FIBs, medical error, resuscitation directives and ‘where the *@#! is the intralipid’?!

It is an eerily quiet Tuesday morning in ED. You have just returned from a coffee round to hear the arrest buzzer sound from bed 18. Edna is 89 and is currently unresponsive after an inadvertent intravascular administration of ropivacaine in an effort to analgese her fractured NOF.

She is unresponsive, hypotensive and tachycardic with a broad, erratic rhythm on the monitor. She subsequently suffers a generalised seizure, following which she becomes apnoeic and arrests into pulseless VT.

You commence ALS, successfully resuscitate her with sodium bicarb and IV lipid emulsion and transfer her to ICU to await her total hip replacement.

Key Learning Points: Technical

1. Local Anaesthetic toxicity is real! Know weight-based maximum doses and fully consent patients/family for complications prior to undertaking any procedure.
2. Manifestations result from sodium channel blockade and include neurological sequelae including tinnitus, perioral numbness, confusion, drowsiness, loss of consciousness and seizures, closely followed by cardiovascular complications including hypotension, dysrhythmias and cardiac arrest.
3. The key investigation is the 12-lead ECG, which may show signs of Na+ channel blockade: terminal R >3mm in aVR, broad QRS >100ms in II, R/S ratio >0.7 in aVR.
4. Treat dysrhythmias with sodium bicarb eg 2mmol/kgl IV bolus and repeat until cardiac stability is restored.
5. In refractory arrest, use IV lipid emulsion 1-1.5ml/kg bolus repeat at 3-5mins x 1-2 then 0.25ml/kg/min IVI.

Lipid emulsion 20% can be found in the drug cupboard in AAA, resus and fast track. Dosing information should be attached to the bottle but if not (as in this case!) please contact poisons for advice.

Key Learning Points: Non-Technical

1. Role allocation can be very tricky when a critically ill patient is sprung upon us, outside of a familiar resus environment. Have a plan to manage role delineation on-the-fly. Consider pausing to allocate roles; use labels eg stickers/lanyards in acute situations even outside of resus – perhaps keep some on the resus trolleys for this reason. Allocating roles ensures team members are accountable and focused and ensures important tasks are not missed eg time-keeping, drug-drawing.
2. Communicate with and listen to the Team Leader. They will use key phrases to update the team in language that is universally understood. For example, ‘I think we are dealing with local anaesthetic toxicity’, ‘I want to prioritise the IV lipid emulsion’. Use closed-loop communication to inform the TL that tasks have been completed, ‘the defib pads are on, shall I proceed with rhythm check?’.
3. Feel empowered as a team member to speak up if you know something that you feel the rest of the team has overlooked eg the location of important medications in the department. As the TL be open to suggestions and regularly update your team and invite feedback so as to avoid lost communication of vital information.
4. Think about the ethics around over-riding a ‘do-not-resuscitate’ directive in the event of an unexpected, iatrogenic event. If it is clear the directive has been drawn-up with potential iatrogenic events in mind, the patient’s wishes should be respected. Consider incorporating this element into your advanced-care-planning discussions with family and relatives. When consenting for nerve blocks, always disclose risks of LA toxicity including possible cardiac arrest and where possible discuss with elderly, frail patients/families their wishes in the event of cardiac arrest as a result of a procedural complication. By planning in advance we can avoid fraught decision making in the heat of the moment. Remember, it is natural as care-givers to want to correct an inadvertent error by over-treatment. This is not a reasonable excuse for over-riding an advanced care directive. We must always be acting in the patient’s best interests.