C & C June 18 – Case discussions

Hi all

Thanks Aaron, Hannah G, Colin K for showing up and engaging in good discussions.

Case 1 – Amiodarone for cardiac arrest secondary to TCA poisoning

Aaron will follow it up for us but the first question he asked was about the use of (or contraindication of) amiodarone for cardiac arrest secondary to TCA poisoning.

Our CPG gives guidance to increase sodium ion may be beneficial but no mentioning of the harm may be caused by amiodarone administration.


However, on page 114, we have clear guidelines around the use of amiodarone to avoid cardiac toxicity for VT secondary to TCA poisoning, thus the same principle should apply during cardiac arrest.


Case 2 – DKA

Hx: a farm worker 25yom with known T1DM, called in sick stating he is having some symptoms of typical hyperglycaemia episodes. His colleagues drove passed his house in the evening saw lights in the lounge assuming he was OK. No show the next morning and Pt was found unconscious on the floor.
Initial vitals = HR 45 sinus bradycardia, slightly wide QRS, RR 20~34, BP 70/40, SPO2 90% on RA, BGL Hi, Temp Lo, GCS 3

Heli was called to this property with approx 15 mins flight time.

Pt was treated with normal saline and oxygen by the ambulance crew prior to heli arrival.

Heli crew opted to RSI this patient and pre RSI vitals were = HR 45, RR 32, BP 110/60, SPO2 99% on O2, BGL Hi, Temp Lo, GCS 5 (E1, V1, M3).

Mistake 1 – Suxamethonium

Abnormal ECG was regarded mainly due to hypothermia. This patient was, yeah you guessed it, hyperkalaemic at 8.6!

Mistake 2 – Correcting etCo2

Crew opted to slow ventilation to correct etCo2 within “normal” range. Pt was compensating well by keeping up his respiration rate. Respiratory alkalosis to combat metabolic acidosis.

The biggest mistake – opted to RSI!

In this case, Pt had good airway, well oxygenated with basic airway techniques, and compensating well with Kussmaul respirations.
High risk RSI due to haemodynamic instability (although corrected reasonably well), as well having severe acidosis.

OK…this is only a brief key points and it may not make too much sense without digging it in a little deeper and to understand the DKA physiology.

Highly recommended to listen to the podcast that I thought it was created specific for this patient! This is the part 1 of a series of podcasts by Dr Scott Weingart titled “Laryngoscope as a Murder Weapon”!


Podcast 3 – Laryngoscope as a Murder Weapon (LAMW) Series – Ventilatory Kills – Intubating the patient with Severe Metabolic Acidosis


This series also covers other intubation killers that need to be screened, augmented prior to RSI so check it out!

Podcast 173 – LaMW – Oxygenation Kills Part I

Podcast 174 – LaMW – Oxygenation Kills Part II

Podcast 104 – Laryngoscope as a Murder Weapon (LAMW) Series – Hemodynamic Kills



2 Comments Add yours

  1. Tatsu Kuwasaki says:

    Thanks Hannah,
    Just in case you may have not listened to the podcast, Dr Tony Smith recommends that considering the lack of evidence for the theoretical contraindication, as well as the fact that cardiac arrest secondary to TCA poisoning is very rare in NZ, we should not complicate it but focus on delivering the highest quality resuscitation (amiodarone if persistent VT/VF) as per normal CPG.


  2. geehannah says:

    The latest podcast on the clinical wiki http://wiki.stjohn.org.nz/podcasts/cardiac-arrest-in-special-circumstances/ has a bit from Tony on administering Amiodarone in the case of cardiac arrest secondary to cyclic antidepressant poisoning.

    Liked by 1 person

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