in abdomen doesn’t always mean a surgical abdomen / cause. Clinical correlation is important.

Myocarditis in a nutshell (from Life in the Fast Lane)
Possible ECG changes:
  • Sinus tachycardia.
  • QRS / QT prolongation.
  • Diffuse T wave inversion.
  • Ventricular arrhythmias.
  • AV conduction defects.
  • With inflammation of the adjacent pericardium, ECG features of pericarditis can also been seen
Causes:
  • Viral – including coxsackie B virus, HIV, influenza A, HSV, adenovirus.
  • Bacteria – including mycoplasma, rickettsia, leptospira.
  • Immune mediated – including sarcoidosis, scleroderma, SLE, Kawasaki’s disease.
  • Drugs / toxins – including clozapine, amphetamines.

Cliff Reid – Advice to a young resuscitationist


Dr Cliff Reid of Greater Sydney HEMS is probably one of the finest exponents of not only resuscitative science but also in transmitting ideas via talks/presentations. This plenary from SMACC Chicago last year gives us important insights into:

  • overconfidence
  • following up
  • changing oneself and systems when thigns go wrong
  • other specialists and using their skill and experience
  • risks and rewards of being in this field

He has his own channel here for other inspiring talks on resuscitation.

Webucation 29/5/16

Webucation this month comes from the realms of paedatric surgery, urology and even on some tele-medicine. Remember to visit and credit the original posters.


  • Sepsis-3 - This is need to know classification for all who deal with this disease
The last link is a must read for those in our speciality. For it is said many a time that the 2 things that we deal with mostly in our career are related to vascular problems and sepsis. So be good at them.

Another win for U/S

Here's a good one from JournalWatch. Its encouraging to see some myth-busting and new standard setting coming into the mainstream.
Original study lives here.


No Need for Chest X-Ray After Ultrasound-Guided Right Internal Jugular Lines?


Very few complications were picked up by routine chest x-ray at a large academic hospital system.

For decades, dogma has been that chest x-ray should be performed to confirm placement of all internal jugular (IJ) central lines, despite evidence that ultrasound can significantly reduce complication rates. These authors retrospectively assessed detection of complications by routine chest x-rays obtained after ultrasound-guided placement of right IJ central lines in adults at an academic tertiary hospital system.
During 2014, a total of 1322 right IJ central lines were placed with ultrasound guidance in emergency departments, intensive care units, and general wards. Overall, 97% of attempts were successful. Chest x-ray detected 1 (0.1%) pneumothorax, 13 (1.0%) misplaced catheters that required repositioning, and no arterial placements.

COMMENT

For ultrasound-guided, right IJ lines, these findings suggest that routine chest x-ray may eventually be replaced by ultrasound to assess for placement complications. The findings also demonstrate that resuscitation should not be delayed by waiting for the confirmatory x-ray. The case is closed when it comes to the requirement for using ultrasound for IJ line placement. If you aren't using it, be prepared for the difficult conversation explaining why.

Tupac on nurses

Having learnt some hard lessons when I was fresh and having been on the treatment side of medicine, I can attest to the truth of the following video. This is a never ending shout out to the nurses who embody the spirit of healing.
Testify Zdogg...