Case:

• 85 year old male found unresponsive and intubated in the field brought in via EMS
• Per wife, patient was very anxious about election results and took a Valium to relax and sleep
• Wife found him unresponsive next morning

Initial Steps

• Check for a pulse (weak, tachycardic, cold extremities)
• Confirm Endotracheal tube placement: listen for bilateral breath sounds, assess if he's easy to bag (yes & yes)
  
   
• IV, O2, Monitor, EKG (fast, narrow, irregular consistent with atrial fibrillation), Accu-Check (102)
  
   
• Delegate someone to check the chart to look for clues regarding past medical history, recent hospitalizations, etc. (none)
• Vital Signs: 97.6F, P: 160, and irregular on the monitor, BP unobtainable, SpO2 98%, RR: 18
• Physical Exam: Cold and cyanotic feet, 2+ bilateral lower extremity edema, nonpalpable distal pulses, otherwise unremarkable 

Next Steps:

• Unstable Atrial Fibrillation: CARDIOVERT!
• Can consider Heparin before cardioversion if CHA2DS2-VASc ≥1
• Anterior-Posterior placement of pads (left lower sternal border & below left scapula)
• Start at 100J or 200J; make sure it's SYNCHRONIZED (patient converted at 200J to sinus tachycardia around 120 bpm with a systolic blood pressure of 100)
  
  
   
• POCUS: 
• RUSH exam for undifferentiated hypotension (negative)
• Compoments of RUSH exam can be recalled by HiMAP (Heart, IVC, Morrison's Pouch, Aorta, Pulmonary)
• Pan-Scan: CT Head, Cervical Spine, Chest, Abdomen, Pelvis 
• Moderate bilateral pleural effusions, otherwise unremarkable 
• Labs: normal 
• Speak with Family
• Wife: Said patient has living will stating he would not want to live in an incapacitated state or to be intubated (written by patient in his own language and not just the typical DNI order); essentially, patient's wishes are for comfort measures
• Daugther (Dermatologist): Statets not sure if he would want comfort care at this stage and would like to hold off until she arrives
• Other Daughter: begging to remove endotracheal tube 

Palliative Care & Palliative Extubation in the Emergency Department

• Does this patient have a meaningful chance of recovery or is he going to live in an incapacitated state on mechanical ventilation? (4 hours into ED course, off sedation, GCS 3, not over-breathing the vent, was decided still too early to prognosticate)
• Do you keep the endotracheal tube in or do you proceed with palliative extubation?
• How do we go about palliative extubation in the ED?
• Take patient off the monitor (alarms can be stressful for family)
• Have respiratory therapist there ot take patient off ventillator and to control ventilator alarming 
• Consider Palliative Care consult 
• Consider extubating to High Flow Nasal Cannula for dyspnea 
• Avoid BiPAP or CPAP as tight mask and restricts any sort of communication 
• Family asked: What if he doesn't die? When will he die? Will it hurt?
• Make the patient comfortable
• Morphine or Fentanyl drip for pain and dyspnea
• Benzodiazepene for agitation 
• Glycopyrrolate for secretions 
• Prepare the family for what they will see and hear
• Attempt to give a reasonable time frame ("hours to days")
• Remove all unnecessary lines & tubes

Case Conclusion:

• 5.5 Hours into ED Course, patient began to wake up with spontaneous eye opening, following commands, nodding head when asked if he wanted the endotracheal tube removed 
• Unclear if patient understood thee consequences of extubation (pososible deteriooratino and/or death)
• Critical Care Medicine was consulted and discussed goals of care and new status of patient with the family
• Critical Care Medicine team performed biliateral thoracentesis for bilateral effusions and attempted extubation (patient indicated he would desire reintubation if extubation fails)
• Patient was unable to be weaned from the ventilator, admitted to the ICU, and extubated the next day
• ECHO showed EF 40%, patient went back into atrial fibrillation and was stated on Amiodarone
• 1 week later, patient was discharged to rehab facility, neurologically intact 

TAKE AWAYS:

• Consider patient's functional status prior to event
• Goals of care discussion with family are essential 
• Remeber the limitations of prognosticating patients in the Emergency Department
• Pallaitive extubation in the ED can be tricky [have a plan and utilize your resources(RT, Palliative, Pastoral Care, etc.)]

References:

Case provided by: Rich Byrne, MD

Brady WJ, Laughrey TS, Ghaemmaghami CA. Cardiac Rhythm Disturbances. In: Tintinalli JE, Stapczynski JS, Ma O, Yealy DM, Meckler GD, Cline DM eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 8ed. New York, NY: McGraw-Hill; 2016:(Ch) 18.

Ong MEH, Lim SH, Venkataraman A. Defibrillation and Cardioversion. In: Tintinalli JE, Stapczynski JS, Ma O, Yealy DM, Meckler GD, Cline DM eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 8ed. New York, NY: McGraw-Hill; 2016:(Ch) 23.

Tan, Audrey DO News, Emergency Medicine News: March 2017 - Volume 39 - Issue 3 - p 24

doi: 10.1097/01.EEM.0000513588.80154.aa