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MRI Critical Care Teaching - PBL Case 1. Luka Randic. Case 1. 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.
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MRI Critical Care Teaching - PBL Case 1 Luka Randic
Case 1 • 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.
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?
Case 1 • 12 lead ECG: • SR120, normal QRS & QTc. • ABG: • pH 7.38, p02 13.7, 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?
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.
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).
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.
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.
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.
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…
TCA OD case group learning points? General OD mangment ED management Transfers ICU managment
TCA learning points • Toxicity with >5mg/kg, severe toxicity with 10-20mg/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.