Thread by @WesElyMD

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.