[Mike MacKinnon]

You are kicked out at noon to a small rural ER which is generally staffed by locum family doctors. The rural ER is only 20 min from you but the nearest cardiac facility is 1.5 hours in flight.


The Report:

Your dispatch tells you that the patient is a 56 y/o male in "acute distress"

Hx: IHSS, Severe MR, pulm. HTN, CHF, post TBI & SCI

The patient had a severe car accident with ejection (no seatbelt) 5 years previous which resulted in severe TBI. His current mental state is low functioning and non-verbal. He has been, essentially, bedridden since recovering from the accident. He has no use of his legs (paralysis) below the waist.

The Story

While headed to a rehab camp for the patient, he began to act "short of breath" and "agitated" per the caregiver who was driving. She diverted to the nearest ER where the attending called you.

Diagnostics

CXR shows cardiomegaly mild-mod CHF
EKG shows LVH with flipped T waves in precordial leads
They didnt do any labs

Looking at the Paitent

You see a middle aged man who is non-verbal and clearly agitated.

Vitals:

HR: 120
BP: 80/50
RR: 25
Sat: 89% on 2/l n/c

They want you to leave "right now", per the attending who meets you at the door of the pts room.

[EDMEDIC]

Nice Mike! tachycardic,hypoxic,tachypneic and hypotensive. I can understand why they want the pt "out right now", but.... Is there a reason they didn't do a chest CT or any labs?..My first thoughts are, Hi flow O2, PIV access x2 large bore and a fluid bolus to see if there is any improvement. Agitation could be 2' hypoxia? Sudden onset of symptoms make me think a catastrophic event vs gradual onset. Maybe a PE? Would be nice to get some cardiac labs, d-dimer,BNP?.. Chest CT...my .02 to kick it off...Brian

[JBERGENRN]

I'll jump in , not really more intervention to add by me ,yet. 02 NRB, IV access, "cautious" fliud bolus (NS), try to establish a position of comfort, good physical assessment.
My thoughts and questions:
Appearance? flushed?pale? diaphorectic? cool? warm?
Lung sounds?
Any indication of pain? location? severity? (low fuctioning correct?)
Any sort of labs? even a "finger stick"?
Meds?
Additional HX?
AMI?
and Like Brian asked" PE?"
" inverted T waves? hhmmm?

[medicerik]

Start with the easiest intervention. 15 LPM O2 via NRB. If the agitation is from hypoxia, we can start working on that with the high flow O2. Establish 2 large bore IV's if not already done. Does a small fluid bolus improve the hypotension or worsen the shortness of breath? Then time for me to do my own physical exam on the patient. Do we have the ability to do any point of care lab testing to help further the diagnostic impression?

I'd also like to talk to the caregiver for a minute to get a better history. Were these symptoms sudden onset? (That, plus the prolonged immobility are suggestive of the PE) Has he/she noticed the symptoms getting worse over a longer period of time? A list of meds, allergies, and further history would also be helpful.

For clarification, did the CXR show no CHF or mild to moderate CHF?

Erik

[Mike MacKinnon]

ewps, fixed it, mild-mod chf

[EDMEDIC]

Even /c the mild/mod CHF, I think a small fluid bolus, carefully infused is indicated. We may need to use some pressors, maybe nor-epi ( is already a bit tachy). I'd like to hear a bit more from the family, and get a list of the pt's meds. need a better PEx too. skin diaphoretic, pallor, cyanosis? Can we see the 12 lead ECG that was done? Does the hi flow O2 improve his SpO2? how about an ABG added to the mix as well. Be prepared to intubate, even if it is not indicated right now. depending no how agitated the pt is, may not be safe to transport him in the aircraft if we don't get that resolved....Brian

[doz2240]

Sounds like PE to me, due to hx and presentation. Obvious NRB 15lm, ECG, Bilat large bore IVs. What are LS? 12Lead ( Any evidence of S1, Q3, T3). Would like labs and ABG's. Would concider a pressor drug over fluid ( Dobutamine due to being a little tachy) Any changes with O2 admin. Would be prepared to RSI and intubate. Would set vent up per ABGS and presentation. Any history of PE in the past?

A lot of the same. but would base further tx on labs, 12 lead and pt status....

[medic31]

Any more info on the IHSS? As far as I know it is usually a tollerable condition and at other times, kills you. Any Hx. on his Dx. of IHSS?

[EDMEDIC]

flipped T waves in the precordial leads is suggestive of PE. Although I knew this to be true, I didn't know the statistics. looks like ~68 % of PE's have inverted T in the precordial leads. The subaortic stenosis could be a problem /c using pressors, so I would be cautious about getting his B/P too high. If this is really a PE, should start thinking about heparinizing the pt, be prepared to manage his airway. Have any of the interventions we've discussed thus far had any improvement or made any change ( + or -) in the pt's V/S, or appearance? Have any tests been done ( Labs,ABG,CT,et al)..Brian

[Mike MacKinnon]

Be careful to define those conditions and how they effect a pt and are usually treated before jumping to treatment. When a patient comes with multiple issues, there is often a compromise that dosent fix any one Ds perfectly.

If your walking into the ER, noone is going to give you the low down on these diseases so this is the best time to hash it out

[bertmict]

I agree with the typical first line treatments mentioned. However, I don't know that this small facility will likely have abilities to do a CT. While I agree that his agitation could quite easily be due to hypoxia, we must (in this case) also look at his PmHx. With the pt having severe MR, he could quite likely just be scared out of his pants with everything going on. In this specific case, we must consider this and contemplate whether or not a dose of ativan should be used. His anxiousness could be making everything worse than it actually is.

As a side bar, I have a sister with Landau-Kleffner syndrome and has severe MR...she is 16 with a mind of a 2-3 y/o. She has been through two brain surgeries. Back in my early EMS career when still living at home, she would not come near me if I had a stethoscope around my neck. My sisters accidentally found out that she has a major fear of cotton balls, and would run away screaming from them when trying to clean her nails. With her being in our lives, I have a whole new outlook on treating those with mental disabilities. Just food for thought with this case.....

I can't wait to see this unfold. Thanks Mike.

[JPatterson]

I believe the MR being referenced is Mitral Regurgitation.

Along with the subaortic stenosis, cardiomyopathy, and Pulmonary HTN, this person is a treatment nightmare. I believe that he probably has a PE which sparked a Pulmonary HTN crisis, which reduced his return to the Left side of his heart causing his hypotension potentiated by his subaortic stenosis. I am still thinking about the medication route that could help this person while not complicating his other chronic factors...tough case. Treatment for one makes the other worse...

I would like some labs and to get a foley in to monitor urinary output and check for retention.

[RoadieRN]

I get the impression with this case less will be more. Pulmonary HTN in the ICU setting can be scary enough, with all of the toys in the world at your disposal, ie, nitric oxide, milrinone, ECHO, etc. Managing this guy prehospital is going to be a helluva tight rope. With all of his cardiac hx, I imagine his BP doesn't see much above SBP 100, 110 when he is excited. I think kid gloves are gonna to be needed here. I'd start my tx w/a 250ml fluid challenge and see where we are after that for our BP/HR. I'd maybe increase his O2 up to 4-6L, so we don't flood his pulmonary bed with too much O2. I know he is tachypneic and acting hypoxic, in addition, to his sat, but trying little incremental increases in our care would, likely, be the most prudent actions here. ABG would certainly be nice to see if we are dealing with an oxgenation vs. ventilation picture. BNP or D-dimer, if we happen to be so lucky? All the other typical stuff too, of course, CBC, CMP, PT/PTT/INR, UA from our foley we or they put in. For giggles, what is our airframe? Reason I'm asking is, I am debating between possibly tubing now vs. waiting and seeing how he does. My biggest hestitance to tubing at all is this guy is going to do some funky things with intubation. He is only a paraplegic so the likelihood of some weird autonomic thing is less likely. However, what you use to induct is going to have to be very specific to him. Unless his BP improves dramatically, I would use Versed very sparingly and in little doses(2-3mg at a time) d/t it's propensity to drop BPs like it's job. I'd go with Etomidate and Roc for induction followed up with little doses of Fentanyl(50mcg q2-4min) to help sedate this guy once he is down with the Versed I mentioned above. To me, at least, Propofol is out for any sedation use.

I agree we the sending doc, we should boogie ASAP with our transport time being what it is. I think our hospital in 20 minutes may come into play here if this guy becomes unstable on our way to the receiving hospital.

As far as my DDx goes, here it is:
PNA
PE
CHF excerbation possibly r/t increased pulmonary HTN
Really freckin' ugly zebra!

Curious to see where this one leads us!

[RoadieRN]

Mike MacKinnon, on Jun 3 2008, 11:07 AM, said:

ewps, fixed it, mild-mod chf

Oh yeah! What does EWPS stand for? Couldn't find it.

Thanks!

[ST RN/PM]

JPatterson,
Excellent post, and I agree.... a freakin nightmare. This definitely is not a "insert protocol here" clinical scenario. This time, the title "Cardiac Conundrum" already suggests a B$#@h of a scenario. OK, so IHSS.......Subaortic Stenosis....this diagnosis is evidenced by decreased LV filling due to hypertrophic septum.....so Beta and Ca Channel blockers are indicated to slow rate, increase filling time..... but ya caint give em with a pressure of 80/40........MR...Mitral Regurg.???? or Mentally Retarded... if Regurg........is evidenced by decreased filling of the LV.....which is treated by ACE inhibitors, diuretics, anticoagulation and Calcium and Beta blockers..... which ya caint give with a pressure of 80/40. Pulmonary HTN......is this venous or arterial.......Mitral regurg. can cause Pulmo HTN.....venous congestion......RV hypertrophy, R heart failure......which is treated by increasing the preload...... which in this guy can worsen the LV failure that his prior diagnoses and CXR are suggesting are brewing. There are no hard and fast answers here, and as Mike says.....we gotta hash this one out. Definitely sounds like a PE, which can cause Pulmonary HTN........we dont have a lot in our toolbox for Pulmo HTN.......but our immediate problems are Hypoxia, which we can treat with oxygenation, first with Bipap, if no dice, mechanical ventilation. Heparinize for the PE......a conservative fluid bolus, if the pressure comes up, Nitroglycerin may relieve some of the congestion. Others have given all treatments already......this seems like a complicated Cardiogenic shock scenario with a PE thrown in the mix, and we arent gonna totally fix most of his problems. I am not replacing his Mitral Valve, starting Flolan or giving Nitric in my aircraft. Lets see how this one plays out. Bergen asked all the good questions.......Lung sounds, are the heart sounds as expected, (S3, Split S2, S4)? CT chest? My brain hurts, and I'm goin to bed...........Steve

[fire_911medic]

Okay, I couldn't help but bite on this one....first time in so please be somewhat gentle with me here

First thoughts - the guy could be agitated for multiple reasons. No 1. post TBI - you are someone he doesn't know, doesn't state where injury occurred, so he may have memory or judgement issues and if he doesn't know you becomes combative. No 2. Hypoxia - which is along the lines of what I'm thinking right now, first impression is PE with CHF exacerbation. With an O2 sat of 89% on 2 L, I'm gonna bump him up to NRB at 15 and see what we get with that. I'd be prepared to intubate if neccessary. With this, I'm thinking least to most invasive here. Being non verbal, he can't express if he's having chest pain, but the tachycardia gives me a hint that he is (or it could simply be due to the anxiety). You don't mention if we have a line on him yet, so I'm going to vote definitely get one in if not ! BP is a little lower than I'd like, but with the mild/mod CHF - speaking of which did he have this previously or is this new?, I don't want to push him over the edge so no bolus, just KVO. Lasix may be in order along with morphine (but BP may preclude this). You don't mention lung sounds, or if he's having difficulty breathing or just increased rate. What does this guy look like physically? Pale, cyanotic, diaphoretic? I'm not convinced this is cardiac, but from what I've seen in the past, I'm about to go to the zoo.

[mjcmedic]

RoadieRN, on Jun 3 2008, 09:24 PM, said:

Oh yeah! What does EWPS stand for? Couldn't find it.

Thanks!

That is Canadian for "Ooops"

hehe

[JPatterson]

Airdude, on Jun 3 2008, 10:57 PM, said:

JPatterson,
Excellent post, and I agree.... a freakin nightmare. This definitely is not a "insert protocol here" clinical scenario. This time, the title "Cardiac Conundrum" already suggests a B$#@h of a scenario. OK, so IHSS.......Subaortic Stenosis....this diagnosis is evidenced by decreased LV filling due to hypertrophic septum.....so Beta and Ca Channel blockers are indicated to slow rate, increase filling time..... but ya caint give em with a pressure of 80/40........MR...Mitral Regurg.???? or Mentally Retarded... if Regurg........is evidenced by decreased filling of the LV.....which is treated by ACE inhibitors, diuretics, anticoagulation and Calcium and Beta blockers..... which ya caint give with a pressure of 80/40. Pulmonary HTN......is this venous or arterial.......Mitral regurg. can cause Pulmo HTN.....venous congestion......RV hypertrophy, R heart failure......which is treated by increasing the preload...... which in this guy can worsen the LV failure that his prior diagnoses and CXR are suggesting are brewing. ...........Steve

I think that RATE is a big factor here which is potentiating most of his chronic issues. His current rate of 120 is too high. He doesn't have time for the blood to leave his Hypertensive lungs through his poorly functioning Mitral valve and therefore can't get enough blood into his LV to pump out through his subaortic stenosis. I am guessing that his Pulmonary HTN is Venous 2' to severe MR 2' to or wosened by his IHSS. Add a PE to the top of this and that is probably where your rate increase came from...Increased anxiety and hypoxia.

I believe that if we can decrease his rate without decreasing his afterload, his B/P will increase to an acceptable level. If we somehow decrease his afterload, then it will worsen his IHSS. It looks to me like he has enough pre-load d/t his mild-mod CHF. If we drown him too much more he will just have an Increased HR making things even worse.

Labs I am looking for: CBC, Chem 7, BNP, D-Dimer, Coags, Trop, CK, CKMB, ABG (we can put in an a-line to help us treat)
Central access (IJ or Sub-Clavian to get a good CVP) Mainly depends on how fast you can put it in. Don't delay too much if you have other access) Nice to have

Now the big part that I may get dinged on...I would like to lower his rate with either esmolol (I know what you are thinking...b/p already low) or something similar that is short acting and can be turned off. Once his rate comes down, his B/P should increase to provide better perfusion. Getting more blood through the LV will allow the lungs to drain better which could improve his oxygenation. If this makes his condition worse, we shut down and regroup which is why I want to stay away from traditional tachycardia protocols that use longer acting drugs. My big concern with esmolol is the negative ionotropic effect. We may need to support is contractility with the rate reduction. Digoxin does both, but I have no experience using it in the acute setting so I can't comment on it....anyone else? Please...

I have read about adenosine being used in pts with Mitral regurg and aortic stenosis who are decompensating d/t a relative increase in HR, but still need to read more...

This patient could turn out to not have a PE and just a rate problem which caused his acute decompensation

Jeff

[MSDeltaFlt]

Sys of 80, HR 120, breathing 25 and SATing 89% on 2 l/m. Those VS tell me he's at the end of being able to compensate. HR's fast, but not lethal. BP's low, but still able to perfuse enough to read a SpO2. Breathing's fast, but we've all seen faster.

I think we're not behind the 8 ball yet, but if we don't jump on this guy, we will be... and quickly. This is the kind of guy that will crap out on us at the worst possible time. Like, say... on final.

We've got to get his heart beating more efficiently, so it'll slow down, raising the BP up, clearing the lungs out bringing his pO2 up so he won't have to breathe as fast. That's assuming "C" is effecting "B".

Out of curiosity, what's his LOC? Is his level of consciousness at his normal level?

[Mike MacKinnon]

You asked for some other diagnostics


The Attending says he sees no reason for extra tests, he called you to take him out of here. Please, start moving.


Now what?