Need opinions on difficult code

[EDRN522]

Pt is a female in her 60s, presents to ecc complaining of generalized weakness, anorexia, nausea, vomiting, generalized abdominal discomfort, and weight loss x 6 months.

History of hypertension and chronic back pain. Only home medication is lorcet which pt admits to taking every hour for an unknown length of time in an attempt for pain relief.

Initial vital signs: temp 98.5F oral, HR 120s-140s atrial fibrillation, BP 150s/100s, RR 20, SPO2 98% on room air.

On exam pt appears cachexic, jaundiced, is alert and oriented to person place and time but clearly has some confusion as demonstrated by not knowing how long she was taking the extra lorcet tabs, peripheral pulses, no cardiac murmurs noted, lungs clear bilaterally, bowel sounds normoactive in all 4 quadtants, no tenderness or obvious masses on palpation of the abdomen, +2 pitting edema to bilateral lower extremities, denies trauma.

Abnormal labs: potassium 1.7 (this was rechecked on the same sample and a new sample was sent to triple check), bili 3, hemoglobin 10, creatinine 2.4, acetaminophen 5.

Normal labs: wbc, ast, alt, magnesium, calcium.

Pending labs: hepatitis panel, hiv.

Per poison control as ast and alt are normal chronic acetaminophen overdose causing jaundice is not possible

Potassium replacement is started about 1hr into pts stay: 40meq in 1L NS at 500mls/hr into each arm (1000mls/hr of this solution total), 2G magnesium sulfate given. At this point pt has 22G bil forearms and 18G R ac.

Ultrasound RUQ and CT abd/pelvis ordered but are deferred due to concerns from rn and md of pt having a lethal arrhythmia outside of the ecc.

1hr after potassium replacement is started level is rechecked and found to be 2.3 (2 hours into pts stay)

3 hrs into pts stay pt was assisted onto bedpan, immediately lost consciousness for ~15 seconds, did not lose pulse but HR decreased to the 50s during this period, remained atrial fibrillation. Pt was then able to wake up and speak to staff but was clearly "in a fog", GCS 14, vitals essentially same as arrival.

3.5 hours into pts stay: md and rn at bedside, pt is acting same as 1/2 hour ago, pt has sudden decrease in loc, GCS 5, HR 50s atrial fibrillation, BP 80s/40s, pulse present. Pt is ambu bagged while being moved to trauma room. Pt lost a pulse, PEA on monitor, BLS and ACLS measures started, humeral IO, intubated (moderate amount of blood required suctioning), and femoral triple lumen placed. Along with the usual acls meds, pt recieved 80meq iv potassium bolus, 6g iv magnesium sulfate, and 120mg succinylcholine. At one point pts rhythm was vtach to torsades and was defibrillated at 200joules with conversion to PEA. Pt was declared dead after 30 minutes and a bedside ultrasound showing no cardiac activity.

I'm having a hard time with this case because we never really found out what was wrong with this pt. Unsure why pt coded, undiagnosed pancreatic cancer, aggressive potassium replacement, hypokalemia, acetaminophen overdose, or other cause? Thoughts?

[PeakRN]

Potassium releases myocardial contraction. Low K leads to ectopy but typically not something you would ever give that aggressively. We don't replace more than 1meq/kg/hour to a max of 20meq.

You noted a wide complex dysrhythmia and didn't give a amio or lido?

You drilled an IO when you had two working IVs?

You were concerned that the patient was too sick for CT but sat in the department for three and a half hours without being admitted to the ICU?

I don't know if I would be publicly telling this story.

[EDRN522]

My facility gives up to 40meq/hr on cardiac monitored critical care beds.

Wide complex dysrhythmia was treated with electrical therapy first per ALCS guidelines. After defibrillation rhythm was PEA, no reason to give lido or amio at that point.

Humeral IOs can be infused with up to 6L/min under pressure, necessary for rapid fluid resuscitation on this pt.

Pts sitting in the ECC when beds are unavailable is a nationwide issue I believe.

I don't appreciate the negativity at the end. This is an anonymous forum and I am looking for outsider perspective. Thank you for your feedback.

[JKL33]

Does your facility undertake debriefing routinely? I think you should talk to your educator/manager about it. It's ridiculous to think that we would just run around from one tragic thing to another without concerning ourselves with the type of things that are bothering you.

[traumaRUs, MSN, APRN]

Critical incident stress debriefing is definitely needed here. I'm sure the woman had an autopsy? Have you talked to the coroner?

[eacue]

Based on the OP, it would be hard to tell immediately why the patient crashed, they could have had a bleed, septic shock, heart failure, I mean who knows. However I must ask, if the patient was in PEA, why did you give succs? according to your post the pt was already dead. This reminds me of a time I went to a code on the floor and primary RN said pt is in Asystole and charged the zoll, she was quickly asked to leave the room. Another time during a code the pt's belly was about to blow and I warned my coworkers, the PA running the code offered us Zofran...she was also asked to leave the room.

I think your ER needs to run some mock codes TBH. You don't give a paralytic to a patient that's already dead, honestly an RN should have caught that and stopped the MD. Other than that I wouldn't stress it, sometimes its just that time.

[PeakRN]

On 8/2/2019 at 9:49 PM, EDRN522 said:

My facility gives up to 40meq/hr on cardiac monitored critical care beds.

Wide complex dysrhythmia was treated with electrical therapy first per ALCS guidelines. After defibrillation rhythm was PEA, no reason to give lido or amio at that point.

Humeral IOs can be infused with up to 6L/min under pressure, necessary for rapid fluid resuscitation on this pt.

Pts sitting in the ECC when beds are unavailable is a nationwide issue I believe.

I don't appreciate the negativity at the end. This is an anonymous forum and I am looking for outsider perspective. Thank you for your feedback.

Unless a patient is dumping potassium and has tolerated incrementally larger doses then I highly doubt that a rate faster than 20 an hour will be safe. Just because you have a policy doesn't mean you are doing the right thing.

The average adult has 50-70 meq of K total in their body, and you gave her 120 meq during her ED course. You don't know what her intracellular K actually is, you easily could have removed her ability to squeeze (see PEA, also cardioplegia).

The last time I checked, the AHA doesn't recommend pushing 80meq of K or 6 grams of mag, so I wouldn't be so quick to shut down the idea of lido or amio early in arrest because of 'acls guidelines'.

You have an 18 gauge which flows at about 90 mL/minute (5.4 L/hour) with one meter of elevation, and over 200ml/minute on a rapid infuser. Also if your worried the patient is hypokalemic then why flood her with fluids. Not every resuscitation requires massive fluid resuscitation, and can often be detrimental.

At our center we do not hold ICU patients in the ED. If we can't get a bed in our hospital then we will transfer to another, preferably to a sister hospital but I've sent some to outside systems.

To your original post I would guess the patient probably deteriorated and died due to an endocrine/metabolic or neurological etiology (whether it be oncogenic, some kind of endocrine storm, an imbalance due to her anorexic state or whatever else). If your are not extremely careful managing these patients they very quickly can deteriorate (see refeeding syndrome).

Even though this site is anonymous if some family member finds your post and wants to figure out who you are they can potentially have the court subpoena this site's data records, and rather easily track IP addresses. I wasn't trying to be rude, I was trying to give you some insight.

[momoneypls, RN]

At my facility, the MD's find out from coroner what was the cause of death and hold an informal M/M meeting monthly to discuss. It helps us out and allows some kind of closure; I feel we learn a lot as a group and it helps our teamwork.

We also hold ICU patients for WAY longer than we should. We never divert, and take all-comers from different counties.

I hear you with the negativity comments, btw. I think your question should be answered in a more pragmatic, positive manner than what I've seen posted here. A code is a team event, and not one nurse calling the shots. It is quick and often blind as we don't often know the cause for decompensation. A little understanding for OP would go far.

[medic 2 RN, ASN, RN, EMT-P]

On 7/31/2019 at 3:56 PM, EDRN522 said:

Along with the usual acls meds, pt recieved 80meq iv potassium bolus, 6g iv magnesium sulfate, and 120mg succinylcholine.

Am I reading this right that the pt was given 80 meq of potassium by IV push? Succs after she was in cardiac arrest?

[canoehead, BSN, RN]

She was building up to this for months, and in the ER K was replaced but her body had been compensating for low K and functioning. I know normal is defined within a certain range, but she was so low (probably for a long time) that I think she was replaced too fast. She was already fragile, and her body couldn't adjust as fast as you were fixing it.

It was a crap shoot- you can't leave her with a K of 1.7, she could arrest at any time, so you do your best for her and hope her body is strong enough to recover. It didn't work out. I'd really be pushing to review this case and get autopsy results.

[Guest219794]

You are looking for outside opinions. Don't get too defensive if some of these opinions second guess the treatment.

You mentioned sux in what seems to have been a pulseless pt.

Also, potassium bolus? I am a bit lost on this one. Is that a thing?

I know it is done in lethal injections, but haven't heard other indications. And mightn't the sux increase any potntial ill effects?