Jump to content


Photo
* * * * - 1 votes

Case #34 Young + Ami = ?


  • Please log in to reply
62 replies to this topic

#21 mecpplu

mecpplu

    Newbie

  • Members
  • Pip
  • 4 posts

Posted 03 December 2007 - 12:11 PM

Great post. I love these so much I read word for word, but now have little time to research due to "real job" requirements right now. I'd like to hear some more about her recreational pharmaceutical ingestion that I suspect is the root cause of all this evil. Gotta run, but will return later to see how things progress and may have something more smart to say by then.
  • 0

#22 cumedic

cumedic

    Advanced Member

  • Members
  • PipPipPip
  • 88 posts

Posted 03 December 2007 - 02:36 PM

We just covered the poor sensitivity and specificity of drug screening in my biostats class... Was someone reenacting a scene from Blow...


Take care all.
  • 0
CUmedic, NREMT-P

who is john galt?

#23 BamaFlightRN

BamaFlightRN

    Member

  • Members
  • PipPip
  • 22 posts

Posted 03 December 2007 - 03:43 PM

Hey Mike, did the referrring have ECHO capability? Would love to see what her valves look like. Prefer TEE but any echo would tell you the valve function. As far as the flight crew, she has decompensated heart failure and needs to be intubated early on. Intubate, agree with the medications to improve hemodynamics. I like Nipride but Nitro will do, and add a touch of Dobutamine. If I had the capablility I would place a quick arterial line. Foley cath with judicious lasix. Renal function is probably compromised. I wouldnt get tunnel vision on the EKG. I highly doubt the girl is having a AMI, coronary vasospasm possible but not likely. If she had a positive cocaine screen I would think that would be a possiblity. I see the title though, Young + AMI makes me think a Zebra is causing her to actually have a AMI, gotta hate those Zebra induced MI's. Either way, get in the air and be sure your "local cath lab" also has the capablity of doing valvular surgery. Cant wait to hear more.
  • 0

#24 ST RN/PM

ST RN/PM

    Advanced Member

  • Members
  • PipPipPip
  • 160 posts

Posted 03 December 2007 - 05:00 PM

Hey,
Just a general question to those in the forum.....(I know whats goin on with this patient...hee hee hee). When using Sodium Nitroprusside to reduce afterload/SVR in heart failure, is there a specific target MAP/Coronary perfusion pressure when starting the infusion? Titrate to effect always works for down and dirty, but in LV failure that looks like it's heading for cardiogenic shock, an initially high pressure turns into a crappy one......and I am always a little hesitant about expediting this clinical phenomenon. A Little Dobutamine goes a long way for squeeze in this patient, but the Hypotension associated with the Beta 2 can come into play as well.......Also....would starting Nipride at 0.1 mcg/kg/min be the most judicious... and titrate up? Thanks, Steve
  • 0
Steve T. RN, PM

#25 ST RN/PM

ST RN/PM

    Advanced Member

  • Members
  • PipPipPip
  • 160 posts

Posted 03 December 2007 - 05:00 PM

Hey,
Just a general question to those in the forum.....(I know whats goin on with this patient...hee hee hee). When using Sodium Nitroprusside to reduce afterload/SVR in heart failure, is there a specific target MAP/Coronary perfusion pressure when starting the infusion? Titrate to effect always works for down and dirty, but in LV failure that looks like it's heading for cardiogenic shock, an initially high pressure turns into a crappy one......and I am always a little hesitant about expediting this clinical phenomenon. A Little Dobutamine goes a long way for squeeze in this patient, but the Hypotension associated with the Beta 2 can come into play as well.......Also....would starting Nipride at 0.1 mcg/kg/min be the most judicious... and titrate up? Thanks, Steve
  • 0
Steve T. RN, PM

#26 dan bergman

dan bergman

    Newbie

  • Members
  • Pip
  • 6 posts

Posted 03 December 2007 - 05:57 PM

Hello to all, I'm new to the forum and just landed my first flight job. Thats my excuse for hanging out here and looking retarded but maybe I can learn a little and thats what this is for right?. So with my limited knowledge(have not even finished ground school) Here is what my plan would be.(by the way I really have learned alot just from reading but wanted to give a go and get a little critique maybe) 1. of course airway, airway airway so NRB to start with highflow o2. next breathing her rate seems ok and may improve with a few more o's around, at 19 with this history would I be completely off track to think a lytic? Smoker, probably Birth control but unk. The PE question ? Chest pain and eleveted inflamation markers. If nothing else it could rule out something for me and help in a hurry? 3. The bolus then crackles have me concerned so maybe some lasix, I don't know if I am comfortable with the dobu-pride combo but that is just from lack of personal experience and I really want to admit what I don't know. Other than that I think loading and going to the next higher level of care is what is needed for deffinitive diagnosis. I know from my time in the er that the drug question may be a real one and throwing a zebra at us but a cardiac cath can answer a whole lot of questions. If its clean you start the next line but we have to treat the most life threatening first correct? Well that's my little contributiona nd I know I didn't add to much I just wanted to throw it out to get any feed back on thought process.

Thanks and be safe
  • 0

#27 Speed

Speed

    Advanced Member

  • Members
  • PipPipPip
  • 1100 posts

Posted 03 December 2007 - 10:35 PM

Hey,
Just a general question to those in the forum.....(I know whats goin on with this patient...hee hee hee). When using Sodium Nitroprusside to reduce afterload/SVR in heart failure, is there a specific target MAP/Coronary perfusion pressure when starting the infusion? Titrate to effect always works for down and dirty, but in LV failure that looks like it's heading for cardiogenic shock, an initially high pressure turns into a crappy one......and I am always a little hesitant about expediting this clinical phenomenon. A Little Dobutamine goes a long way for squeeze in this patient, but the Hypotension associated with the Beta 2 can come into play as well.......Also....would starting Nipride at 0.1 mcg/kg/min be the most judicious... and titrate up? Thanks, Steve


Your definitely right about turning a pressure crappy when you get things "moving". I would make sure that the IV nitro was well on board and it's efficacy in this case was well defined, and then go slowly with the nipride. I was thinking about Dobutamine as well, to get the pump going and pull some of that back-up out of the lungs. BUT... if the heart's intake from the lungs was narrowed wouldn't you just be "revving" a near-dry pump as well? I would go with getting to a lower PAP first, see how things are going, and save the Dobutamine to "test out" later, definitely needs a consult with med control on it for me.
  • 0
Mike Williams CCEMT-P/FP-C

#28 Mike MacKinnon

Mike MacKinnon

    Advanced Member

  • Members
  • PipPipPip
  • 920 posts

Posted 03 December 2007 - 11:30 PM

Just got home :)

Gonna put up some more info tonight/tomorrow

And i do have some more images :P
  • 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

#29 jwalshfan

jwalshfan

    Advanced Member

  • Members
  • PipPipPip
  • 46 posts

Posted 04 December 2007 - 03:21 AM

PMH Rheumatic Fever. Probable undiagnosed Rheumatic heart disease as a child. In most cases, by the time the MV regurg is detected in the 15 to 30 year old population, surgical intervention is the only option.

Would be interesting if they had an ECHO to get an idea of what the CV function/structure was.

So regardless....... isn't going to get better just sitting there. I would also contact the recieving hospital's heart guy/gal and get his/her thoughts for immediate interventions as this seems like a pretty unusual case.


Warren, LP/RN
  • 0

#30 MSDeltaFlt

MSDeltaFlt

    Advanced Member

  • Members
  • PipPipPip
  • 559 posts

Posted 04 December 2007 - 05:41 PM

There are several things happening here that are NOT supposed to happen.

1. 19 yo /c symptomatic CP/SOB
2. Correlating ECG changes. Physiologic L Axis and Ant/Lat ischemia on a 19 yo
3. A 19 yo is not supposed to have wet lungs
4. ...or a MAP of 128

She needs an interventional cath performed... now. Whatever gets done should get done on the way to the AC and in the air.

Get 20 steps ahead of her.
Get her pain free. If you can't get it with her own airway intact, then get it post intubation, and go by VS.
In the mean time, 15 l/m NRM. Lay off the CPAP or BiPAP, she's probably too keyed up to tolerate that anyway. Get intubation stuff out and ready.
Get the fluid off of her. Either with Nitro alone or with some added diuretics.
Put pacer pads on her. There's a good chance you might need 'em.
I personally don't like Nipride without an A-Line. Crank up the Nitro. Get some Dobutamine goin. Get Dope spiked.
Stay 20 steps ahead of her.
Get her to the cath lab.

Please correct me if I'm wrong. That's just the way I see it.

Fly Safe
  • 0
Mike Hester, RRT/NRP/FP-C
Courage is resistance to fear, mastery of fear - not absence of fear -- Mark Twain

#31 Pippy187

Pippy187

    Newbie

  • Members
  • Pip
  • 2 posts

Posted 05 December 2007 - 01:54 AM

This could be the precursor to a catastrophic cardiac event, her S/S are pretty scary ( v/s, LAD, Bi-phasic t's ). Her history scares me even more ( Rhumatic HD?, Mitral valve regurg, smoker, she on BC? ) with a slew of differential Dx: AMI, Mitral failure, Wellens, RHD, PE. ~ My Diff Dx is going to be possible rhumatic HD...w/ possible mitral valve failure and has compensatory v/s. Id be ready to control her airway ( and add some PEEP for those wet lungs).... Look at this use of some after load reducers ( Nipride ) possible consider sort acting beta blockade such as esmolol. I would have Inotropes and pressors ready to rock, hopefully have TLC and some peripheral lines in place and an a-line. This pt need to go to a level one cardiac center.
  • 0

#32 MFlightRN

MFlightRN

    Advanced Member

  • Members
  • PipPipPip
  • 282 posts

Posted 05 December 2007 - 02:59 AM

It's very difficult, although not impossible for a 19 yr old to be experiencing ACS. Her pmhx of rheumatic HD leads one to believe her symtpoms and work up are related to either a failing left ventricle or failure of the mitral valve. I would be careful with diuresis, as there could be a 'remote' possibility of hypertrophic cardiomyopathy (HCM)? She needs an ECHO!!

Any fevers? If so, maybe corticosteriods?


Hmmmm?????????????? :blink:
  • 0
Lou-

#33 Mike MacKinnon

Mike MacKinnon

    Advanced Member

  • Members
  • PipPipPip
  • 920 posts

Posted 06 December 2007 - 12:59 AM

Ok

To answer some of the general questions:


1. Does she have any peripheral edema? The biphasic T wave in V1 makes me suspicious of ventricular hypertrophy.

Nope ;)

2. Did they do a BNP? If so what was that?

Nope :)

3. What were her electrolyte studies? In particular K+, Ca and Mag. Did they do a D Dimer?(Not a great test but warrants further looking if really elevated)

All normal

. Did they CT her chest for PE?

Yup Negative as was ddimer

Is she on birth control pills?

She has not taken them for 3 months.


I'd also want to know what the ED had done for her in the past that resolved her similar episodes.

Ativan & home


do we have her previous 12 leads to compare?

None done that are available.

can we get a quick abg?

Yup, comin in next post right after this one :)

how bad is her murmur?

You can barely hear it

is the MD able to appreciate it as worse than before?

They dont think its any different

what is the description of the chest pain?

Dull pain to crushing pain.


any aggravating/alleviating factors?

Not that she knows of. It comes randomly and not related to activity. She says it is often when she is in her room alone.

how fast was the onset?

Very acute.

what was she doing when it happened?

In her room alone crying about her dad.

was the medication the RN was administering a the bedside when we walked in the last increment of metoprolol?

RN gave morphine and last metoprolol was 20 min ago

Previous visits to this facility: any findings that were suggesting CHF?

None suggestive of CHF

Why was a fluid bolus given?

"Support pressure" was the official explanation.

How old was Dad when fatal MI?

58 y/o

Any JVD?

Not obvious

Does the murmur have an "odd" sound to it?

Nope

CXR: is cardiac shadow enlarged?

Nope but the echo is interesting and coming up.

What transport time by the way Mike?

By air it will be 2 hours to the receiving

Talk to the receiving cardiac team and fax EKG to them. Decision on lysis should be made in consultation in this setting.


The receiving does not want her given lysis, they are taking her right to cath.

Did the pain/presentation change at all with the NTG? It seems she's received a bunch by this point.

Mild decrease in pain but not relieved. MS also helps.

After the NTG, Morphine, and lopressor, why is the blood pressure still so high?

Hmmmm :)

Why give a liter of NS to a patient with wet lungs and hypertension?

Seems crazy dosent it?

On the ECG there seems to be fairly limited ST segment changes (limited in anatomy, I mean), with no recroprical changes.

VERY true. No reciprocals...



SEE NEXT POST FOR MORE INFO
  • 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

#34 Mike MacKinnon

Mike MacKinnon

    Advanced Member

  • Members
  • PipPipPip
  • 920 posts

Posted 06 December 2007 - 01:21 AM

more info.


Ok So she tells you she might be pregnant. Noone did a screen and so its added to the blood, she is. 2-3 months.

Here is the TEE

Posted Image

Attached is the moving version

Posted Image
  • 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

#35 Flightgypsy

Flightgypsy

    Advanced Member

  • Members
  • PipPipPip
  • 104 posts

Posted 06 December 2007 - 01:38 AM

Ok, the more information you give us the more I am thinking a congenital heart defect. Any chance they took BP's in all her limbs and any differences? How about a chest x-ray? Anything unusual about it (like say "rib-notching")?
Could be an ALCAPA (Anomalous Left Coronary Artery from the Pulmonary Artery) which often presents with an MI but they are usually very sick very young. Occasionally they can be asymptomatic until late teens. I'm guessing something like a Co-arctation of the Aorta with her history of hypertension.

She needs lasix for the CHF and PEEP for sure if you have to intubate her. Some kind of afterload reducer maybe but if it is a co-arc. it will not help her and will just end up making her worse. I would also be careful about giving her something to increase her contractility as that could make it worse as well. There are so many possible CHDs that you need a lot more information before I would start any treatments. (unless she deteriorates to the point of coding or you need to intubate her). I think I would be on the phone to a pediatric cardiologist as opposed to an adult one or as well as.

I really don't think anti-thrombolytics are going to be called for in this case. Interventional cardiology may be necessary or she may need to go straight to surgery.

Another thing to think about is if it is a CHD then she really should be started on antibiotics especially if she needs to go to surgery.

Waiting for more info......

Cheers all,

Addit: A murmur in CHD can be very misleading. Some of the most critical and messed-up hearts you can think of can have absolutely no murmur.
  • 0

#36 RoadieRN

RoadieRN

    Advanced Member

  • Members
  • PipPipPip
  • 94 posts

Posted 06 December 2007 - 02:08 AM

By no means am I a cardiologist or ECHO tech, but it looks like to me that she may have an ASD(atrial septal defect) and maybe the tiniest VSD(ventricular septal defect) and possibly some vegetation growing on her mitral valve. Like I said, by no means an expert at reading ECHOs. If that is the case, I would do supplemental O2 like maybe 2-3L NC just so we didn't flood the capillary bed w/too much O2 d/t this young lady possibly being a mixer. I would make sure I had two large bore IVs at KVO w/a 250 ml fluid challenge so we didn't flood her as well as possibly some Lasix (20mg) after our bolus w/a foley to measure our end organ perfusion. I wonder if may be she did some blow aggrevating her already unknown precarious cardiopulmonay system, perhaps a straw breaking the camel's back scenerio.
Something else I thought of prior to hearing about her cardiac silouette on CXR was that maybe she had Marfan's Syndrome. Mike, what's her stature and hand size like, just for giggles? Just something else to go with our differential.
That's all I got for now. My brain is jelly after my training academy today. Ouch!

Take Care,
Nick Crusius RN, BSN
Flight Nurse, PHI/Airevac 23
  • 0
Nick Crusius RN, BSN

Keep the rubber(or skid, if it applies) side down!

#37 Speed

Speed

    Advanced Member

  • Members
  • PipPipPip
  • 1100 posts

Posted 06 December 2007 - 04:04 AM

I'd also want to know what the ED had done for her in the past that resolved her similar episodes.

Ativan & home

is the MD able to appreciate it as worse than before?

They dont think its any different

It sounds like they've altered from their past treatment and disposition so something's different from last time right?

what is the description of the chest pain?

Dull pain to crushing pain.

Doesn't really go with Marfan's / Aneurysms, but still not completely ruled out.

any aggravating/alleviating factors?

Not that she knows of. It comes randomly and not related to activity. She says it is often when she is in her room alone.

Anything more than what the patient's telling me and quantitative evidence is going to be mere speculation on my part.

how fast was the onset?

Very acute.

I'd say that's an emergency warranting a definitive answer.

what was she doing when it happened?

In her room alone crying about her dad.

Maybe spend some alone time getting a good straight story just in case... I always educate them of how invasive some of the options could be and describe the increased risks of medical errors and... they sometimes talk.

was the medication the RN was administering a the bedside when we walked in the last increment of metoprolol?

RN gave morphine and last metoprolol was 20 min ago

I would feel very comfortable getting a little more aggressive in controlling the BP then I want to see the results and tolerance of resolving her moderately elevated BP, especially due to the pulmonary edema.

Previous visits to this facility: any findings that were suggesting CHF?

None suggestive of CHF

Yet another statement that indicates that "somethings" different this time.

The receiving does not want her given lysis, they are taking her right to cath.

Well, sounds like an acceptable destination that can do interventions cardiac services. I'd say pack up, go, and follow your protocols.

Did the pain/presentation change at all with the NTG? It seems she's received a bunch by this point.

Mild decrease in pain but not relieved. MS also helps.

Hell if it (morphine) helps, keep giving it within reason and smartly titrated. And hey, if ativan could get her feeling well enough to go home last time, might as well try it now just because it wouldn't hurt. Just enough to get her comfortable for the ride. Whether she's a seeker or not a benzo seems warranted with chest pain and hypertension. Just make sure she doesn't start to increase her WOB with the edema on board.

After the NTG, Morphine, and Lopressor, why is the blood pressure still so high?

Hmmmm

At this point I'm gonna have to just play paramedic and roll with the punches. Do what I know would be safe and keep things from getting worse. You know, just stay ahead of everything.
  • 0
Mike Williams CCEMT-P/FP-C

#38 justlookin

justlookin

    Advanced Member

  • Members
  • PipPipPip
  • 117 posts

Posted 06 December 2007 - 05:15 AM

Is she also Japanese? ;)

Looks textbook for Takotsubo CMO, also known as "transient left ventricular apex ballooning".

Her history, symptoms, and ECHO match perfectly with the cover article by Brenda McCulloch in this month's edition of "Critical Care Nurse" from AACN.

She doesn't need lytics, plavix, inotropes, an IABP, etc.......She needs something to make her go to a happy place and relax for a while.

This is why the "Ativan and home" plan worked for all the other ED visits. Her pre-existing MR is worsened when the shape of her LV becomes acutely distorted due to the catecholamine rush of a severe emotional event. Thus the crackles, but no peripheral edema. The ativan reduces her BP, removes the emotional stimulus, thereby lowering the circulating levels of catecholamines in her bloodstream. Her LV can "chill out" and the symptoms dissappear.

I don't think putting this emotionally labile girl in a helicopter for 2 hours is a good idea right now....
  • 0

#39 rfdsdoc

rfdsdoc

    Advanced Member

  • Members
  • PipPipPip
  • 129 posts

Posted 06 December 2007 - 05:17 AM

Hey Mike and co

Been away on remote clinic so only just caught up with progress of case. Seems my initial impressions of acute MI were wrong on viewing in the TEE images. Well if you told me we could get a TEE then I would not have been in the dark so much before making my first response at the case!

Someone has already mentioned the diagnosis so hats of to them. Yeah the TEE images show asymmetric interventricular septal shape suspiscious for HOCM. I can't really see any signs of an ASD or VSD nor vegetations. The apex looks dyskinetic but the diagnosis is HOCM and it fits the clinical picture. There is mild SAM of the mitral leaflet shown on the video which also fits.

ANyway this is all a bit academic as it just tells me she needs to be under cardiac specialist care now and I would not waste much time as many have already suggested. I'd still tube her using a cardiac anaesthetic, put some defib pads on as HOCM is at risk of ventricular arrhythmias and get going.

Try to slow her heart rate would be good and you could use esmolol infusion or more metoprolol if you did not have esmolol.

Now is the early pregnancy a problem for transport and packaging, probably not. It might explain why she decompensated though with her HOCM given extra fluid load in pregnancy.

Why is her BP still high...not sure yet, bit early in pregnancy for PIH. Certainly HOCM is associated with hypertension that can be difficult to treat so I would blame it on that for now..ok

Great case Mike and great images and video..you will have to share your secret teaching library with me someday..lol
  • 0
Minh Le Cong
Medical Officer
MBBS(Adelaide), FRACGP, FACRRM, FARGP, GDRGP, GCMA
RFDS Cairns base , Queensland, Australia

#40 buffettrn

buffettrn

    Advanced Member

  • Members
  • PipPipPip
  • 78 posts

Posted 06 December 2007 - 01:22 PM

MMMMhh a happy place.
Let's try some ativan like medication (for the patient). It worked before and it certainly can not hurt at this point. Does she have proteinurea? Could BP be PIH? NOw not being a cardiologist and not the eye sight of your youngin's (I could not get the dynamic echo to enlarge) I believe I see a couple things. The lower valve does not seem to be moving the wall motion is abismal except for a couple of isolated areas.
I will plan on the following:
Ativan is Class D in pregnancy, Benadryl is class B and may get you a similar effect.
If her sats do not come up after this RSI her for the 2 hour flight. This will definatley relieve any anxiety.
Bump up the nitro and add a bit more morphine (helps with anxiety, pain, and BP).
Foley and a wee bit of the lasix.
Give this all a bit to mix and stir with the big turbine engine and transport.
  • 0
Jeff Fein
"We are right, they are wrong, END OF STORY"