The Resuscitology Team discuss the management of bleeding patients from the prehospital phase through to in-hospital care. Trauma and ‘medical’ bleeding are covered, in adults and kids.
Notes and References
Haemorrhage Control Quick Reference Guide for ED
This is the third hypothetical case discussion based on real cases submitted to the Resuscitology Team for analysis and debrief on the Resuscitology Course. Course participants are asked: “Please describe a resuscitation case that you have been involved in or witnessed that you feel (a) either had great learning points for other people on the course or (b) you feel didn’t go as well as it should and would appreciate the chance to analyse and discuss it.”
Case details are removed or altered to guarantee anonymity and confidentiality while preserving learning points. Cases are shared with the permission of the submitting clinician.
This case discussion was facilitated and summarised by Chris Nickson
A young adult female presents to the emergency department in septic shock. She has a diagnosis of metastatic cancer and is receiving chemotherapy. She is critically ill, with an altered mental state and is hypotensive.
She has no advance directive and the oncology consultant advises that “full resuscitation” should be performed. The ED team are not completely at ease with this, however, they continue to resuscitate the patient.
Eventually, the decision is made to intubate the patient, who has no externally apparent features of difficult anatomy. Two operators are unsuccessful with intubation attempts despite the use of video laryngoscopy. The patient is able to be oxygenated and ventilated until an anaesthetist is available to assist with the intubation.
Discussion points
Recognition and initial management of septic shock
Definition and recognition of sepsis is detailed in the LITFL CCC (https://lifeinthefastlane.com/ccc/sepsis-definitions/). Key elements to note:
Initial management is detailed in the LITFL CCC (https://lifeinthefastlane.com/ccc/initial-sepsis-management/) under these headings:
What specific considerations are there in the oncology patient?
Likely sources of sepsis
Differences in the manifestations/ recognition of sepsis occur as oncology patients, and immunosuppressed patients, may lack normal inflammatory response
Effect of ICU/ critical illness on cancer
Sepsis may directly impact on tumour growth (Staudinger and Pene, 2014)
Many ICU drugs are thought to promote neoplastic growth:
Critical illness may:
Should a young patient with metastatic cancer be “for resuscitation”? How much is “too much”?
Key considerations
How certain is the information we have?
What does ”metastatic cancer” mean? Is the chemotherapy curative or palliative?
What is the advice of the consultants and “where are they coming from”?
What are the patient values?
In most situations, the prognosis of the critical illness overrides the prognosis of the oncological diagnosis
Why might attempts at intubation with video laryngoscopy fail, and how should we manage this?
Key considerations
Failed airway algorithm – “ensure first attempt is best possible attempt”, for example:
How to optimise intubation attempts using the “STOPME” mnemonic:
Remember that DL commonly rescues VL, and vice versa! It makes sense to use a standard geometry VL blade that can also be used for DL, in most circumstances.
Specific reasons for failure of VL technique (see LITFL CCC for a description of video laryngoscopy: (https://lifeinthefastlane.com/ccc/video-laryngoscopy/)
Potential reasons for failure in this case based on the limited vignette alone (using STEPS and GPAS approaches)
STEPS approach:
Self/ Team Leader
Team
Environment
Patient
System
GPAS approach:
Goal
Plan (Strategy)
Actions (Tactics)
Skills
References
Biskup E, Cai F, Vetter M, Marsch S. Oncological patients in the intensive care unit: prognosis, decision-making, therapies and end-of-life care. Swiss Med Wkly. 2017;147:w14481. [article]
Champigneulle B, Cariou A, Vincent F. Cardiopulmonary Resuscitation and Benefit to Patients With Metastatic Cancer. JAMA Intern Med. 2016;176(1):142. [article]
De jonge E, Bos MM. Patients with cancer on the ICU: the times they are changing. Crit Care. 2009;13(2):122. [article]
Kiehl MG, Beutel G, Böll B, et al. Consensus statement for cancer patients requiring intensive care support. Ann Hematol. 2018;97(7):1271-1282. [article]
Mack JW et al. End-of-Life Care Discussions Among Patients With Advanced Cancer. A Cohort Study. Ann Intern Med 2012;156:204-210. [article]
Nassar AP, Dettino ALA, Amendola CP, Dos santos RA, Forte DN, Caruso P. Oncologists’ and Intensivists’ Attitudes Toward the Care of Critically Ill Patients with Cancer. J Intensive Care Med. 2017;:885066617716105. [article]
Nickson CP. Sepsis Definitions and Diagnosis. LITFL Critical Care Compendium. Available at URL: https://lifeinthefastlane.com/ccc/sepsis-definitions/ [Accessed 14 December 2018]
Nickson CP. Patients and Families that “want everything done”. LITFL Critical Care Compendium. Available at URL: https://lifeinthefastlane.com/ccc/patients-families-want-everything-done/ [Accessed 14 December 2018]
Nickson CP. Initial sepsis management. LITFL Critical Care Compendium. Available at URL: https://lifeinthefastlane.com/ccc/initial-sepsis-management/ [Accessed 14 December 2018]
Nickson CP. Hemophagocytic lymphohistiocytosis (HLH). LITFL Critical Care Compendium. Available at URL: https://lifeinthefastlane.com/ccc/haemophagocytic-lymphohistiocytosis-hlh/ [Accessed 14 December 2018]
Sehatzadeh S. Cardiopulmonary Resuscitation in Patients With Terminal Illness: An Evidence-Based Analysis. Ont Health Technol Assess Ser. 2014;14(15):1-38. [article]
Staudinger T, Pène F. Current insights into severe sepsis in cancer patients. Rev Bras Ter Intensiva. 2014;26(4):335-8. [article]
This is the second hypothetical case discussion based on real cases submitted to the Resuscitology Team for analysis and debrief on the Resuscitology Course. Course participants are asked: “Please describe a resuscitation case that you have been involved in or witnessed that you feel (a) either had great learning points for other people on the course or (b) you feel didn’t go as well as it should and would appreciate the chance to analyse and discuss it.”
Case details are removed or altered to guarantee anonymity and confidentiality while preserving learning points. Cases are shared with the permission of the submitting clinician.
This case discussion was facilitated and summarised by Cliff Reid
60 year old male with End Stage Renal Disease (ESRD). Admitted to ICU after a MET call for possible sepsis.A formal echo showed severe LV systolic dysfunction, severe aortic stenosis, and RV dysfunction.
Three hours into the ICU admission he became peri-arrest. He was grey in colour, distressed and c/o central chest pain or pressure. He became hypotensive and was peri-arrest for about one hour, then arrested.
The patient’s young family was outside watching and crying. We had a lot of staff in the room and outside helping. Possibly too many, but it was useful to have a good line up for CPR. An airway was established early on in the code. And the person on the airway was watching the art line and ETCO2 for effective CPR and providing some coaching. It was chaotic, but we had good role allocation.
The cardiac arrest resuscitation lasted 30 minutes before being discontinued. He was mostly in a non-shockable rhythm.
There was a comment made afterwards, a concern by the person doing airway that he may have been aware/semi-conscious during part of the arrest.
Resuscitology Discussion Points
1. Cardiac arrest in ESRD patients.
The prognosis from cardiac arrests is even worse in patients with kidney dysfunction in which survival probability decreases with a declining GFR. Among patients with ESRD who have a witnessed cardiac arrest at an outpatient dialysis facility, more than three-quarters are not discharged alive from the hospital. Structural and electrophysiologic remodeling of the heart, vascular calcification and fibrosis, autonomic dysregulation, and volume and electrolyte shifts are some of the underlying processes thought to explain the increased predisposition for sudden cardiac death in people with chronic kidney disease.(1)
2. Establishing goals of care
This patient has significant co-morbidity and severe physiological derangement and is therefore likely to have a grim prognosis. It is key to establish the patient’s wishes and minimise unnecessary suffering or futile interventions. On the other hand, curable causes of deterioration such as sepsis or pulmonary embolism may be present and early aggressive resuscitation and investigation are likely to be appropriate for this chronologically relatively young patient.
Often a parallel approach is required: aggressive resuscitation at the bedside and a concurrent discussion about the patient’s wishes with the relatives. A useful question to pose to relatives, used by Chris Nickson (often more appropriate further along into an ICU stay) is: “If he could talk to us now, what would he say about this?”
3. Likely causes of his arrest and their prevention / management
The underlying causes of haemodynamic deterioration can be rapidly differentiated into problems of relative or absolute hypovolaemia, pump dysfunction, or obstructive causes (pulmonary embolism, tamponade, tension pneumothorax)(2). Clinical assessment combined with point of care ultrasound (POCUS) allows immediate selection of fluids, vasopressors, inotropes, cardiac management, or surgical or decompressive procedures. An early blood gas can identify haemodynamically significant electrolyte derangement, in particular ionised hypocalcaemia.
In this patient’s case the presence of both severe aortic stenosis and right ventricular dysfunction contribute to significant haemodynamic management challenges. He may require emergent procedural intervention such as balloon aortic valvuloplasty and senior intensive care, cardiothoracic, and cardiology personnel would need to be mobilised. In a non-tertiary centre or middle-of-the-night scenario this could bring its own challenges and frustrations.
4. Team and communication factors
Following admission to ICU, he was peri-arrest for around one hour prior to arresting. The management of a crashing hypotensive patient like this requires a team approach and an appropriate degree of resuscitative momentum. It is critical that senior doctors and nurses are mobilised to the bedside and that the mental model is shared that immediate resuscitation is required. If this is not happening then appropriately assertive but non-judgmental / non-confrontational language should be used by the nursing or junior medical staff to highlight the urgency of the case. Examples are:
5. Management of the cardiac arrest on the ICU
The presence of invasive arterial monitoring allows chest compressions to be optimised in terms of location, rate and depth to titrate to an optimal diastolic blood pressure to support coronary perfusion. It allows early identification of ROSC and also titration of vasopressor doses to a target blood pressure rather than blindly administering 1mg doses of adrenaline (3). Continuous waveform capnography allows identification of tracheal tube placement and, like arterial blood pressure monitoring, can assist in optimisation of chest compressions, and identification of ROSC.
Crowd control is important. As additional team members arrive at different times but all wanting information regarding the case and their role, it can be helpful to allocate a ‘meet and greet’ person to update them and to protect the team leader from distraction. This ‘Resus Marshal’ can also police the number of people at the bedside and ensure non-contributors remain ‘behind the line’.
6. The ‘awake’ CPR patient
If CPR is sufficiently effective to perfuse the brain (its goal) then awareness and even full consciousness is possible. This has certainly been witnessed many times with mechanical CPR devices. While it is likely that staff may be more likely to remember this than the patient, the inevitable discomfort and distress can be mitigated with sedatives and analgesics. Ketamine provides both and would be the recommendation of most of the Resuscitology faculty. Fentanyl and/or midazolam may be considered as alternatives or in addition to ketamine. Some services have developed protocols for this situation(4).
7. Learning as a team from suboptimal cases
A full debrief is ideal but often hard to achieve. A ‘hot debrief’, conducted briefly by the team immediately after the event, can identify learning points and also review what worked well, leading to action points to take forward. Once such method is the ‘STOP 5’ debrief developed in Edinburgh by Dr Craig Walker’s team. A version used in Sydney is shown here:
References
1. I.R. Whitman, H.I. Feldman, R. Deo. CKD and sudden cardiac death: epidemiology, mechanisms, and therapeutic approaches. J Am Soc Nephrol, 23 (2012), pp. 1929-1939
2. Desbiens NA. Simplifying the diagnosis and management of pulseless electrical activity in adults: a qualitative review. Crit Care Med 2008;36(2):391-6
3. Meaney PA, Bobrow BJ, Mancini ME, Christenson J, de Caen AR, Bhanji F, et al. Cardiopulmonary Resuscitation Quality: Improving Cardiac Resuscitation Outcomes Both Inside and Outside the Hospital: A Consensus Statement From the American Heart Association. Circulation. 2013 Jul 22;128(4):417–35
4. Rice DT, Nudell NG, Habrat DA, Smith JE, Ernest EV. CPR induced consciousness: It’s time for sedation protocols for this growing population. Resuscitation. 2016 Jun;103:e15–6
This is the first of a regular posting of hypothetical cases based on real cases submitted to the Resuscitology Team for analysis and debrief on the Resuscitology Course. Course participants are asked: “Please describe a resuscitation case that you have been involved in or witnessed that you feel (a) either had great learning points for other people on the course or (b) you feel didn’t go as well as it should and would appreciate the chance to analyse and discuss it.”
Case details are removed or altered to guarantee anonymity and confidentiality while preserving learning points. Cases are shared with the permission of the submitting clinician.
This case discussion was facilitated and summarised by Chris Nickson
Male in his 20s, Motorcycle accident. No pre-arrival notification. Arrived in very busy ED (2 arrests ongoing including a paediatric arrest). Traumatic brain injury and cardiac arrest at scene then ROSC.
Patient suffered devastating head injury and severe chest trauma. Profoundly hypoxic, with SpO2 persistently in the 70s despite being intubated on 100% oxygen with bilateral intercostal catheters.
The CT showed severe subarachnoid haemorrhage and fractured skull and tonsillar herniation (coning). The patient’s (English speaking) family was overseas. It was a highly emotive situation with 3 cardiac arrests in ED within an hour.
Clinical Priorities in the Resus Room
The overall goals in this scenario include:
Aggressive resuscitation of a patient who is suspected to have non-survivable injuries can cause individual cognitive dissonance and tension within the team. In general, it is important to “resuscitate before you prognosticate”. It may help to explicitly state and acknowledge this openly with the team, e.g. “Team, this is a difficult situation. The patient may have non-survivable injuries, we need to determine this as soon as possible. Until we know for sure, we will resuscitate him as best we can.”
Causes of hypoxia in major trauma
In an intubated patient always remember to check DOPES first:
Patient factors in this case can be:
Causes of hypoxia resulting from major trauma include:
In Traumatic Brain Injury (TBI), proposed mechanisms of hypoxia (apart from brain impact apnea) include:
Brain impact apnoea is a potential cause of death immediately after TBI. Such patients may have a normal, or near normal, CT brain and if adequately supported can make a full recovery. Without intervention, apnoea may lead to death.
Management of refractory hypoxaemia in a TBI patient
Observational studies consistently show that hypoxaemia is associated with worse outcomes including increased mortality following severe TBI. Evidence of harm from hyperoxia is less consistent. Current BTF guidelines do not specify a target SpO2 for severe TBI.
A step-wise approach to post-intubation hypoxaemia is described in LITFL’s Critical Care Compendium. Lung recruitment manoeuvres are controversial, and have primarily been studied as part of an open lung approach to mechanical ventilation in ARDS. They are worth considering as a rescue technique for refractory hypoxaemia with lung infiltrates as they can sometimes elicit a physiological response, even in the absence of ARDS (e.g. lung collapse), though it is uncertain if they improve patient outcomes. There are numerous other ways to improve oxygenation in ARDS, some of which could be considered in non-ARDS patients.
Unless there is obstructive lung disease (e.g. asthma, COPD), a protective lung ventilation strategy is generally appropriate for both ARDS and non-ARDS patients (e.g. patients with pulmonary contusions). For example, low tidal volumes (4-8 mL/kg PBW with plateau pressures <30 cmH20). However, this approach typically allows for permissive hypercapnia, which is not optimal for TBI patients as hypercapnia promotes cerebral vasodilatation and raised intracranial pressure (ICP) (Della Torre et al, 2017). High PEEP settings can be used to treat hypoxia in TBI patients, despite a raised ICP. However, excessive PEEP sometimes worsens oxygenation (e.g. overdistention in unilateral disease may increase shunt). In lungs with normal compliance, usually no more than 25% of the PEEP is transmitted to the central veins. In poorly compliant lungs (e.g. ARDS) very little PEEP is transmitted to the ICP. A small study found that PEEP up to 15 cmH20 has minimal changes in ICP and no change in CPP with normal lungs (McGuire et al, 1997). Furthermore, another small study showed that PEEP up to 15 cmH20 improves brain tissue oxygenation in severe TBI patients with ARDS (Nemar et al, 2017). A greater concern is the effect of PEEP on haemodynamics (Doblar et al, 1981). High PEEP – especially in hypovolaemic patients (e.g. haemorrhage) and patients with right heart failure – can decrease venous return, decreasing cardiac output and MAP. The decrease in MAP will decrease CPP and contribute to secondary insults in TBI. However, the decrease in MAP from PEEP can usually be prevented or corrected by appropriate use of vasopressors (e.g. noradrenaline) and fluid resuscitation (e.g. blood in a trauma patient). Overall, a PEEP of 15 cmH20 appears safe in TBI patients, and higher levels of PEEP could be considered in patients with refractory hypoxaemia as the harm from hypoxaemia may outweigh the potential harm from raised ICP and correctable effects on MAP.
In TBI, maintain cerebral perfusion pressure (CPP = MAP – ICP) in usual ways and decrease O2 consumption:
Head at 30 degrees (or greater if severely increased ICP) Avoid neck constrictions (e.g. loosen C-spine collar and ETT ties if needed)
Resuscitation room palliation
The CEASE mnemonic has been proposed as a systematic approach to discontinuing resuscitation:
The decision to take the patient to the CT scan, even with suboptimal oxygen saturations, is appropriate.
Attempts to optimise oxygenation should be time-specified and task-specified. If all reasonable options have been tried, and sufficient time allowed to check for improvement, then it is important not to “flail” but to proceed to the next step (CT brain to confirm diagnosis and guide ongoing management).
The mantra “resuscitate before you prognosticate” applies. In this situation, there may be tension in the team between ongoing attempts at aggressive resuscitation and the expectation of probable palliation. Aggressive therapy should continue until the appropriateness of palliation is confirmed. Furthermore, if the patient’s wish was to be an organ donor, ongoing organ support will be in the patient’s interest even after brain death.
Prognosis is always challenging, and should involve a neurosurgical opinion. We should avoid giving up hope purely on the basis of “bilaterally fixed dilated pupils”, because favourable outcomes are possible (Scotter et al, 2015) (especially if an extradural haemorrhage is present).
Palliation can be performed in the emergency department, but suitability is context-dependent (e.g. clinical suitability, how busy the ED is, available quiet space and meeting rooms, family dynamics, etc). Transfer to ICU for ongoing care and/or consideration of organ donation may be appropriate.
Breaking Bad News on the Telephone
The first rule of breaking bad news is: do not do it over the phone. However, in some situations – such as family being overseas – it is unavoidable.
Here is an approach:
Hot tip (from Vera Sistenich):
The VitalTalk app (and website) is very useful for helping to develop your communication skills about serious illness with patients and families.
Team Debrief and Counselling
After an arrest, make sure loose ends are TIED up:
You might also want to conduct a “pause”. Taking a moment as a team to acknowledge the life of the person who has died and the efforts of the team in trying to save them.
“Team check” means checking in on how team members are coping. They may say they are fine, but look for signs of stress or distress. If present, affected team members may need to take a break or even go home early.
An approach to “hot debriefs” (immediately after the event), along with links to references on the topic, is described on INTENSIVE. “Closing the loop” after the “hot debrief” should include checking in on people affected by the event and providing access to counselling, following up a patient’s outcome, reporting a sentinel event, or instigating a guideline change.
References
Bartels J. About the Medical Pause. ThePause.me. Accessed 12 May 2018. Available at URL: https://thepause.me/2015/10/01/about-the-medical-pause/
Della Torre V, Badenes R, Corradi F, et al. Acute respiratory distress syndrome in traumatic brain injury: how do we manage it?. J Thorac Dis. 2017;9(12):5368-5381. Available at URL: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5756968/
Doblar DD, Santiago TV, Kahn AU, Edelman NH. The effect of positive end-expiratory pressure ventilation (PEEP) on cerebral blood flow and cerebrospinal fluid pressure in goats. Anesthesiology. 1981;55(3):244-50. [pubmed]
Mcguire G, Crossley D, Richards J, Wong D. Effects of varying levels of positive end-expiratory pressure on intracranial pressure and cerebral perfusion pressure. Crit Care Med. 1997;25(6):1059-62. [pubmed]
Nemer SN, Caldeira JB, Santos RG, et al. Effects of positive end-expiratory pressure on brain tissue oxygen pressure of severe traumatic brain injury patients with acute respiratory distress syndrome: A pilot study. J Crit Care. 2015;30(6):1263-6. [pubmed]
Nickson CP. Brain Impact Apnoea. Critical Care Compendium, Lifeinthefastlane.com. Accessed12 May 2018. Available at URL: https://lifeinthefastlane.com/ccc/brain-impact-apnoea/
Nickson CP. Brain Impact Apnoea. Critical Care Compendium, Lifeinthefastlane.com. Accessed 12 May 2018. Available at URL: https://lifeinthefastlane.com/ccc/oxygen-saturation-targets-critical-care/
Nickson CP. Amazing and Awesome “Hot Debriefs” after Critical Incidents. INTENSIVEblog.com. Accessed 12 May 2018. Available at URL: http://intensiveblog.com/amazing-awesome-hot-debriefs-critical-incidents/
Nickson CP. Lung recruitment manoevres. Critical Care Compendium, Lifeinthefastlane.com. Accessed 12 May 2018. Available at URL: https://lifeinthefastlane.com/ccc/recruitment-manoeuvres-in-ards/
Nickson CP. Platypnea-Orthodeoxia Syndrome. Critical Care Compendium, Lifeinthefastlane.com. Accessed 12 May 2018. Available at URL: https://lifeinthefastlane.com/ccc/platypnea-orthodeoxia-syndrome/
Nickson CP. Post-intubation hypoxia. Critical Care Compendium, Lifeinthefastlane.com. Accessed 12 May 2018. Available at URL: https://lifeinthefastlane.com/ccc/post-intubation-hypoxia/
Nickson CP. Improving Oxygenation in ARDS. Critical Care Compendium, Lifeinthefastlane.com. Accessed 12 May 2018. Available at URL: https://lifeinthefastlane.com/ccc/improving-oxygenation-in-ards/
Nickson CP. Breaking Bad News to Relatives. Critical Care Compendium, Lifeinthefastlane.com. Accessed 12 May 2018. Available at URL: https://lifeinthefastlane.com/ccc/breaking-bad-news-relatives/
Nickson CP. Protective Lung Ventilation. Critical Care Compendium, Lifeinthefastlane.com. Accessed 12 May 2018. Available at URL: https://lifeinthefastlane.com/ccc/protective-lung-ventilation/
Scotter J, Hendrickson S, Marcus HJ, Wilson MH. Prognosis of patients with bilateral fixed dilated pupils secondary to traumatic extradural or subdural haematoma who undergo surgery: a systematic review and meta-analysis. Emerg Med J. 2015;32(8):654-9. [pubmed]
Torke AM, Bledsoe P, Wocial LD, Bosslet GT, Helft PR. CEASE: a guide for clinicians on how to stop resuscitation efforts. Ann Am Thorac Soc. 2015;12(3):440-5. Available at URL: https://www.atsjournals.org/doi/full/10.1513/AnnalsATS.201412-552PS