Case presentation

Case presentation
Dr. W.S. Ng
Dr. K.P. Yau
1

• 00:20
• Phone call from ambulance
• M/74 OAHR
• c/o SOB and labored breathing with SaO2
40%
• Will arrive AED in 10 minutes time
2

• On arrival, vital signs
• BP 92/52
• P 129
• SaO2 59% on non-rebreathing mask
• RR 30
• Temp 35.7
• GCS E4V5M6
3

What to do next?
4

Proceed to RSI for
mechanical ventilation
immediately?
What’s in your mind?
5

Differential diagnosis
• Pulmonary
• Asthma, COAD, PE, pneumothorax, pleural
effusion, pneumonia, interstitial lung disease…
• Cardiac
• ACS, CHF, Cardiac tamponade
• Psychogenic
• Hyperventilation, panic attack
• Others
• anemia, anaphylaxis, endocrine, acidosis…
6

• Approach by ABC
• P/E
• Tachypnoic
• Can hardly speak
• Air entry was present both sides but shallow
• Bilateral crepitations at lung base
• Trachea central
• No stridor
• No ankle edema
7

What to do next?
8

Investigations
• ECG
• At Arterial lblood gas
• CXR
• H’stix
• Any other bedside investigations help you making
decision?
9

• See USG
• http://vimeo.com/1025553
12

Sliding sign
Comet tail artifact
13

Sea shore sign
Barcode sign
14

Now patient got Type 2
respiratory failure
What next? Intubation? How?
15

RSI
• General anaesthesia induced by a rapid acting IV induction agent and a rapid
acing muscle relaxant with application of cricoid pressure
• 7P
• Preparation
• prepare all necessary equipment, drugs and back-up plans
• Preoxygenation
• with 100% oxygen, replace nitrogen in the functional residual capacity (FRC) of the
patient's lung with oxygen.
• Premedication
• depending on the patient
• Paralyze +induction of anaesthesia
• Suxamethonium, thiopentone, etomidate, ketamine…
• Pass the tube
• visualize the tube going through the vocal cords
• Proof of placement
• Post intubation care
• secure the tube, ventilate
16

• RSI
• Suxamethonium 75mg
• Etomidate 15mg
• Size 7.5ETT at 22cm first go
• Post intubation
• CXR
• Bilateral diffuse lung fibrosis, no pneumothorax, ETT in situ.
• SaO2 99%
• ETCO2 38
• BP 142/100mmHg P 127
• ICU consulted
• unlikely l to benefit from ICU care
• Admitted to general ward
17

Post intubation ti Xray
18

Progress
• Extubate on the same day due to patient’s
discomfort and irreverible cause.
• Passed away on same day.
• Family members did not satisfy with the
decision of intubation as the patient would
feel discomfort and pain.
• They also disagree on the decision of active
resuscitation and they think that it actually
prolong suffering of Mr. Lo
19

What do you think?
Will you resuscitate the patient
when you are the case MO?
20

• PHx.
• Retired businessman
• Interstitial lung disease dx.2008 in GH On LTOT
5L/min
• PHT
• Gout
• Gall stone
• Chair bound
• OAHR since 8/2010
21

• Hx. Of NIV in UCH
• Very distressing to him
• Refuse any invasive procedure to prolong
dying
• Patient and family opt for DNR in Sept.2010
• “DNR” written in CMS ALERT
25

Pulmonary Fibrosis
26

Pulmonary fibrosis
• Scarring in the lung
• Causes:
• Secondary to
• Chronic inflammation
• sarcoidosis
• Infections
• Environmental agents
• asbestos, silica, exposure to certain gases
• Ionizing radiation
• radiation therapy to treat tumors
• drugs
• Nitrofurantoin, t i methotrexate, t t amiodarone…
• Hypersensitivity pneumonitis
• inhaling dust contaminated with bacterial, fungal, or animal
products
• Idiopathic pulmonary fibrosis (IPF) 27

Diagnosis
• Progressive shortness of breath, cough, and
diminished i i d exercise tolerance
• P/E: Fine inspiratory crackles at the lung bases
• CXR
• Lung function test
• Restrictive lung disease, FEV1and FVC are reduced so the
FEV1/FVC ratio normal or increase
• high-resolution CT
• confirmed by lung biopsy
28

Complications
• Pulmonary hypertension
• Heart failure of the right ventrible
29

Treatment
• limited treatment options
• Corticosteroids, colchicine or
immunosuppressant for some type
• No evidence that any medications can help
this condition (IPF)
• because scarring is permanent once it has
developed
• Lung transplantation is the only therapeutic
option available
30

Prognosis
• Life expectancy 2-5 years after diagnosis
• Factors lengthen the life expectancy
• A younger age (under 50 years old)
• Female
• Symptoms that began less than one year
• If the pulmonary fibrosis i is associated with certain diseases
(such as systemic sclerosis) compared to idiopathic
pulmonary fibrosis
• Minimal SOB at diagnosis
• Less lung damage based on the high-resolution CT (HRCT)
at the time of diagnosis
• A positive response to treatment after three to six months
31

Now you know the
history and DNR
Will you resuscitate the patient?
And why?
32

Guideline
33

HAHO guideline on in-hospital
resuscitation
• Enable us to arrive at professionally and ethically
sound resuscitation ti decision i and safeguard the best
interests of the patient and clinician
• Before arriving resuscitation decision
• Consider ethical principles
p
• P. of beneficence
• P. of nonmaleficience
• P. of patient autonomy
• P. of medical futility
• P. of non-abandonment
34

• Resuscitation decision should be based on
• Patient’s medical condition
• Overall treatment plan
• Likelihood of patient benefit
• Patient’s wishes
• Should be initiated by doctor IC with his team
members and review at regular interval or
when there’s change in patient’s condition.
35

DNR
Ambulance Command
Standing Orders
ACP & AD
36

• DNR
• Forego resuscitation measures include chest compression,
assisted ventilation, ETT, defibrillation, and using
cardiotonic drugs regarding g patient’s decision/condition
• Not affect the provision of life sustaining measures like
artificial nutrition, hydration or other emergency care such
as treatment t t of pain, haemorrhage, h dyspnoea, etc
• Effective to that particular period only
• Based on clinical i l judgment at a specific time point,
• Need periodic review.
• Unlikely l to be applicable to other clinicians i i and across
medical institutions
37

• Ambulance Command Standing Orders
• There’s existing arrangement for HA terminal
oncology pediatric patient between FSD and HA
• Stating patient’s grave illness and agreement by
parents known to both FSD and HA,
• Will not be resuscitated if fall into Cardiac arrest.
40

Advance Directives &
Advance Care Planning
41

• Advance Directives (AD)
• Back in 2004, the Law Reform Commission recommended the
concept of AD to medical treatment.
• The Government accepted the Concept of Advance Directives
under the common law framework but was not prepared to make
AD statutory.
• AD’s implemented July, 2010
• A valid AD is legally binding,
• Applicable across medical institutions if its validity can be
ascertained on the spot.
• A proxy health care directive does not have legal status in HK
42

• Operation of AD
• Terminally ill
• In a state of irreversible coma
• Persistent vegetative state
43

• Advanced Care Plan (ACP)
• A process enabling a patient t to express wishes
about his or her future health care in consultation
with their health care providers, family members and
other important people in their lives.
• Based on patient t autonomy and patient t consent, to
help ensure that the concept of consent is respected
if the patient becomes incapable of participating in
treatment decisions.
• ACP is traceable to specific doctor-patient
relationship
44

Thank you
45