Medical Scenario III

Sdiver · 06-13-2013, 11:10

Okay gang, get out your calipers .....

Your patient is a 63 yo female, "sick". She looks pale. She responds to verbal stimuli, but does not seem alert or oriented. Her HR is as shown, BP is 86/60. Her friend called 911 because she was acting "confused this morning". The friend tells you she has not been feeling great for a couple of days, but seemed worse today. Other hx is unknown.

What is the rhythm?
What is your treatment?

Trapper John · 06-13-2013, 11:42

Which lead on the ECG are we looking at?

First, impression is A-fib (absent P wave with irregular HR ~160 bpm). Patient needs a full cardiac workup. Transport to ER with IV NS slow drip (10 gtt/min) just to have a line open. (Bet ya thought I was gonna say Dextran

). O2 nasal cannula. Transport semi-reclined. Aspirin sublingual wouldn't hurt to prevent clotting and possible occlusive stroke.

adal · 06-13-2013, 12:09

Agree with Trapper. Be ready if she converts. I've had this convert simply by moving them from bed to gurney. If she has been this way for a few days (greater than 24 hrs) you could be getting ready for PE or stroke.

Sdiver · 06-13-2013, 12:20

Quote:

Originally Posted by Trapper John

Which lead on the ECG are we looking at?

Lead II

Don't have a 12-lead. Sorry.

Trapper John · 06-13-2013, 12:34

Quote:

Originally Posted by Sdiver

Lead II

Don't have a 12-lead. Sorry.

Ok thanks! Sticking with AF.

PedOncoDoc · 06-13-2013, 12:43

Quote:

Originally Posted by Trapper John

Which lead on the ECG are we looking at?

First, impression is A-fib (absent P wave with irregular HR ~160 bpm). Patient needs a full cardiac workup. Transport to ER with IV NS slow drip (10 gtt/min) just to have a line open. (Bet ya thought I was gonna say Dextran

). O2 nasal cannula. Transport semi-reclined. Aspirin sublingual wouldn't hurt to prevent clotting and possible occlusive stroke.

I agree with your assessment of the rhythm, but I am worried that she already had a thromboembolic stroke given her altered mental status.

Trapper John · 06-13-2013, 12:53

Quote:

Originally Posted by PedOncoDoc

I agree with your assessment of the rhythm, but I am worried that she already had a thromboembolic stroke given her altered mental status.

Agree. Probable TIAs. My question for you, Doc, is TPA indicated here?

Sdiver · 06-13-2013, 12:55

Quote:

Originally Posted by Trapper John

First, impression is A-fib (absent P wave with irregular HR ~160 bpm). Patient needs a full cardiac workup. Transport to ER with IV NS slow drip (10 gtt/min) just to have a line open. (Bet ya thought I was gonna say Dextran

). O2 nasal cannula. Transport semi-reclined. Aspirin sublingual wouldn't hurt to prevent clotting and possible occlusive stroke.

Just wondering here, you've got your IV set up for TKO but yet she's hypotensive. Would you consider a fluid bolus and if so, how much?

Also, would you consider cardioverting as an option and if so, how? (Adel, this is for you as well.

)

Oh and BTW .... How much ASA and O2 are you giving? #attentiontodetail

Sdiver · 06-13-2013, 12:58

Quote:

Originally Posted by PedOncoDoc

I agree with your assessment of the rhythm, but I am worried that she already had a thromboembolic stroke given her altered mental status.

True she may have had a thrombus break loose due to the a-fib, but she's also had poor cardiac output for the past x2 days. This could be the cause of her "confusion and disorientation".

MR2 · 06-13-2013, 13:01

Quote:

Originally Posted by Sdiver

Your patient is a 63 yo female

Trapper John · 06-13-2013, 13:05

Quote:

Originally Posted by Sdiver

Just wondering here, you've got your IV set up for TKO but yet she's hypotensive. Would you consider a fluid bolus and if so, how much? No, not hypovolemic shock.

Also, would you consider cardioverting as an option and if so, how? (Adel, this is for you as well.

) OK that one is outside of my wheelhouse. I'm in learning mode here, so teach me

Oh and BTW .... How much ASA and O2 are you giving? #attentiontodetail

80 mg ASA, 2L/min O2

PedOncoDoc · 06-13-2013, 13:56

Quote:

Originally Posted by Trapper John

Agree. Probable TIAs. My question for you, Doc, is TPA indicated here?

TIA can only be diagnosed in hindsight - if symptoms last for <24 hours without residual neurologic sequelae. I would consider this an acute thromboembolic stroke until proven otherwise.

If she seemed confused this morning, the stroke could've happened overnight, so it may not be outside of the therapeutic window for TPA. Then again - I coudln't tell you the last time I took care of an acute stroke in an elderly patient with AF, so I'm not sure on SOPs here.

I think a baby aspirin is 81mg (not 80), and (getting on my pediatric high horse here) never give aspirin to a pediatric patient unless advised to do so by a cardiologist.

Trapper John · 06-13-2013, 14:33

Quote:

Originally Posted by PedOncoDoc

TIA can only be diagnosed in hindsight - if symptoms last for <24 hours without residual neurologic sequelae. I would consider this an acute thromboembolic stroke until proven otherwise.

If she seemed confused this morning, the stroke could've happened overnight, so it may not be outside of the therapeutic window for TPA. Then again - I coudln't tell you the last time I took care of an acute stroke in an elderly patient with AF, so I'm not sure on SOPs here.

I think a baby aspirin is 81mg (not 80), and (getting on my pediatric high horse here) never give aspirin to a pediatric patient unless advised to do so by a cardiologist.

Thanks for the info Doc! Yeah, 81 mg (not 80 mg). Rounding error

I have often wondered why the 81 mg aspirin was called "baby aspirin" anyway. I always thought it contra-indicated in children under 2 yo (maybe even 3 yo)?

PedOncoDoc · 06-13-2013, 14:48

Quote:

Originally Posted by Trapper John

Thanks for the info Doc! Yeah, 81 mg (not 80 mg). Rounding error

I have often wondered why the 81 mg aspirin was called "baby aspirin" anyway. I always thought it contra-indicated in children under 2 yo (maybe even 3 yo)?

We worry about Reye syndrome if children receive ASA while having viral illness - so it is not used in children <12 if recovering from varicella or flu-like illness. ASA is only used in children with a clear cardiac indication or an acute thromboembolic stroke. ASA can be used at any age (no absolute age cutoff), but we are very careful about dosing.

Back to the scenario: Looking at current ASA guidelines, I would administer 325mg x1 with plans for a baby ASA daily thereafter.

adal · 06-13-2013, 15:18

Doc I,
Generally the only rhythm that is irregularly irregular is AF. Even the SVT's are regular for the most part. At least in my train of thought, there would be some sort of pattern to it.

A 12-lead would be nice.

Our protocols for ASA are 324mg PO. 4 x 81mg.

O2 until SPO2 above 92-94%.