Best Case Ever 46 – Chris Nickson on Hickam’s Dictum

EM Cases Best Case Ever – Chris Nickson on Hickam’s Dictum.

Usually we use the heuristic of Occam’s razor to help us arrive at one diagnosis that makes sense of all the data points that a particular patient presents to us. However sometimes it’s not so straight forward and we need to think about multiple diagnoses that explain a patient’s condition – Hickam’s Dictum. Dr. Chris Nickson, the brains behind the Life in the Fast Lane blog tells his Best Case Ever from the SMACC Conference in Dublin, in which a patient thrombolysed for massive pulmonary embolism suffers a cardiac arrest, and the thought process he went through to discover the surprising complicating diagnoses that ensue…

emergency management of pediatric seizures

Recorded and published June 2016 from SMACC Dublin by Anton Helman & Chris Nickson

Complications of Massive Transfusion

In addition to the usual complications of regular transfusion such as TACO, TRALI and Graft vs. Host Disease (see Episode 36 Transfusions, Anticoagulants & Bleeding ) massive transfusion confer additional risks:

  • Thrombocytopenia
  • Coagulation Factor Depletion
  • Hypocalcaemia
  • Hyperkalaemia
  • Metabolic alkalosis
  • Hypothermia
  • Acute Respiratory Distress Syndrome (ARDS)


Traumatic Hemorrhage after Thrombolysis during Cardiac Arrest

In patients requiring CPR and thrombolytic therapy after cardiac arrest, while major traumatic and non-traumatic bleeding complications can lead to deterioration after ROSC, most bleeding complications are not life-threatening and can easily be managed. Duration of CPR longer than 10 minutes is not associated with increased risk of major hemorrhage in patients after thrombolysis. Sources of traumatic hemorrhage after thrombolysis in cardiac arrest to look out for include spleen and liver lacerations as well as hemothorax.


Dr. Nickson and Dr. Helman have no conflicts of interest to declare.



M.D. Donaldson, M.J. Seaman, G.R. Park. Massive Blood Transfusion. British Journal of Anaesthesia. 1992;69:6721-630.

Sihler KC, Napolitano LM. Complications of massive transfusion. Chest. 2010;137(1):209-20.

Kurkciyan I, Meron G, Sterz F, et al. Major bleeding complications after cardiopulmonary resuscitation: impact of thrombolytic treatment. J Intern Med. 2003;253(2):128-35.

Spohr F, Bottiger, BW, Safety of Thrombolysis during Cardiopulmonary Resuscitation. Drug Safety 2003; 26 (6): 367-379. Full PDF


Other FOAMed Resources on Complications of Massive Transfusion

Transfusion for massive blood loss on

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About the Author:

Dr. Anton Helman is an Emergency Physician at North York General in Toronto. He is an Assistant Professor at the University of Toronto, Division of Emergency Medicine and the Education Innovation Lead at the Schwartz-Reisman Emergency Medicine Instititute. He is the founder, editor-in-chief and host of Emergency Medicine Cases.

One Comment

  1. LITFL Review 237 – FOAM Ed June 28, 2016 at 10:33 pm - Reply

    […] Cases features our own Chris Nickson describing his Best Case Ever, and discusses Hickam’s Dictum. […]

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