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Old 11-14-2013, 23:30   #1
Sdiver
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Medical Senerio IV

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?
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Old 11-15-2013, 04:46   #2
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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.
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Old 11-15-2013, 07:35   #3
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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.
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Old 11-15-2013, 12:39   #4
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Quote:
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.
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Last edited by Trapper John; 11-15-2013 at 12:42. Reason: added additional thought
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Old 11-15-2013, 18:26   #5
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I think I'm catching on here. Sdiver is getting you guys to do his homework for him.

Pat
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Old 11-15-2013, 18:43   #6
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Pat, go away ....

.


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Old 11-15-2013, 18:46   #7
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I think I'm catching on here. Sdiver is getting you guys to do his homework for him.

Pat
I don't care, I'm just tryin' to get rid of this damned nipple ring!
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Old 11-15-2013, 20:52   #8
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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.

Quote:
Originally Posted by Brush Okie View Post
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?

Last edited by NurseTim; 11-15-2013 at 21:04.
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Old 11-15-2013, 20:56   #9
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I don't care, I'm just tryin' to get rid of this damned nipple ring!
AM would probably suggest several turns of det cord. Me, I'd go with a bolt cutter. Pick your poison.

Pat
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Old 11-17-2013, 15:24   #10
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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?
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Old 11-17-2013, 15:42   #11
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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.
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Last edited by Trapper John; 11-17-2013 at 16:00. Reason: typo meant hyper- not hypokalemia
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Old 11-17-2013, 19:47   #12
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What am I missing? How are y'all coming up with high K? His ECG?
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Old 11-17-2013, 20:34   #13
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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 ). 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.
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Old 11-18-2013, 09:27   #14
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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?
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Old 11-18-2013, 14:28   #15
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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. Somehow, I think that was your intention, Doc. Love it - gonna learn somethin here!

HR ~100 bpm not exactly bradycardic 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.
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