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Case #34 Young + Ami = ?


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#41 chris

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Posted 06 December 2007 - 02:44 PM

I could not get the active motion to enlarge, but it looks like some hypokinesis in the ventricle. So I agree with RSI, sedation and continue with afterload reduction. A whiff of lasix maybe some Nipride if her bp continues to be problematic. Then the quickest trip to nearest interventional cardiac center.
Chris
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#42 MSDeltaFlt

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Posted 06 December 2007 - 07:34 PM

What are the odds here of this lady being Pre-Ecclamptic and having a bad heart she inherited from dear old dad? If that's the case, how about a Mag drip for the smooth muscle relaxation? Mag's normal, and I'm sure the heart and lungs might appreciate the gesture.
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Mike Hester, RRT/NRP/FP-C
Courage is resistance to fear, mastery of fear - not absence of fear -- Mark Twain

#43 GravyMedic

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Posted 06 December 2007 - 08:33 PM

What are the odds here of this lady being Pre-Ecclamptic and having a bad heart she inherited from dear old dad? If that's the case, how about a Mag drip for the smooth muscle relaxation? Mag's normal, and I'm sure the heart and lungs might appreciate the gesture.


Biatrial enlargement and probably mitral regurg... Although without the color it's hard to tell. I dont see any prolapse. In agreement that right now she needs some ativan for starters.
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#44 MSDeltaFlt

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Posted 07 December 2007 - 05:22 PM

It difficult to determine from the story line, Mike M, but it sounds like we're focusing on her heart... possibly a little too much.

This is not her first rodeo. She has a bad heart. She's always had a bad heart exacerbated by anxiety and fixed with benzo's and calming environment. What's changed? She's pregnant. Any more info on this, Mike?
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Mike Hester, RRT/NRP/FP-C
Courage is resistance to fear, mastery of fear - not absence of fear -- Mark Twain

#45 STPEMTP

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Posted 07 December 2007 - 08:17 PM

I don't know much about reading the echo's but it looks like she has some problems with the septal wall, and I don't think the motion with the mitral valve is normal. I think I'm going to jump on the bandwagon that Speed, Justlookin, Buffettrn have suggested that we try to calm her down with some ativan or your benzo of choice. With her sats of 92%, I don't think I would RSI yet, but definitely would have everything ready to go. A small dose of Lasix might help clear up the rales that she has and if we're lucky improve her sats. Before adding in Nipride to this mix, I'd try upping the Nitro drip to see if we can bring her pressure down with that.
If she hasn't already been loaded into the aircraft, let's get her there and get going. This is going to be an interesting ride........
Hopefully this is the only zebra, not a situation where we're looking at one and ignoring the herd.......
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#46 rfdsdoc

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Posted 08 December 2007 - 01:20 AM

Hey folks

Fair point about not needing to tube her right now. I am only preparing for the probable VF/VT arrest inflight.

Look up HOCM , guys. THis is the diagnosis. The clinical picture fits as well as the EKG and the echo images.

Stop the nitrate drip, no veno or arterial vasodilators as these worsen the obstruction to LVOT. Control heart rate and BP with esmolol drip, chest pain needs opiates such as fentanyl, wait in ED till HR and BP better before moving.

Ativan good idea. Lasix not so good an idea, she is not fluid overloaded, just got a crappy left ventricle outflow obstruction.
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Minh Le Cong
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#47 Speed

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Posted 08 December 2007 - 02:39 AM

Hey folks

Fair point about not needing to tube her right now. I am only preparing for the probable VF/VT arrest inflight.

Look up HOCM , guys. THis is the diagnosis. The clinical picture fits as well as the EKG and the echo images.

Stop the nitrate drip, no veno or arterial vasodilators as these worsen the obstruction to LVOT. Control heart rate and BP with esmolol drip, chest pain needs opiates such as fentanyl, wait in ED till HR and BP better before moving.

Ativan good idea. Lasix not so good an idea, she is not fluid overloaded, just got a crappy left ventricle outflow obstruction.


When they said she had the murmer I was focused on the mitral valve, especially with her history of rheumatic fever.
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Mike Williams CCEMT-P/FP-C

#48 MFlightRN

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Posted 08 December 2007 - 03:28 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:


Guess the 'remote' possibility of HCM wasn't so 'remote!' ;)
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Lou-

#49 rfdsdoc

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Posted 08 December 2007 - 03:42 AM

Once again Big Lou
You be the MAN!


Oh and Mitral regurg often goes along with HOCM so I am sure Mike McKinnon threw the rheumatic heart disease thing in to confuse us, but not you, mate.

Actually for those who have suggested that speedy transport is going to make the difference I guess once you have a diagnosis on the echo then speed is not so vital, more so adequate flight preparation of a cardiac unstable patient. Its easy to just call your receiving cardiac team tell them or email them the echo findings and get them to sort out a management plan to prepare this patient for a 2hr flight.

If you leave with crappy ABCs then you are going to have a hard time improving them along the way at altitude in a noisy vibrating coffin, and now that you have a diagnosis I find it hard to justify spending less time preparing a patient for flight.

certainly turning off some of the treatment we have going would be a good start before leaving the ED!
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Minh Le Cong
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RFDS Cairns base , Queensland, Australia

#50 BackcountryMedic

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Posted 08 December 2007 - 04:26 AM

certainly turning off some of the treatment we have going would be a good start before leaving the ED!


I've been a lurker on this one because I did not have a clue what was going on. Once again I've learned a ton.

rfdsdoc: What should we turn off? after you gave me the Dx I did some research and the AHA recommends beta blockers (http://www.americanh...identifier=4468) I can't tell if this is for long term Rx or for an acute case like this. With this pt HTN a blocker may not be a bad idea, but I'll admit to being out of my element. What meds do you recommend (if any)?

Thanks for your help!
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"If everybody is thinking alike, then somebody isn't thinking" - Patton

#51 Sbastian

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Posted 08 December 2007 - 05:55 PM

OK here goes.....

I will throw my hat into the ring and go with Tako Subo Cardiamyopathy AKA Broken Heart Syndrome. A definite zebra, but in this case an accurate Dx. The history, S/S, and echo all confirm the Dx. Need to support the left ventricle until it can recover. Had a patient with this diagnosis a few months ago. The cardiac team placed an LVAD and allowed complete rest of the left ventricle. The patient walked out of the hospital with an normal EF after three days rest on the LVAD. This case is more the "classic" presentation of this phenomena, unlike the medically induced case that my colleague and I transported.

The young lady's coronary arteries will, most likely, be clean on catheterization. Tako subo usually has little to no coronary artery disease. It is thought to be caused by an acute increase in sympathetic tone, psychogenic in this case (stress of pregnancy and death of father). The cardiomyopathy is reversible in this syndrome, so she will need all of the ventricular support that we can muster until this passes.

A two hour ride to the cardiac center is a long haul. Probably doesn’t need to suck air through plastic, and the deleterious effects of positive pressure ventilation on he already poor cardiac output. Inotropes, chronotropes, and reduction in afterload is our best course of action. If maximal pharmacological support fails, she will need a LVAD. I don't have a protocol for one of those, any of you?
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Audiatur et altera pars!

#52 MFlightRN

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Posted 08 December 2007 - 06:54 PM

Once again Big Lou
You be the MAN!
Oh and Mitral regurg often goes along with HOCM so I am sure Mike McKinnon threw the rheumatic heart disease thing in to confuse us, but not you, mate.

Actually for those who have suggested that speedy transport is going to make the difference I guess once you have a diagnosis on the echo then speed is not so vital, more so adequate flight preparation of a cardiac unstable patient. Its easy to just call your receiving cardiac team tell them or email them the echo findings and get them to sort out a management plan to prepare this patient for a 2hr flight.

If you leave with crappy ABCs then you are going to have a hard time improving them along the way at altitude in a noisy vibrating coffin, and now that you have a diagnosis I find it hard to justify spending less time preparing a patient for flight.

certainly turning off some of the treatment we have going would be a good start before leaving the ED!


Ready for that beer now! :P
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Lou-

#53 Speed

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Posted 08 December 2007 - 07:18 PM

Sbastion,

Broken heart syndrome! I think that sounds more believable. Seems to fit better. I'm still sticking with my prior treatments and can see how the Ativan sent her home last time. Guess there wasn't much difference from her past presentations except for more of an acute exacerbation, plus the added burden of pregnancy. I'm sure she would've benefited from a good conversation with the attendants, "talked down".

Nice catch!
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Mike Williams CCEMT-P/FP-C

#54 Mike MacKinnon

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Posted 09 December 2007 - 03:21 PM

Well done everyone!

Yup, this girl did have "broken heart syndrome" otherwise known as Takotsubo cardiomyopathy.

Takotsubo cardiomyopathy, also known as transient apical ballooning and stress-induced cardiomyopathy, is a type of non-ischemic cardiomyopathy in which there is a sudden temporary weakening of the myocardium (the muscle of the heart). Because this weakening can be triggered by emotional stress, such as the death of a loved one, the condition is also known as broken heart syndrome .

The typical presentation of someone with takotsubo cardiomyopathy is a sudden onset of congestive heart failure or chest pain associated with EKG changes suggestive of an anterior wall heart attack. During the course of evaluation of the patient, a bulging out of the left ventricular apex with a hypercontractile base of the left ventricle is often noted. It is the hallmark bulging out of the apex of the heart with preserved function of the base that earned the syndrome its name "tako tsubo", or octopus trap in Japan, where it was first described. Evaluation of individuals with takotsubo cardiomyopathy typically include a coronary angiogram, which will not reveal any significant blockages that would cause the left ventricular dysfunction. Provided that the individual survives their initial presentation, the left ventricular function improves within 2 months. Takotsubo cardiomyopathy is more commonly seen in post-menopausal women. Often there is a history of a recent severe emotional or physical stress.

The hypothesis is that massive amounts of these stress hormones can go right to the heart and produce a stunning of the heart muscle that causes this temporary dysfunction resembling a heart attack. It doesn't kill the heart muscle like a typical heart attack, but it renders it helpless.

The recovery is often quick as well.

I wonder how many of these people actually come into the ER but are never correctly diagnosed!



Sbastion,

Broken heart syndrome! I think that sounds more believable. Seems to fit better. I'm still sticking with my prior treatments and can see how the Ativan sent her home last time. Guess there wasn't much difference from her past presentations except for more of an acute exacerbation, plus the added burden of pregnancy. I'm sure she would've benefited from a good conversation with the attendants, "talked down".

Nice catch!


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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

#55 rfdsdoc

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Posted 10 December 2007 - 02:39 AM

Fancy that!

Well done to Sbastian.

Learn something new every time..
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Minh Le Cong
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MBBS(Adelaide), FRACGP, FACRRM, FARGP, GDRGP, GCMA
RFDS Cairns base , Queensland, Australia

#56 fiznat

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Posted 11 December 2007 - 01:29 AM

Well that is some cool stuff. Excellent case!

haha so is this the other PMS? (P meaning "post" in this case, I guess...)

Can someone explain to me the persistent hypertension then? Stress induced? My small brain can't quite figure it out: LV dysfunction, beta blockers, vasoactive drugs, and the SBP was still in the 180's? I don't understand how that fits...

Also I haven't found it yet in searching, but what is the incidence of this condition? I found that 10% of sufferers will experience the condition again, but not how often this actually happens...
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#57 Mike MacKinnon

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Posted 11 December 2007 - 10:00 PM

Ah yah I forgot about that part.

So..


Why is it that this pt was tachycardic and hypertensive for so long while getting these meds?


Well that is some cool stuff. Excellent case!

haha so is this the other PMS? (P meaning "post" in this case, I guess...)

Can someone explain to me the persistent hypertension then? Stress induced? My small brain can't quite figure it out: LV dysfunction, beta blockers, vasoactive drugs, and the SBP was still in the 180's? I don't understand how that fits...

Also I haven't found it yet in searching, but what is the incidence of this condition? I found that 10% of sufferers will experience the condition again, but not how often this actually happens...


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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

#58 cumedic

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Posted 11 December 2007 - 10:53 PM

Ah yah I forgot about that part.

So..
Why is it that this pt was tachycardic and hypertensive for so long while getting these meds?


Circulating excess catecholamines from anxiety/stress? Her history indicated improvement with a benzo, so the anxiety part fits at least.

Take care all.
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CUmedic, NREMT-P

who is john galt?

#59 Mike MacKinnon

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Posted 11 December 2007 - 11:02 PM

Exactly CU

Here is a girl who is lamenting over her fathers death, her pregnancy (which her mom dosent know about) and now has pain. She is VERY young and so has the ability to pop off catecholamines more than the vast majority of our pts. Essentially, she was better than the drugs but ativan/versed/valium does the trick ;)


Circulating excess catecholamines from anxiety/stress? Her history indicated improvement with a benzo, so the anxiety part fits at least.

Take care all.


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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

#60 Canis doo

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Posted 29 July 2009 - 07:43 PM

Hey Mike,

I know I'm half a year late but hey, it took me that long to study this.

Not really, I wanted to add my input of a similar case a while back.

Called to transfer a 87yom to a teritary ceter, the weather was no bueno, so it was a hour and change ground haul. Just as well, we would not have been able to pry his wife off of him. She kept saying that "the big guy cant have him yet". per verbatim

He was transfering for Pneumonia and persistant chest pain. OOPS!!!! the tech put the leads on wrong so when we placed our 12 lead the bigO AMI monster was seen. That changed the game. Anyway, wife wanted to stay on his hip.
It was a bit concerning due to the weather and his severe possiblity of decompensating, however it was decided to let her stay there.

Arrived and he was fair to midland. Upon unloading, one of the cables came off snag on the horns. The monitor lit up BEEEEEP. His wife looked at me and started to crying and yeld his name. He look up at her and said " Gez, woman I'm fine". she then had a brief loc. and said my chest hurst and feels like a hot knife is in it.
Long story short, she was taken to the cath lab in the next room to her husband at the same time. That surge of endorphins, and hormones sent her to an AMI. DX as broken heart syndrome and LAD occlusion which was probally already there.

Thank you for the forums, I get a lot of atypical pt and I continue to learn every time. We have a very lenient, and impartial protocol for Benzo or anytype of sedative use ranging from decreasing CP with AMI to SOB maximizing FRC or VT. guess she should have recieved some PO prior to transporting the S/S were there we just missed it.
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Jason Howard LP, FP-C
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