FROM THE BLOGOSPHERE
BETTER TO BE LUCKY THAN
GOOD
Eric Yazel, MD
B
usy shift, so of course I get called to
a code in the ICU. I walk into the
room, 30ish y.o. IVDA hx, admitted
for sepsis, septic emboli, and ARDS. Stable
vital signs 10 minutes previously, now in
PEA (Pulseless Electrical Activity) arrest.
Already tubed and had a triple lumen. Not
a whole lot for me to add for immediate
stabilization since the patient had a secure
airway and access. Already had epi x1. Accucheck was 149 (never, never forget this
in a code).
So I immediately get to go to the second
phase and start thinking reversible causes.
With that history, all sorts of interesting
diagnoses on the playing field. The one
major thing I noticed was the patient was
extremely cyanotic from the upper chest on
up. CBC, lytes, cardiac enzymes from a few
hours ago essentially unremarkable aside
from a white count of 26. Coags normal.
Actually starting to kick around the idea of
empiric thrombolysis. All of a sudden, quick
run of v-fib, zap him with 200 and voila!
We have a pulse. I order a new rainbow of
labs, cxr, call his pulmonologist to recite my
efforts, and start to leave.
I sit down, take a deep breath, and head
to see another patient. And BOOM! Code
alarm goes off once again. Head back into
the room, next verse same as the first. PEA,
CPR in progress. No labs back. I have them
pull up the CXR.
I swear I listened to him during the first
code. Bilateral breath sounds (crappy, but
there). I listen again, knowing there is a
big pneumo, still can hear breath sounds.
Obvious tracheal deviation on the CXR,
also not overly apparent on physical exam.
Regardless, time to get moving. So I ask for
an angiocath and a chest tube set up - deer in
headlights, no one moves. Someone finally
scurries off to find a pleurovac and tube.
36
LOUISVILLE MEDICINE
Still waiting for
an angiocath, they
hand me something that looks like
something I’d LP a
10 day old with, not
gonna cut it. Finally they walk in with
this kit that looked
like they pulled off
a dusty shelf. Has
what looks like an
8 inch spinal needle
with a pigtail catheter already attached to it. That’s it. Nothing
else in the kit besides an adaptor to attach
to the pleuravac. Don’t have a lot of time to
search for anything else so I went with it.
Was actually really smooth- put the needle
into the chest cavity, pulled out the inner
cannula, heard the hiss and fed the pigtail. That’s it, working chest tube in place
in about the same time it would take to do
a needle decompression.
Aha - immediate return of pulse and
stable blood pressure. If I hadn’t ordered
or remembered to check th