Jump to content


Photo
- - - - -

Case #42 Football Player Collapses


  • Please log in to reply
114 replies to this topic

#101 shock360j

shock360j

    Member

  • Members
  • PipPip
  • 24 posts

Posted 22 August 2008 - 02:21 AM

]
  • 0

#102 Speed

Speed

    Advanced Member

  • Members
  • PipPipPip
  • 1100 posts

Posted 22 August 2008 - 02:44 AM

Pheo would be the perfect zebra because it was discussed in a very recent case study on Flightweb and it does fit nicely in the differential as Flyin Dutch pointed out. Labetolol working some also could fit because of the Alpha and Beta properties, but the couple times that I have seen a Pheo pt, they required Alpha blocking before Beta and the 1:7 a:b doesn't seem like it would be enough to prevent unopposed Alpha if this were a true Pheo. I almost would have expected him to get worse after labetolol.
My gut tells me that this kid was a bit hypertensive from the ephedra prior to sustaining some trauma that resulted in a pneumo and a head injury. The hypertension caused the bleed to occur easier and evolve faster. If I can't use my mannitol, I want to lower his B/P with the nipride...slowly.
Thank you for these cases, they are helping me as I am getting into CCT



This is when I think Mike starts just throwing stuff in? That sounds very likely, but what slim chances at that age? Treatment plans have been OK if so. I'd feel OK with continuing/finishing the Labetolol and going ahead and adding Nipride. Although... I just can't imagine not having control with Labetolol, I'm always titrating it down around 2-3 mg/min? And it would be fine for an adrenal stressor/tumor. I think we've recognized an "excited adrenal/sympathetic state". I guess it could be that refractory in pheo? Added with everything we've listed up to now (heat, stress, trauma, ephedrine).
  • 0
Mike Williams CCEMT-P/FP-C

#103 shock360j

shock360j

    Member

  • Members
  • PipPip
  • 24 posts

Posted 22 August 2008 - 03:52 PM

Is this a big boy, as in long, gangly arms and legs, long fingers, and a long face? If so, should we be thinking Marfan's Syndrome, and as such Aortic troubles at this point?
  • 0

#104 fire_911medic

fire_911medic

    Advanced Member

  • Members
  • PipPipPip
  • 175 posts

Posted 23 August 2008 - 03:59 AM

Is this a big boy, as in long, gangly arms and legs, long fingers, and a long face? If so, should we be thinking Marfan's Syndrome, and as such Aortic troubles at this point?


That thought crossed my mind earlier shock 360, however at six foot and 200lb he's not really disproportionate so I'm voting that's probably not the case. Glad to see somebody else had the thought pop in their head though.
  • 0
When once you have tasted flight, you will forever walk the earth with your eyes turned skyward, for there you have been, and there you will always want to be. ~~~Leonardo DaVinci

#105 shock360j

shock360j

    Member

  • Members
  • PipPip
  • 24 posts

Posted 23 August 2008 - 04:55 AM

That thought crossed my mind earlier shock 360, however at six foot and 200lb he's not really disproportionate so I'm voting that's probably not the case. Glad to see somebody else had the thought pop in their head though.


I thought the same as you initially, however Marfans isnt necessarily a giant, so much as larger than the rest of your family; IE if his family averages 5'2" on both sides and he's 6ft 200lbs, that is a significant size difference....
  • 0

#106 Mike MacKinnon

Mike MacKinnon

    Advanced Member

  • Members
  • PipPipPip
  • 920 posts

Posted 23 August 2008 - 03:29 PM

Very good!

This case study was always about pheo. These are neuroendocrine tumors of the medulla of the adrenal glands. With a triggering event they can secrete excessive amounts of catecholamines, usually epinephrine and norepinephrine. This explains both the HTN and Tachycardia. The trigger can be anything that causes undue stress (trauma) or direct trauma (getting hit in a football game) to the abdomen. Alos, and the "tip off" in this case study ephedrine. A very common symptom is anxiety like a panic attack. This fellow was taking ephedra and any Indirect-acting sympathomimetics cause further release of norepi/epi from the tumor.

As for treatment choices, the general rule is alpha before beta. This is simply because if we block beta alone then there is an unopposed alpha effect which the results in hypertensive crisis.

As for options:

Labetalol (Trandate, Normodyne) is a noncardioselective beta-adrenergic blocker and selective alpha-adrenergic blocker that has been shown to be effective in controlling hypertension associated with pheochromocytoma. However (as speed mentioned) there have been documented incidents of paradoxic hypertension thought to be secondary to incomplete alpha blockade.

Phenoxybenzamine (Dibenzyline) is the preferred alpha-blocker in preparation for surgery. After effective alpha blockade, administer a beta-blocker. Beta-blockers are needed to control the tachycardia associated with high circulating catecholamine levels and alpha blockade. Of course noone EMS would carry this.

So the next choice might be Nitroprusside for a drip. However, not all HEMS has this drug avaliable.

The other choice is hydralazine. Often avaliable to HEMS for use with high risk OB pts. While it does have a risk of paradoxic tachycardia that is easily controlled with labetolol after BP decreases. Only issue with hydralizine is that it generally takes 5-10 minutes to reach peak effect.

So this is one of those conditions which requires dual alpha beta therapy and critical thinking. It would be easy to discount this drug just because you have a hypertensive tachycardic pt. but the risk of tachycardia is outweighed by the risk of the BP in this young pt. Secondly, we can control the HR with beta blocker after the alpha has started to work on the BP, it is not contraindicated then.

Nitro was also mentioned and it is certainly an option, though an indirect one. Nitro is a vasodilator and pheo releases norepi causing significant arterial constriction. While dilating the venous system WILL treat the HTN it may not be the best treatment. The literature in this regard is almost non-existent. I have read case reports where nitro was used but the suggestion was that the catecholamine release was mild to moderate for ntg to work at all. The level best tx is pure alpha like nipride then beta for the tachycardia.

Recently, i had a pt in the OR who was 18 with a pheo getting surgery, he had a crisis and I treated it with nipride and labetolol together. Worked well but then i knew it was coming :L)

Excellent work all!

OK . . . so, this could be WAY off, but what about a pheo? (that's my dif dx). A pheochromocytoma would be the perfect "zebra" for this case :) and the palpitations, light-headed feeling, and headache after repeated hits to the gut set off alarm bells in my head. Manipulation of the tumor(s) by the mutliple tackles sets off a sympathetic response, thus releasing epi and norepi, raising the heart rate and BP and could have precipitated a head bleed. (Still haven't quite placed the pneumo . . .) The small amount of ephedra that he did take for the first time didn't do him any favors, as it would add to epi and norepi effects. I would opt for the nipride, start at 0.5 mcg/kg/min and titrate to a MAP around 100-120 for the hypertensive crisis. Since he likely has a head bleed (blown pupil, etc) it complicates BP control, still needing adequate cerebral perfusion without enlarging the bleed . . . This guy is a nightmare, even if it's not a pheo! Thanks for the great case, Mike!


  • 0
Mike MacKinnon MSN CRNA
WWW.NURSE-ANESTHESIA.ORG

"What gets us into trouble is not what we don't know
It's what we know for sure that just ain't so" - Mark Twain

#107 Speed

Speed

    Advanced Member

  • Members
  • PipPipPip
  • 1100 posts

Posted 23 August 2008 - 07:19 PM

Nice catch JPatterson & flyin dutch.
  • 0
Mike Williams CCEMT-P/FP-C

#108 rfdsdoc

rfdsdoc

    Advanced Member

  • Members
  • PipPipPip
  • 129 posts

Posted 23 August 2008 - 08:35 PM

thanks, MIKE
  • 0
Minh Le Cong
Medical Officer
MBBS(Adelaide), FRACGP, FACRRM, FARGP, GDRGP, GCMA
RFDS Cairns base , Queensland, Australia

#109 JPatterson

JPatterson

    Advanced Member

  • Members
  • PipPipPip
  • 47 posts

Posted 23 August 2008 - 11:26 PM

Nice catch JPatterson & flyin dutch.


Thank you. We had a Pheo case recently at my facility and it became a case presentation for the Critical Care Department after problematic surgery x2. I am fairly new to this and appreciate the years of experience and education that the people on this forum provide. I always learn something new.
  • 0
Jeff Patterson NREMT-P

#110 JPatterson

JPatterson

    Advanced Member

  • Members
  • PipPipPip
  • 47 posts

Posted 23 August 2008 - 11:27 PM

Mike,
I do have a question...what about Regitine (?spelling)
  • 0
Jeff Patterson NREMT-P

#111 Mike MacKinnon

Mike MacKinnon

    Advanced Member

  • Members
  • PipPipPip
  • 920 posts

Posted 24 August 2008 - 01:40 AM

Hey JP

Phentolamine mesylate (Regitine) is also an option but again something most people dont have. For those who are unfarmiliar with it, its a nonselective alpha-adrenergic blocking agent. Drug action is transient and alpha-adrenergic blockade incomplete. Often used immediately prior to or during adrenalectomy to prevent or control paroxysmal hypertension resulting from anesthesia, stress, or operative manipulation of the tumor. Alpha1- and alpha2-adrenergic blocking agent that blocks circulating epinephrine and norepinephrine action, reducing hypertension that results from catecholamine effects on alpha-receptors.

The adult dose would be 5-15 mg IV; used to control intraoperative hypertensive crises

Mike,
I do have a question...what about Regitine (?spelling)


  • 0
Mike MacKinnon MSN CRNA
WWW.NURSE-ANESTHESIA.ORG

"What gets us into trouble is not what we don't know
It's what we know for sure that just ain't so" - Mark Twain

#112 flyin dutch

flyin dutch

    Advanced Member

  • Members
  • PipPipPip
  • 31 posts

Posted 24 August 2008 - 02:01 PM

Nice catch JPatterson & flyin dutch.


Thanks ;) It's always a GREAT learning experience!
  • 0

#113 EDMEDIC

EDMEDIC

    Advanced Member

  • Members
  • PipPipPip
  • 94 posts

Posted 25 August 2008 - 02:57 PM

Great case. I knew there was a zebra, just couldn't spot it! Thanx, Mike....Brian
  • 0
Brian EMT-P/CC
"failing to prepare is preparing to fail"
" you don't know what you don't know"

#114 Mike MacKinnon

Mike MacKinnon

    Advanced Member

  • Members
  • PipPipPip
  • 920 posts

Posted 25 August 2008 - 03:04 PM

NP

I love doing these. I generally learn or "relearn" something everytime I present them. Often peoples responses teach me alot as well!

Great stuff!
  • 0
Mike MacKinnon MSN CRNA
WWW.NURSE-ANESTHESIA.ORG

"What gets us into trouble is not what we don't know
It's what we know for sure that just ain't so" - Mark Twain

#115 EDMEDIC

EDMEDIC

    Advanced Member

  • Members
  • PipPipPip
  • 94 posts

Posted 07 September 2008 - 01:23 PM

hey Mike, awaiting the next case...I'll look at little harder for the zebra this time around..They're always great, Brian
  • 0
Brian EMT-P/CC
"failing to prepare is preparing to fail"
" you don't know what you don't know"