Save of the Month – January 2020

The first save of the month (and decade) goes to consecutive CCT Teams!

Team #1: Dr S Johnson and Dr S Gopaul for stabilizing a sick patient and avoiding potentially catastrophic interventions in an undifferentiated patient who could have crashed

Team #2: Dr S Desai and Dr R Walsh for avoiding diagnostic momentum bias, advocating for patients even after they were admitted, and focusing on life-saving interventions after the correct diagnosis was made

4:00pm – A 61-year-old male with a long-smoking history comes in for “gas pain” that started 2 days prior. He is brought into CCT for clearance because of “tachypnea” but is speaking full sentences. He is in mild distress and chest is clear. ECG shows tachycardia but no ST changes. The patient is started on nebs and steroids for presumed COPD. While waiting to be moved to main ED, the patient becomes diaphoretic, more tachypneic, and assumes a tripod position. He is noted to be hypoxemic and normotensive on the monitor. He is given a dose of epinephrine and placed on BIPAP with significant improvement. Bedside US shows hyperdynamic contractility, reduced EF with B lines bilaterally, and L pleural effusion; there is no R ventricular enlargement. He is given furosemide for now what appears to be a “CHF exacerbation”. He is also started on antibiotics for possible pneumonia given the unilateral nature of effusion. The patient is admitted to the MICU.

9:00pm – The patient is initially comfortable on BiPAP.  He has been endorsed to the admitting team, as well as to the overnight CCT team. During the first two hours of night shift, he begins developing intermittent, self-resolving episodes of diaphoresis and tachypnea. A chest tube is considered to relieve the effusion, but the CCT team would like to do CTA first to both characterize L pleural effusion vs mass, and rule out a PE simultaneously.

10:30pm: CCT team views the CTA images and notice a false lumen in the thoracic aorta, and discusses this with the radiology resident. The study is read as complex L sided pleural effusion with solid components that may be possible malignancy and incidental thoracic aneurysm with thrombus. There is no pulmonary embolus. The attending radiologist is called due to the nature of the thoracic aneurysm.

11:30pm: CTA read is addended by attending radiologist: Acutely leaking thoracic aneurysm vs. dissection with thrombus and subsequent L hemothorax – no active bleeding. Also there has been a 4 hgb drop on serial VBGs.

12:00am: The patient remains stable on BiPAP, tachycardic but normotensive. Esmolol infusion is started. Since respiratory status and hemodynamics have been stable, the team prioritized transfer for higher level of care and definitive treatment.

1:00 am The patient arrives at Bellevue and has an uneventful night. A repeat CTA chest and abd shows “ruptured thoracic aneurysm” with intramural hematomas extending into carotids concerning for type A dissection. The patient is taken to the OR by vascular and CT surgery. It’s decided that it would be “most prudent” to stabilize the aorta first before evacuating the L chest. The patient arrests during intubation, and there is ROSC after 1 round of CPR. A thoracic endovascular aortic repair (TEVAR) and L thoracostomy is done. The patient is extubated on POD 2 off of pressors. He has retained L side hemothorax and VATS is pending. He is normal neurologically and starting physical therapy.