1/🧵🎥 How do “Dominoes of life” fall in critical illness⁉️
A pt arrives awake & talking but vomiting. In just 8 hrs he nearly dies of sepsis 🤯
Lung & kidney failure, heart attack, coma.
How can this happen & can we save him?
This🧵can help us understand the “arc of illness”
2/ His disease is Ascending Cholangitis
A gall stone lands in his common bile duct
📍Pain & vomiting
📍He’s admitted to the ICU
📍GI performs an ERCP to place a stent, bypass the stone, drain pus & control the source of sepsis
📍Add fluids & antibiotics
📍But he gets worse
Why?
3/ We bypassed the septic source (stone) & drain the pus, but dominoes were already falling.
Bacteria had gotten into his blood.
Too much inflammation & capillary blood clotting occurred, just like in COVID.
What happens when “cellular” dominoes start to fall uncontrollably?
4/ Our bodies can’t work well without blood & O2.
His BP dropped (shock) & didn’t perfuse his vital organs, so his heart, lungs, kidneys, brain went down.
CXR👇shows a catheter in his heart to measure pressures.
NOTE: Not everyone so sick needs a ventilator (no ET tube on CXR)
5/ We found his “WEDGE PRESSURE” initially to be >20mm Hg, which is very high & indicated his shock was not purely septic.
Indeed, his Troponin peaked at a whopping 77.
A heart cath showed clean coronaries.
This was a stress-induced heart attack, not blocked arteries.
6/ Here is a good one-pager to learn about the Swan Ganz Catheter and right heart catheterization.
It’ll tell you what different measurements mean.
In his case, we used norepinephrine, vasopressin, sedation with dexmedetomidine & a little fentanyl.
7/ While he was in multi-organ dysfunction…
☑️ Our focus on the #A2Fbundle kept #humanism at the forefront of our game plan
☑️ Awake/alert, light sedation, mobilizing, family
☑️ We kept his daughter at the bedside
☑️ She helped him through a 48-hour period of #delirium
8/ Sepsis care today is very different than 20 yrs ago.
We improved it but then COVID brought antiquated practices like deep sedation & immobilization.
This man’s family advocated for him. Please do the same for your loved ones.
ICU Liberation data:
bit.ly/3elkHq2
9/Follow Up: He’s doing well, but #Recovery from Sepsis can take years.
He’s suffering from #PICS & 2 weeks later can’t walk yet.
He’ll attend support groups & get cognitive & physical rehab in his “new normal.”
Long COVID pts need similar programs‼️
bit.ly/3DhC6Xe
10/Pro-Tip quiz question:
My patient presented with Reynold’s Pentad. What is that?👇
#MedTwitter #MedicalResidency #medstudenttwitter
12/fin
Spiritual Rounds - 2 weeks following ICU discharge, I went to find my patient recovering ❤️🩹 from his sepsis.
He taught me all about the power of acceptance & being spiritually grounded. What a beautiful man. I thought I’d help him, but he helped me way more as usual.
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