Thread by @IM_Crit_

ICU stories (from the trenches): It's been a bit more than 2 hrs in your night shift & you are checking some labs signed out to you to be followed on. A rapid response is called for "agitation" in Rm 666; in less than a minute the operator calls for a "Code Blue" in the same room

When u arrive @ the code, u see a very young pt white as a sheet w CPR in progress. Presented to ED 12 h earlier c/o non-bloody emesis & abd pain x 1 wk. Uses daily NSAIDs for chronic pain. Vitals in ED: 125/77, HR 125, Hb 7.9 g/dl. Guaiac(+) stools. Vitals improved w hydration

and EGD was performed that showed "normal esophagus, large amount of food in the stomach, 6 mm non-bleeding antral ulcer & a large non-bleeding duodenal bulb ulcer". Evaluation was thought to be "limited" & plan was to repeat EGD next am. Back to the code, which is a PEA arrest

Pt has one 22g peripheral iv of "questionable functionality" & no IO is available. While Anesth intubate, a RN places another piv (and then people say that miracles don't happen...). Epi is pushed a couple of times & NS is "bolused" (what can you bolus from 22g?). Pulses

are felt after 5 min of CPR. I hope you have realized that pt is bleeding to death and your night will be long, right? What will be your next step? Anesthesia walking away & you are "alone"; no fellows, residents, NPs/PAs. Will you?

No right answer... Pt will probably code again because the underlying cause has not been addressed. An important skill in these scenarios is "situational awareness". U have to "read the room". I prefer to bring the pt to the ICU where I have the "home court advantage". Next step?

Trust me, you will be of little help when pt codes in the elevator. You better go back to the ICU & get things ready. Sure enough, less than a minute after pt arrives in the ICU room, pulses are lost again. CPR starts & epi is pushed. While monitor leads are attached,

& you get ready for line placement, you see this 👇 in the canister connected to the nasogastric tube. The diagnosis has been confirmed:

In this case @ThinkingCC, I was hoping I could place a #REBOA (Resuscitative endovascular balloon occlusion of the aorta) but not available. So, what line should we place first?

Even though in cardiac arrest an arterial line can be very helpful (must read @emcrit 's posts), you do know what this pt is dying from & will "keep dying" if you don't fill the tank... So you have to start with a big venous catheter. And then the arterial line. And then what?

While you ask the charge RN to activate the "massive transfusion protocol", u drape & clean the R groin. This is not the time to play around in multiple sites. Place first whatever big iv you have (8.5Fr introducer sheath in this case), so u can start reliable fluid resuscitation

You will need more than 1 venous catheter because the patient will need sedation, pressors, pantoprazole etc... One big line for blood/"volume", another multi-lumen cath for "drips" and an arterial line. The femoral vessels at the end will look (and looked) like this:

While you are placing the lines, they show to you (you know that "multitasking" is in our job description, right?) a venous blood gas drawn immediately post-arrest:

pH 6.5 & lactate of 30 mmol/l. This is what the ICUs are for... After more epi pushes & bicarb & Ca, pt has ROSC, is receiving levo 0.5 mcg/kg/min & vaso 0.2 u/min. Blood already started (give it fast w rapid infuser, not 999 ml/hr...). Twenty minutes later, ABG a bit better:

(Please ignore Hb/K values in blood gas. Not accurate). After pt is lined, catecholaminized & transfused, almost always you will have to talk to IR/GI/GenSurg. Include ALL of them in the same message to save time & to have everybody on the same page. IR next:

Active bleeding noted from a branch point of the gastroduodenal artery & the common hepatic artery. Coils were deployed. Bleeding controlled. Pressors titrated down fast. The anatomy is 👇 but variations can make things complicated:

Next am, pt w recurrent GI bleed & underwent repeat angio (no active bleeding) + EGD (too much blood; no view). 25 u of blood later: transferred to the flagship hospital. Developed AKI (requiring CRRT) & shock liver. The next 2 wks underwent R hemicolectomy for necrotic colon w

pericolonic pus, distal gastrectomy for duodenal perf, creation of gastrojejunostomy/end-ileostomy etc etc. Several intra-abd abscesses, drained by IR. Spent > 3 months in the hospital. Six months later: at home, eating, normal renal fx, drains removed... Happy end, hopefully...

Thanks for reading!

#FOAMed #FOAMcc #MedTwitter #MedEd #MedStudentTwitter @msiuba @HeyDrNik @NickjohnsonMD @TaotePOCUS @nickmmark @cjosephy @KalagaraHari @critconcepts @MediCasos @FisioPocus @MegriMohammed @emily_fri @EricCD10

Take-home messages:
1. You cannot practice Critical Care without good iv access
2. When you step into a disaster outside the ICU, you have to decide fast if you will stay and play (and pray) or scoop and run
3. Know your resources and use them
4. The dose of vasopressin for

massive upper GI bleeding is NOT the same as the one used in sepsis. Use an infusion rate of 0.15 - 0.4 u/min iv (not 0.03-0.04)
5. In these vasopressin doses, the use of proton pump inhibitors does not add much. The gastric acid secretion will have been inhibited

6. In cases of severe GI bleeding, ppi drip will not save the patient. Despite what your attending is telling you, ppi drip is not better than ppi twice a day…

7. The blood urea nitrogen (BUN)/creatinine ratio is considered a good predictor of active GI bleeding (I use it too…). But no test is perfect. See how it evolved in this patient:

Bonus "stuff":

1. I know, every case needs a bit of POCUS... This was patient's abdomen US:

Correct, bowel loops were full of blood...

2. A few minutes after ICU arrival with the lines in place and just pressors infusing at industrial doses (hundreds cc/hr), the new femoral art line (flushed; working well) had this waveform:

Please notice that we could not get pulse ox (pt VERY cold/vasoconstricted). It seems that not every QRS is followed by an arterial waveform. Why?

Let's ask @msiuba @khaycock2 @ArgaizR @vaszochios @iceman_ex