2. Mr. XYZ, M/59  27th Feb 2012  Found collapse at home  Hstix ‘HI’ by ambulance crew  15:16  Triage, vitals BP 96/56, T 27.8 o C, response to pain  15:25  Cat 2, seen in resuscitation room

3.  15:30  Witnessed cardiac arrest in cubicle  Initial rhythm VF  Defibrillation x 1  1mg adrenaline given x 2  Down time 7 minutes  Intubated with #7.5 ETT

4. Past history 1.DM complicated with overt nephropathy and retinopathy, baseline Cr (8/2011) 118 HbA1c 13.4 on insulin injection and Diamicron 2.HT on Norvasc and hydralazine 3.IHD 4.Hep B carrier 5.Hx of skull fracture with cranioplasty 6.Old CVA 7.Hx of retrorectal sarcoma with resection in 1996 QMH

5. History of present illness  Information by friend  Teacher in career development  Flu like symptoms in recent few days, on TCM  No reply from phone call  Broke in by fireman  Allergic to penicillin  angioedema

6. Resuscitation room  Physical examination immediate after ROSC  Vitals  BP 80/56, pulse 82/min  T 27.4 o C, cold peripheries  Cap refill fair  CNS  GCS E1VTM1, pupils 1mm sluggish  Flaccid tone  Neck soft, no rash  CVS  JVP not elevated  HS dual no murmur

7. Resuscitation room  Resp  SpO2 100% on 100% FiO2, AE satisfactory  Bilateral crepitations  GI  Abdomen: soft, not distended  No cullen/ Grey Turner sign  BS positive  Renal  yellow urine  Urine ketone 4+

8. Resuscitation room  Bedside investigation  H’stix HI  i-stat: pH 6.709, pCO2 4.4, pO2 58, BE -30, HCO3 4  Na 138 K 4 iCa 1.26 Hct 0.42 iCa 1.4 Cl 101  Hemocue 13  Urine ACON kit –ve  Urine ketone 4+ glu 2+ WC/nit –ve

10. Shock  Hypovolaemic  Cardiogenic  Distributive  Septic  Anaphylaxis  Obstructive  Endocrine

11. Hypothermia  Lost temperature to surrounding environment  Inability to produce heat, shivering

12. Altered mental state  AEIOU TIPS  Alcohol  Epilepsy, electrolytes, encephalopathy  Insulin  Opioids / overdose  Urea (Metabolic)  Trauma  Infection  Psychiatric  Shock, SAH, stroke

13. Metabolic acidosis  Respiratory compensation?pCO2 14+/-2kPa  Anion gap?37  Delta anion gap?37 - 12 = 25  Delta HCO3?24 – 4 = 20  Delta anion gap / Delta HCO3?25 / 20 = 1.25  High anion gap metabolic acidosis with inadequate respiratory compensation

14. High anion gap metabolic acidosis  MUDPILES  Methanol  Uraemia  DKA, beta-hydroxybutyrate  Paraldehyde  Isoniazid  Lactate  Ethylene glycol  Salicyate

15. Reversible causes for cardiac arrest 5Hs  Hypothermia  Hypoxia  Hypo/Hyperkalaemia  Hydrogen ion  Hypovolaemia 5Ts  Tension pneumothorax  Tamponade  Thromboembolism, pulmonary  Thromboembolism, cardiac  Toxin Take Temperature POCT, i-stat Echocardiogram and bedside USG

16. ECG

17. CT brain CT brain:left craniectomy. Encephalomalacia at high left parietal lobe, probably old

20. Disposition  ICU consulted  Response from ICU colleague: no bed available  Suggested inter-hospital transfer after discussion among ICU seniors  Now what?

21. Guideline Head Authority Head Office Operations Circular No. 10/2006

22. Indications Critically ill patient(s) require intensive monitoring and treatment which will only be available in ICU, and the patient(s) is likely to benefit from such ICU care

23. Service networkService network Fax the form to your sister hospital ICUs, wait for a reasonable period of time Contact them direct if no reply after a reasonable period of time Group fax to all ICUs over the territory, wait for one hour Contact them direct if no reply receive then

24. Parent teamParent team Our AED colleagues should call receiving hospital parent team, say medical in our case, for agreement to take over before transferring to the receiving hospital ICU (subject to futher discussion)

25. Transport

31. How to stablize? 1.Post VF arrest  Tx: amiodarone infusion 150mg in 100ml D5W over 30 min then 1mg/min amiodarone infusion for 6 h  Therapeutic hypothermia: to keep core T 32-34 o C for 12-24 hr, however he is already hypothermic, has to be very cautious especially during transfer for fear of triggering arrhythmia (VF) again

33. How to stablize? 2. DKA - Insulin bolus 12 U then 4 U/hr - NS bolus keep CVP 12-15mmHg - A total of 3L NS given in 2 hr - Sodium Bicarbonate 8.4% 100ml given i-stat pH 6.86, pCO2 4.66, pO2 48.4 BE -27, HCO3 6.2

34. Diabetes Care. 2009 July; 32(7): 1335–1343 Hyperglycemic Crises in Adult Patients With Diabetes 2009 by the American Diabetes Association

35. Is a priming dose of insulin necessary in a low-dose insulin protocol for the treatment of diabetic ketoacidosis?  Based on small RCT without clinical outcomes  37 patients aged 19-66 yrs with DKA randomized to 1 of 3 insulin regimes 1.Loading dose 0.07U/kg plus 0.07U/kg/hr 2.0.07U/kg/hr with no loading dose 3.0.14U/kg/hr with no loading dose  No sig difference in time to reach 1.glucose < 14 2.pH > 7.3 3.HCO3 > 15  Supplemental insulin required in 42% of group having 0.07 U with no priming  No supplemental insulin required in priming or 0.14 U groups Diabetes Care 2008 Nov; 31(11): 2081-2085

36. How to stablize? 3. Septic shock - Early goal directed therapy - Inotrope support Noradrenaline 8mg in 100ml D5@ 20ml/hr, ~27mcg/min, latest ABP 108/59 before departure - Rocephin 2g IV - Klacid 500mg IV - Hydrocortisone 100mg IV

37. EGDT in QEH Severe sepsis / septic shock ARISE study

38. Our patient  2 peripheral lines  1 central line  1 arterial line  2 infusion pumps  1 cardiac monitor  1 physio monitor (MP20)  1 ETCO2 monitor  1 ventilator  Bear hugger  Rectal Temp probe etc..

39. Timeline 15:16 triage 15:30 Cardiac arrest 15:37 ROSC, consult ICU 16:00 No bed in QEH, decide interhospital transfer 17:00 No reply from UCH.TKOH, fax to PWH Bed av in PWH 17:30 18:00 Received call from ICU/UCH, bed av, decide to proceed to PWH after discussion Depart from QEH Arrived at PWH 18:39 18:54 Length of stay in ED/QEH: 3h23min

40. Later on, results coming back… Hb 11.7 WC 30 Na 137, K 4, Cl 101, HCO3 4 Anion gap 37 Urea 15 Cr 267 (baseline 112) RG 46 Trop I 0.23, CK 369, LDH 289 Lactate 3 BHBA 13.6

41. Progress  Stay in ICU/PWH for 9 days  Upon discharge  Tracheostomized, on 4L oxygen  Wean off inotropes  Cardioembolic stroke with Rt hemiparesis, likely due to VF arrest, GCS E4M4Vt  Discharge to medical ward then back to QEH  Further drop in GCS 2 days later  CT brain: acute infarct in left medial occipital lobe  Cardiac arrest on the same day  Failed resuscitation and succumbed