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Sdiver
11-14-2013, 23:30
Haven't done one of these in awhile.

Remember, think the problem through and think outside of the box, or as my ethics professor said, "Instead of thinking outside the box, just expand your box."

Let's go ....


Dispatched on a cardiac emergency, you arrive to a physician's office and are quickly lead to an examination room by office staff.

As you walk into the room you see a male supine on an exam table, profoundly diaphoretic, and lethargic. His skin color is grey and ashen. The doctor meets you at the bedside and shows you this EKG. (see below)

The doctor notes that he knows the patient well, and that he has an extensive cardiac history, and has had two stents placed in his circumflex and RCA within the past year. He walked into the office complaining of chest pain, and then suddenly collapsed about 10 minutes prior to EMS arrival.

The patient is allergic to aspirin (it causes anaphylaxis), and he takes Plavix, Lipitor, Procardia, Vasotec, Glyburide, and isosorbide dinitrate.

He has marked JVD, and ankle edema. His lungs have crackles at the bases, but he is moving air. He responds with a moan to painful stimuli, and has a gag reflex. GCS E2, V3, M4 = 9.

BP 50/30, HR 104, RR 20, SpO2 92% NC 4L, Temp 98.6 F / 37 C
Cap blood glucose = 110.

You are 45 minutes by ground to the nearest PCI (cardiac catheterization) capable center. There is a non-PCI center 15 minutes away by ground. There is a landing zone nearby for a helicopter at the local FD.

What are you next steps in patient stabilization and care, and what would be your transport destination and method? Other thoughts / considerations?

NurseTim
11-15-2013, 04:46
Place an NPA, oxygen 15 lpm via, NRB mask, establish an IV, 5mg morphine, rotating tourniquets, 80mg of lasix, foley to bag if that is in protocols, air lift to PCI facility.

Trapper John
11-15-2013, 07:35
As I said before, cardiac cases scare the crap out of me - too many ways to screw up and only one way to get it right. Supportive care and transport is the priority here. This patients ECG is a mess and no time to interpret. I'm thinking pulmonary embolism and possible CHF. Elevate the patient, start IV (NS drip 10 gtt/min). O2 by mask 15L/min, morphine 5 mg IV, 80 mg lasix as Nurse Tim said. Not sure about rotating tourniquets (that's a new one on me, so NT would you educate me?). The pO2 at 92% concerns me - possible respiratory acidosis if this has been going on for awhile. I would push an amp of bicarb. Transport to the nearest primary care facility (15 min by ground). This one is going to need a dDx by a cardiologist. I will try to decipher the ECG and post my dDx and Rx plan later. The primary goal at the moment is respiratory support and get him to the nearest primary care facility.

Trapper John
11-15-2013, 12:39
He demonstrates Beck's Triad, raising the flag for cardiac tamponade. Are his heart sounds muffled? Good one, Doc, but I'm betting that the neck vein distention resolves when the patient is raised to semi-reclining position.

DDX: After thinking about it and looking at the medical history, the patient is Type II diabetic (Glyburide) but blood glucose is normal therefore no keto-acidosis. He is on anti-coagulant (Plavix) prophylactic for a patient with CHF (Vasotec and Procardia) and isorbide dinitrate to treat angina.

The ECG leads me to think of hyperkalemia (small or absent P waves and a wide QRS complex with wide (tented) T-waves.

Order blood chems to measure K+ level, kidney function markers.

Rx Plan: withdraw isosorbide dinitrate and Vasotec (ACE inhibitor) both of which are contraindicated and can induce (probably did in this case) hyperkalemia. Admin Na Bicarb and titrate to blood pH. Calcium chloride (1 ampoule IV) titrate to ECG response, Ventolin nebulizer (10 mg) to follow as needed (monitor ECG). The treatment goal is to reduce K+ level. Re-evaluate meds for long term maintenance. This patient dodged a bullet. Discharge when stable.

Brush Okie
11-15-2013, 17:54
My first thought was cardiac tamponaid as well.

Does pt have recent history of chest trauma or infections/ fevers?


are there muffled heart sounds.

High flow O2
IV NS tko
No nitro or ferosimide due to low BP. Lasic has an initial vaso dilation effect initially before kicking out water. Same for MS. BP 50/30 is low woth low pulse pressure



I would consider Dopamine 2-10 ug/kg/min and external pacing.

Dopamine is only a short term fix. If heart sounds are muffled and he needs a paracenthisis this is the fix plus find out root cause ie infection, trauma etc etc.

If it is a basic bradycardia from a MI that needs to be treated asap as well not to mention he will probably wind up with cardio myopothy

Medevac to more equipped hospital.

BTW my spelling sucks on my best days, today is really bad so please forgive my lack of skills. Picture a gorilla pounding on a keyboard and that is me.

PSM
11-15-2013, 18:26
I think I'm catching on here. Sdiver is getting you guys to do his homework for him. :D

Pat

Sdiver
11-15-2013, 18:43
Pat, go away ....

.


;)

Trapper John
11-15-2013, 18:46
I think I'm catching on here. Sdiver is getting you guys to do his homework for him. :D

Pat

I don't care, I'm just tryin' to get rid of this damned nipple ring! :eek:

NurseTim
11-15-2013, 20:52
As I said before, cardiac cases scare the crap out of me - too many ways to screw up and only one way to get it right. Supportive care and transport is the priority here. This patients ECG is a mess and no time to interpret. I'm thinking pulmonary embolism and possible CHF. Elevate the patient, start IV (NS drip 10 gtt/min). O2 by mask 15L/min, morphine 5 mg IV, 80 mg lasix as Nurse Time said. Not sure about rotating tourniquets (that's a new one on me, so NT would you educate me?). The pO2 at 92% concerns me - possible respiratory acidosis if this has been going on for awhile. I would push an amp of bicarb. Transport to the nearest primary care facility (15 min by ground). This one is going to need a dDx by a cardiologist. I will try to decipher the ECG and post my dDx and Rx plan later. The primary goal at the moment is respiratory support and get him to the nearest primary care facility.

Rotating tourniquets is very old school Tx for CHF. I believe it reduces pre-load. Inflate a cuff on 3 of 4 limbs at any one time. Come to think of it it's Tx of pulmonary edema, not CHF. Not this patient's problem, clearly.

My first thought was cardiac tamponaid as well.

Does pt have recent history of chest trauma or infections/ fevers?


are there muffled heart sounds.

High flow O2
IV NS tko
No nitro or ferosimide due to low BP. Lasic has an initial vaso dilation effect initially before kicking out water. Same for MS. BP 50/30 is low woth low pulse pressure



I would consider Dopamine 2-10 ug/kg/min and external pacing.

Dopamine is only a short term fix. If heart sounds are muffled and he needs a paracenthisis this is the fix plus find out root cause ie infection, trauma etc etc.

If it is a basic bradycardia from a MI that needs to be treated asap as well not to mention he will probably wind up with cardio myopothy his rate was tachy, but I agree with the MI Dx.

Medevac to more equipped hospital.

BTW my spelling sucks on my best days, today is really bad so please forgive my lack of skills. Picture a gorilla pounding on a keyboard and that is me.

50/30 is just barely enough to perfuse the beans. Would levophed be appropriate in this situation?

Trapper John, imdur and vasotec are chronic meds and likely taken earlier.

So, if the Pt. recieved nitro, could it cause bradycardia?

PSM
11-15-2013, 20:56
I don't care, I'm just tryin' to get rid of this damned nipple ring! :eek:

AM would probably suggest several turns of det cord. Me, I'd go with a bolt cutter. Pick your poison. :D

Pat

Brush Okie
11-15-2013, 21:05
R



50/30 is just barely enough to perfuse the beans. Would levophed be appropriate in this situation?

You mean leave em dead? :p

Same class of drugs so yes another option. I think dopamine is a derivative of norepinephrine / levophed but a little more specific and less bad side effects. Dopamine is not exactly something to take lightly as well.

Patriot007
11-17-2013, 15:24
We'll let this play out a little, but let's discuss the processes at play here. No matter what level of training you are, the processes are the same and I find it helpful to work through it every time in your head then out loud with your team at the most basic levels. Diagnosis and treatment is a little different depending on your level and we'll discuss that later.

1. Even though you all are intuitively thinking it, come out and state it, this patient is in SHOCK. He is hypotensive with signs of end organ hypoperfusion ( altered mental status).

2. What type of shock could it be (there are only 4 main types) and what type is it most likely?

3. Is there something I have to do right now to prevent this patient from dying en route?

4. What is the best place for him? Is it wise to travel to the best place or use an alternate location for stabilization?

Trapper John
11-17-2013, 15:42
IMO this is cardiogenic shock secondary to hyperkalemia and CHF. Emergency treatment plan is as stated before. Transport to the nearest primary care facility with a cardiologist on duty. Calcium chloride, 1 ampoule IV push and titrate to ECG response should be immediate and is the 1st line Rx. Long term - adjust meds.

NurseTim
11-17-2013, 19:47
What am I missing? How are y'all coming up with high K? His ECG?

Trapper John
11-17-2013, 20:34
What am I missing? How are y'all coming up with high K? His ECG?

I might be wrong (won't be the first time :D). But the ECG (no or small P wave and broad or "tented" T wave and bradycardia) coupled with his medical history (CHF, Type 2 diabetes) and meds (ACE inhibitor Vasotek and isosorbide dinitrate) that have this potential toxic side effect are consistent with that Dx.

Patriot007
11-18-2013, 09:27
IMO this is cardiogenic shock secondary to hyperkalemia and CHF. Emergency treatment plan is as stated before. Transport to the nearest primary care facility with a cardiologist on duty. Calcium chloride, 1 ampoule IV push and titrate to ECG response should be immediate and is the 1st line Rx. Long term - adjust meds.

I agree that this is cardiogenic shock, i.e. pump failure. I disagree with hyperkalemia causing it however. For Hyperkalemia to cause hypotension by itself you would expect more profound EKG changes such as marked widening of the QRS or arrhythmias.

Bradycardic? Check your rate.

Say, while we're on what is the rate, rhythm, and what are the ST, or T wave changes?

Trapper John
11-18-2013, 14:28
I agree that this is cardiogenic shock, i.e. pump failure. I disagree with hyperkalemia causing it however. For Hyperkalemia to cause hypotension by itself you would expect more profound EKG changes such as marked widening of the QRS or arrhythmias.

Bradycardic? Check your rate.

Say, while we're on what is the rate, rhythm, and what are the ST, or T wave changes?

Now I feel like a first year student on grand rounds. :D Somehow, I think that was your intention, Doc. Love it - gonna learn somethin here!

HR ~100 bpm not exactly bradycardic :eek: On closer examination P waves are present. Now I'm doubting hyperkalemia too. Need to hit the books and get back to you with another Dx for the proximate cause of the cardiogenic shock.

Still holding with the primary emergency issue is respiratory distress secondary to CHF (not ruling out pulmonary embolism) and the emergency treatment protocol. Will get back to you after I study a bit and look at the ECG again.

adal
11-18-2013, 15:22
Inferior wall MI. leads 2, 3, aVf with reciprocal in V5, V6.
http://www.learntheheart.com/ecg-review/ecg-topic-reviews-and-criteria/inferior-wall-st-elevation-mi-review-/

Fluids to get pressures up, then a pressor, neosynephrin, or dobutamine. (Neo doesn't tax the heart as much.)

Pain control- fentanyl because of pressures, then Morphine

Fly to PCI center. He has either occluded inferior side OR re-occluded the stents.

Since he is on Plavix already ensure that he is still taking it. (I have a guy here that stopped taking it for a month and re-occluded - yes it can happen that fast).

May get to Nitro drip after fluids are way up (i know, controversial, but I may try to get him open after fluids.

Not too concerned about labs as of yet, but am very concerned about keeping as much of his heart alive as possible. Huge amount of elevation in lead 2 and 3.

As a flight medic - I'd fly faster. :)

NurseTim
11-18-2013, 16:27
Inferior wall MI. leads 2, 3, aVf with reciprocal in V5, V6.
http://www.learntheheart.com/ecg-review/ecg-topic-reviews-and-criteria/inferior-wall-st-elevation-mi-review-/

Fluids to get pressures up, then a pressor, neosynephrin, or dobutamine. (Neo doesn't tax the heart as much.) i would have tried a fluid challenge except for the edema and crackles at the the base of lung.

Pain control- fentanyl because of pressures, then Morphine
call me conventional but I'd still go with MSO4 for the added benefit of smooth muscle relaxation. Even with the hypotension.

Fly to PCI center. He has either occluded inferior side OR re-occluded the stents.
agree

Since he is on Plavix already ensure that he is still taking it. (I have a guy here that stopped taking it for a month and re-occluded - yes it can happen that fast).

great point

May get to Nitro drip after fluids are way up (i know, controversial, but I may try to get him open after fluids.

Possibly, I'd opt for pressors though.

Not too concerned about labs as of yet, but am very concerned about keeping as much of his heart alive as possible. Huge amount of elevation in lead 2 and 3.

As a flight medic - I'd fly faster. :)

Won't your arms get tired? :D

Trapper John
11-18-2013, 21:29
Inferior wall MI. leads 2, 3, aVf with reciprocal in V5, V6.
http://www.learntheheart.com/ecg-review/ecg-topic-reviews-and-criteria/inferior-wall-st-elevation-mi-review-/

Fluids to get pressures up, then a pressor, neosynephrin, or dobutamine. (Neo doesn't tax the heart as much.)

Pain control- fentanyl because of pressures, then Morphine

Fly to PCI center. He has either occluded inferior side OR re-occluded the stents.

Since he is on Plavix already ensure that he is still taking it. (I have a guy here that stopped taking it for a month and re-occluded - yes it can happen that fast).

May get to Nitro drip after fluids are way up (i know, controversial, but I may try to get him open after fluids.

Not too concerned about labs as of yet, but am very concerned about keeping as much of his heart alive as possible. Huge amount of elevation in lead 2 and 3.

As a flight medic - I'd fly faster. :)

Really good assessment there Bro. I was struggling with MI vs BBB and in particular RBBB (M shaped QRS and wide or notched R wave in V1-V2).

It's nice to come out of the lab once in awhile and get exposed to some real medicine. I really appreciate the opportunity to see just how far out my wheelhouse this really is.;)

Still learning :lifter

Sdiver
11-18-2013, 22:41
Gents,
Just to let you know, I'm still checking in from time to time on this thread. I haven't said anything, because I'm liking how you're working it out amongst yourselves.

With that being said, I will post up a couple of things I noticed ...

1) There was no chest trauma to this Pt. so you can r/o a pneumothorax (x-rays at the clinic confirmed this) but nice pick up on Beck's triad, a most probable sign of a pneumothorax.

2) The question of Ground v. Air. As the scenario is set up, the Pt. is at a clinic (ergo, very limited medical capabilities). There is a non PCI facility 15 min away and a PCI facility 45 min away. I think we all can agree this Pt. needs to get to a Cath lab ASAP. So the question(s) is/are .....

Do you call in air to the LZ set up by the local FD. Take into account, calling the air transport service. Spool up time for the AC. Flight time to the LZ. Load time at LZ. Flight time back to PCI. Adel hopefully you can shed some light on these numbers.

There is also, transporting the Pt. to the non-PCI facility, and get the Pt. stable. They would at least have blood and any other type of fluid that would help get that B/P up. They would also have an LZ, so air could be called to that facility, but at least the Pt. would be in a higher level of care facility other than the clinic.

There is also the possibility just of loading and going via ground to the PCI.

Those are a couple of things I just wanted to throw out there. :D

adal
11-18-2013, 22:55
We have a ten minute launch time. Flight time to LZ. I would Hot load - rotors turning - especially since it will be at fire dept. My ground time is supposed to be under ten minutes. I can frequently make it about six and then I'm busy in the air getting things done enroute.

If you go to a hospital, that hospital now has to contact a receiving and EMTALA is in effect. If I (helo) goes to a scene LZ, I can go wherever I can justify for care of the PT and I carry almost as much as an ER would have for resuscitation.

45 min drive could be anything from 10 miles away in Big city ( 5 minutes flight) or 45 miles away in an area like Northern AZ for me. (22 minutes flight.) (I routinely make my 69 mile flight from Tuba City to Flagstaff with MI pts in 30-35 minutes depending on winds.)

Ground doesn't always have the gear or meds OR critical care training for a pt like this. I have seen a BLS crew get launched to a scene and call for a follow on ALS crew. That is more time.

It's a big game of moving pieces and time, but the end result is that this PT needs PCI more than likely and we need to get him there as quick as possible. (He should have driven himself to the PCI unit with his cardiac hx, but I have had this kind of stubborn PT in the past. I'm sure I will have him again.) :)

Patriot007
11-19-2013, 02:12
Strong work all.

Trapper John, I like your wide differential. I know many docs would not have initially thought about hyperkalemia and it should be considered anytime you see funky QRS or T waves. Medicine has many "great masqueraders" and hyperkalemia is one of them and doesn't always show up as classic peaked T waves or simple wide QRS.

As a learning point to all, as stated this is an inferior wall MI and as such it is one of the instances where nitrates (e.g. nitroglycerin) could kill the patient (bottom out the blood pressure). Also, as far as field management, patients in cardiogenic shock with flash pulmonary edema are some of the most difficult patients to manage.

adal, I agree with all you said besides some minor points which may be practice/location/or style specific. It's always good to see how other professionals are doing it. It sounds like I could learn a lot from you when it comes to logistics alone, thank you. Since we're all here to learn from each other here's my 2 cents.

Since this is cardiogenic shock fluids may or may not help. As the patient is showing signs of pulmonary edema I would be very cautious with fluids as they may worsen the patient's pulmonary edema. Small test bolus of 250-500 cc would be a good starting point. If pressure improves without worsening hypoxia you may be ok for another bolus. If intubated and oxygenating well it's not as much concern but for a hypotensive patient with an unsecured airway it may cause a disaster (I know I'm preaching to the choir). For that reason this is one of the very few instances I'd go straight to a pressor, specifically levophed (norepinephrine). We don't carry levophed prehospital in our state expect for CC transports. We have dopamine which I agree has more risk of arrhythmias but has inotropic effects. Phenylephrine is alpha 2 and only and causes vasoconstriction so your patient's heart is going to have have more work to do without any added pump support (not good for a heart that already is not receiving enough oxygen). Dobutamine is an inotrope (pump support) so it will increase contractility but it causes vasodilation also so often times it actually drops BP at first. Epinephrine would increase heart rate too much worsening ischemia.

In our trucks and birds we have dopamine because Levophed is supposedly not as stable in field conditions. However, levophed is the recommended first line pressor in cardiogenic shock. This is a fairly new recommendation.

Too much? Sorry just got off a shift and I'm still jacked up on coffee ;)

Trapper John
11-19-2013, 07:16
Too much? Sorry just got off a shift and I'm still jacked up on coffee ;)

Not too much at all, Doc. Thanks for the primer on pressors and their indications for use. Back in my day the choices were epi or norepi. With their contrasting indications I pretty much thought unless I was absolutely certain, the choice was not to use either.

I learned from this exercise so a tip of the ol' beret to SDiver for another challenging case study.

Adal, do you make flights to PA? I thought if I get into trouble I would just have you on my speed dial. :D Oh, BTW, I have this really nice nipple ring for ya if you want. :p

adal
11-19-2013, 08:53
I love these discussions. Great input from all.

TJ, I could make a trip out east, but I'm not a fan of humidity. But if it's in a emergency, hollar and I'll be there as quick as I can. :)

Patriot007, thanks much. I've had some sick pt's lately that we have used any all sort of pressor combinations in order to help. I think the true key is to get as far in front of the eight ball as you can. (I had one that was post code resuscitation that was on liter number 8 and on three pressors. Not happy.) BTW we are using Levophed a lot out here in our shock protocol.

Sdiver. Keep em up. Love em.

swatsurgeon
11-19-2013, 13:49
Beck's triad is related to cardiac tamponade, not PTX
Tension PTX may reveal distended neck veins, hypotension but not muffled heard sounds.......

Gents,
Just to let you know, I'm still checking in from time to time on this thread. I haven't said anything, because I'm liking how you're working it out amongst yourselves.

With that being said, I will post up a couple of things I noticed ...

1) There was no chest trauma to this Pt. so you can r/o a pneumothorax (x-rays at the clinic confirmed this) but nice pick up on Beck's triad, a most probable sign of a pneumothorax.

2) The question of Ground v. Air. As the scenario is set up, the Pt. is at a clinic (ergo, very limited medical capabilities). There is a non PCI facility 15 min away and a PCI facility 45 min away. I think we all can agree this Pt. needs to get to a Cath lab ASAP. So the question(s) is/are .....

Do you call in air to the LZ set up by the local FD. Take into account, calling the air transport service. Spool up time for the AC. Flight time to the LZ. Load time at LZ. Flight time back to PCI. Adel hopefully you can shed some light on these numbers.

There is also, transporting the Pt. to the non-PCI facility, and get the Pt. stable. They would at least have blood and any other type of fluid that would help get that B/P up. They would also have an LZ, so air could be called to that facility, but at least the Pt. would be in a higher level of care facility other than the clinic.

There is also the possibility just of loading and going via ground to the PCI.

Those are a couple of things I just wanted to throw out there. :D

Sdiver
11-19-2013, 13:53
Beck's triad is related to cardiac tamponade, not PTX
Tension PTX may reveal distended neck veins, hypotension but not muffled heard sounds.......

Aw crap, that's right. Thanks for setting me straight.
Pounding my NVTS now Sir/Doc.

Trapper John
11-19-2013, 14:13
Aw crap, that's right. Thanks for setting me straight.
Pounding my NVTS now Sir/Doc.

Does this mean I can give you the nipple ring.:D

docholiday161
11-19-2013, 18:46
I know that I am chiming in a little on the late side. With both the JVD, distal edema, and the crackles at the bases; I am driven toward a cardiogenic shock secondary to CHF. Pt is obviously not perfusing but HR is not bad.

1. 15 LPM via NRB to increase SpO2. I see this as being low due to the pulmonary edema. NRB should bring the 92 to at least 97.

2. The ECG to me looks as if he is throwing multiple PVCs or wide-complex tachycardia with pulse. Pt could crash at any minute due to the irritation of the cardiac muscle.

3. Major concern for me is to increase his pressure without increasing the workload on the heart so that he can start perfusing. For this I would probably start with two large bore NS (both so a fluid challenge can be done as well as have access for follow on meds). Because of the peripheral and pulmonary edema, the pt is intravascularly dry. Meds would be Levophed 8-12 mcg/min and titrate to maintain B/P or possibly Dobutamine.

4. Also consider a Foley to have better monitoring of I/O because once his kidneys start perfusing by increasing his B/P, he should start dumping some of the fluid from his edema.

5. As for the transport decision, I like the idea of trasporting by ground to a higher EOC that could further stabilize while air assets are getting spun up.

Sdiver
11-19-2013, 19:58
Okay guys, I'm gonna close this one out and wrap up a few points.
Here's the diagnosis and treatment plan for this Pt.

This Pt. is having an Inferior wall MI as seen in Leads II, III and aVF, with reciprocal changes on the Lateral side as noted in Leads I, aVF and V6). This patient is in cardiogenic shock because the right ventricle has been taken out and there is no forward movement of blood through the heart. These patients are preload dependent due to Starling's Law of the heart.

-- This patient is lacking preload due to the inferior MI and his exam is consistent with RIGHT sided heart failure (JVD and swollen ankles) that is often seen in inferior MIs. He has trace crackles in his lungs, but this should not be a distractor. He needs fluids and lots of them, place on NS or Lactated ringers on a pressure infuser. This is due to Starling's Law of the heart which states that the strength of the heart's systolic contraction is directly proportional to its diastolic expansion. More fluids = more preload = more contractility = less failure.

-- This patient needs a pressor as well as he is showing signs of severe hypoperfusion. Levophed (norepinephrine) is currently the preferred pressor in all cases of hypoperfusion / shock, however not all agencies have this. Dopamine is a good alternative if that is the pressor available to you. You must improve this patient's perfusion, his heart is dying from the MI and the lack of coronary artery perfusion pressure is not helping.
http://www.nejm.org/doi/full/10.1056/NEJMoa0907118

-- Do you employ air transport? It depends on the resources the helo will bring. If the helo has a higher level of care (i.e. RN / MD or pressors like levo / anticoagulants like heparin) then this might be a good option. But remember that CPR in a helo is not an easy task. If your ground ambulance has reasonable resources, rapid ground treatment may be just as efficacious.

-- Alternatively, there is a community hospital nearby. Certainly the patient could be stabilized there, given TPA or TNK, or started on pressors and rapidly flown after it is clear that maximal therapy has been initiated to decrease the risk of in-flight cardiac arrest.

-- If pressors are to be given, IO is the best route as IO is considered equivalent to a central line.

-- O2 .... His O2 sats are at 92% on 4L via NC, would a NRB at 15L do anything for him? I've always been a big proponent for higher O2 delivery (it's due to the diver in me) but with this talk of free radicals, keeping his sats right at 92% is fine. But that doesn't mean you should completely r/o higher O2 with the type of fluids given. NS doesn't have the same O2 carrying capacity as plasma or RBCs have, so keep that in the back of your noodle.

-- Also, if this Pt. "crashes" prepare to intubate and BVM with high flow O2.


Thanks for playing, we'll have nice parting gifts for you as you leave.

**Trapper ... I'll take that nipple ring off your hands due to my above boneheaded comment, which was caught by SS.

Trapper John
11-19-2013, 20:07
**Trapper ... I'll take that nipple ring off your hands due to my above boneheaded comment, which was caught by SS.

Yeee Haw! But I have a feeling I will be earning that back in the near future.;)

docholiday161
11-19-2013, 20:48
Thanks SDiver. Made me start thinking again and realizing just how rusty my reading leads is.

Patriot007
11-20-2013, 16:03
-- This patient is lacking preload due to the inferior MI and his exam is consistent with RIGHT sided heart failure (JVD and swollen ankles) that is often seen in inferior MIs. He has trace crackles in his lungs, but this should not be a distractor. He needs fluids and lots of them, place on NS or Lactated ringers on a pressure infuser. This is due to Starling's Law of the heart which states that the strength of the heart's systolic contraction is directly proportional to its diastolic expansion. More fluids = more preload = more contractility = less failure.

-

With all due respect as this is your thread I disagree with the above. You are correct about Starling's Law/Curve, but it is just that, a curve. When you get to a certain preload (tank is full) contractility (pump function) actually starts to decrease. The physiology is that the cardiac muscle is stretched beyond its ideal length for function. As this patent has JVD this means that preload or central venous pressure is extremely high. This is the nitty gritty and the bottom line is nitro is contraindicated, you need an inotrope/pressor, and fluids probably aren't going to help further and may harm if the patient has JVD.

Did someone say airway?!

Bonus question before we close out this great case. Let's say the patient's mental status declines and is not protecting his airway. You are ventilating well with a BVM (good chest rise) and you are getting sats no higher than the low 80s. Breath sounds are equal but with diffuse rales (lots of fluid). Knowing that he may desat, brady and code when you attempt to intubate what small piece of equipment may be helpful to increase O2 sats before intubation, or even just keep him alive while hauling ass if you don't have RSI capabilities. (it's not an oral or nasopharyngeal airway, you are ventilating well)

Brush Okie
11-20-2013, 17:06
With all due respect as this is your thread I disagree with the above. You are correct about Starling's Law/Curve, but it is just that, a curve. When you get to a certain preload (tank is full) contractility (pump function) actually starts to decrease. The physiology is that the cardiac muscle is stretched beyond its ideal length for function. As this patent has JVD this means that preload or central venous pressure is extremely high. This is the nitty gritty and the bottom line is nitro is contraindicated, you need an inotrope/pressor, and fluids probably aren't going to help further and may harm if the patient has JVD.

Did someone say airway?!

Bonus question before we close out this great case. Let's say the patient's mental status declines and is not protecting his airway. You are ventilating well with a BVM (good chest rise) and you are getting sats no higher than the low 80s. Breath sounds are equal but with diffuse rales (lots of fluid). Knowing that he may desat, brady and code when you attempt to intubate what small piece of equipment may be helpful to increase O2 sats before intubation, or even just keep him alive while hauling ass if you don't have RSI capabilities. (it's not an oral or nasopharyngeal airway, you are ventilating well)

I am thinking nasal intubation with a PEEP valve?

adal
11-20-2013, 17:07
capnography?

We have also used a nasal cannula on 6lpm While performing intubation to maintain/increase sats with the procedure in conjunction with BVM.

I was gonna mention the airway. This is a perfect pt that as soon as you traditionally RSI, they code. Ketamine might be the way to go here.

Still a great discussion. :)

PEEP- didn't think of that because it's on all our BVM's already. Good call.

Patriot007
11-20-2013, 21:28
PEEP Valve correct!

I like the nasal cannula on while pre-oxygenating and leave it on while intubating. (If you can spare the O2). It's only a short time, crank that sucker up to 15 LPM and get some flow going, you won't dry out their nasal mucosa and cause harm in that time period.


It's called passive oxygenation and it increases the time your patient can be apneic before desating. It works because you are entraining the nasopharynx and airway with high flow oxygen even though you are not ventilating.

I agree Ketamine is the way to go if sedation is needed.