Author: ICM Case Summaries

Sodium Bicarbonate in Amitriptyline Overdose

Sodium Bicarbonate in Amitriptyline Overdose

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A 40 year old man with pre-existing mental health problems presented after an overdose of 6g of amitriptyline. He was deeply unconscious and required invasive ventilation. He was commenced on bicarbonate therapy and hyperventilated to pH 7.5. Around 12 hours after admission he developed tonic-clonic seizures, a broad complex tachycardia and subsequently suffered a cardiac arrest that was refractory to defibrillation, adrenaline and amiodarone. He was given additional 8.4% bicarbonate and further defibrillation attempts and was successfully resuscitated after 90 minutes.

What is the rationale for the use of sodium bicarbonate in the management of amitriptyline overdose?Read More »

Tranexamic Acid in Trauma

Tranexamic Acid in Trauma

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A 19 year old man experienced a head on collision as the driver of a car. He suffered significant lower limb open fractures, pelvic fractures, lung injuries and a small subarachnoid bleed. Initial management was performed in ED and included oxygen, IV access and fluid, lower limb and spine immobilisation, and analgesia. He underwent a trauma series CT scan, which identified the various injuries given above. At no point was his level of consciousness a concern, and he maintained his own patent airway throughout. He did not show signs of haemodynamic instability or evidence of life threatening haemorrhage. Tranexamic acid (TXA) was not given.

What is the evidence for using tranexamic acid in trauma?

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Botulism

Botulism

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A young female IV drug abuser presented with dysarthria, diplopia and weakness with loss of her gag reflex. She had recently had an abscess wound on her arm debrided. She was intubated for airway protection, and underwent early tracheostomy. She was treated with intravenous antibiotics and botulism antitoxin after electromyography and nerve conduction studies were consistent with a diagnosis of botulism. She was weaned from the ventilator within 2 weeks and the Health Protection Agency later confirmed the presence of botulism neurotoxin A from wound swabs.

What are the clinical features of Botulism and how is it managed?Read More »

Loop Diuretics in Acute Kidney Injury

Loop Diuretics in Acute Kidney Injury

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A 65 year old woman underwent an elective mitral valve repair (MVR) and four vessel coronary artery bypass graft (CABG) procedure. Pre-operatively she was diagnosed with chronic kidney disease (CKD) secondary to hypertensive nephropathy, and chronic airway disease secondary to smoking. Her baseline creatinine was 275. Surgery was uneventful but in the post-operatively period she developed pulmonary oedema and worsening acute kidney injury (AKI). On day 2 her creatinine reached 420 and oliguria occurred (urine output < 0.5 ml kg-1 hr-1). Non-invasive respiratory ventilation provided adequate support and maintained a normal blood PaCO2 and pH, although her base excess drifted to -7 mmol l-1.Dopamine was administered at 2–10 μg kg-1 min-1, titrated to MAP ≧ 75 mmHg; pericardial pacing continued to maintain sinus rhythm at 60 bpm; her CVP was 14 mmHg and stable. Furosemide was started and given by a continuous infusion of 10 mg hr-1 after an initial bolus of 100 mg to try and help with diuresis.

Is there any evidence to support the use of loop diuretics in acute kidney injury?

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Proning for Refractory Hypoxaemia

Proning for Refractory Hypoxaemia

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A 60 yr old woman was admitted to the ICU with a severe community acquired pneumonia and septic shock. She was invasively ventilated with a lung protective strategy, optimised PEEP and recruitment manouvres as needed. Her refractory hypoxia persisted and so she was probed for 16 hours a day for the first 5 days of her admission. She made slow but steady improvements and was discharged from the ICU 10 days later.

What is the current evidence for proning as a rescue therapy for refractory hypoxia?Read More »

Tranexamic acid and rFVIIa in Major Obstetric Haemorrhage

Tranexamic acid and rFVIIa in Major Obstetric Haemorrhage

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A 40yr old multiparous woman required an emergency Caesarean section, during which she had a 3.5L blood loss requiring a B-Lynch suture, a Rusch balloon and 4 units of packed red cells. She suffered a further 1.5L postpartum vaginal bleed, returned to theatre and underwent a subtotal hysterectomy during which she received a massive transfusion. Postoperatively, she had a further 1.5L bleed and had a Rusch balloon reinserted. She was given recombinant Factor VIIa and regular tranexamic acid. Haemostasis was achieved and she left hospital with her healthy baby boy 8 days later.

What is the evidence for using recombinant FVIIa and antifibrinolytics in major obstetric haemorrhage?Read More »

Critical Care Echocardiography

Critical Care Echocardiography

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A 34 year old IV drug abuser was admitted with respiratory failure, bilateral patchy changes on chest X-ray, raised inflammatory markers and septic shock. She was intubated and commenced on antibiotics and noradrenaline. An in-house Focussed Intensive Care Echo was performed to guide fluid resuscitation. This was suggestive of hypovolaemia, but a large mobile mass was also observed in the left ventricular chamber. A departmental echo the next day confirmed the presence of a large vegetation on the anterior mitral valve leaflet with severe mitral regurgitation. She underwent a further period of stabilisation and underwent a mitral valve replacement.

What is the evidence for the development of in-house echocardiography skills within the critical care setting?Read More »

Glycaemic Control on the ICU

Glycaemic Control on the ICU

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A 76 year old man with no comorbidities was admitted to the intensive care unit following an oesophagectomy. During routine blood sugar monitoring, his blood glucose was found to be just over 10 for two consecutive readings so he was commenced on a variable rate insulin infusion. Six hours later, despite hourly monitoring, he had a blood sugar of 3.6. The insulin infusion was stopped and his blood sugar rose back to normal levels. He suffered no apparent ill effects from his hypoglycaemic episode.

What is the rationale behind current glycaemic control on the intensive care unit?Read More »

Neuroprognostication after Cardiac Arrest

Neuroprognostication after Cardiac Arrest

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A 30 year old man suffered a 30 minute cardiorespiratory arrest secondary to an asthma attack. He was resuscitated, had his severe bronchospasm managed and he was treated with therapeutic hypothermia at 33 degrees. Once rewarmed, his neurology was assessed over several days. He was ventilated on a spontaneous mode, but his pupils remained fixed and dilated and there was no higher motor function seen. A CT brain was consistent with severe hypoxic ischaemic injury. After discussion with the family, treatment was withdrawn.

How reliable is neuroprognostication after cardiac arrest? What modalities are tested? Is there a difference in patients treated with therapeutic hypothermia?

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Enteral vs Parenteral Feeding on ICU

Enteral vs Parenteral Feeding on ICU

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A middle aged woman presented with an acute abdomen. At laparotomy she was found to have generalised peritonitis secondary to small bowel perforation due to adhesional obstruction. She remained ventilated and on noradrenaline support for several days post-op. Trophic enteral feeds were introduced at 24hrs post-op, but NG aspirates remained high for a further 48 hours despite prokinetics. The decision was made to institute parenteral nutrition if no improvement at day 5 post-op, but was never commenced as NG aspirates improved and enteral nutrition was gradually increased.

What is the evidence for enteral versus parenteral feed as a source of nutrition in critical ill patients?Read More »