akroeze Posted October 31, 2007 Author Share Posted October 31, 2007 thats a great Scenario so far i would do the same as AnthonyM83 and i would have the defib ready just in case. and cpap Why CPAP? She is breathing just ever so slightly tachypneic, sats are good on O2 and A/E is clear and equal. Link to comment Share on other sites More sharing options...
AnthonyM83 Posted October 31, 2007 Share Posted October 31, 2007 While others chime in, I'll just run through thoughts: Check the specific meds she's been given? OD? (check bottles) Her name on bottle. Interactions? Some environmental condition in the room she's in? Last oral intake? Can't really assess neoro b/c of her confusion, right? Nothing upon secondary physical... No on demand pacemaker? Complication of her gout (not in hx list, but she's taking a med for primarily for it)? Link to comment Share on other sites More sharing options...
akroeze Posted October 31, 2007 Author Share Posted October 31, 2007 While others chime in, I'll just run through thoughts: Check the specific meds she's been given? OD? (check bottles) Her name on bottle. Interactions? Some environmental condition in the room she's in? Last oral intake? Can't really assess neoro b/c of her confusion, right? Nothing upon secondary physical... No on demand pacemaker? Complication of her gout (not in hx list, but she's taking a med for primarily for it)? The nursing home staff administer all her meds so no OD and she hasn't had a med change in a few years. No pacemaker (even if there was, it obviously wasn't working during the sinus brad) Link to comment Share on other sites More sharing options...
triemal04 Posted October 31, 2007 Share Posted October 31, 2007 Since it's open to everybody... Based on what's here, I'll take her up to the ER code 3 with a working assessment of DKA and possible PE. Treatment will be NRB, IV with fluids running, ekg, vitals. I'd like to reassess for chest pain, mentation, lung sounds before I started fluid, dehydration, run a full neuro check, and get more on her recent history and sugar levels. Assuming that her heartrate stays at 128 and her BP doesn't drop to much, that part isn't getting treated yet. That being said, I'd also want to see the 4-lead and 12-lead of the sinus brady to check for any signs of hypo/hyperkalemia. Given that it looks like she is now an insulin dependant diabetic, and may have been one for awhile, it's possible that she's in renal failure and that caused the rhythm changes and SOB. Given my own experiences with nursing homes and "skilled" nursing homes, I'm not to worried that there was such a difference in the cbg that they got and what I got; their equipment is probably either broken or not being used right. I doubt there was a sudden increase in her cbg; more than likely she's been high for quite awhile. Or I could be all wet and making a fool out of myself. Link to comment Share on other sites More sharing options...
zzyzx Posted November 1, 2007 Share Posted November 1, 2007 Have her skins signs, LOC, or BP changed with this change in rhythm? Hx of pacemaker? Link to comment Share on other sites More sharing options...
zzyzx Posted November 2, 2007 Share Posted November 2, 2007 Just realized my questions had already been answered previously. This is a great scenario. If I was doing this in real life, I would hold off on any aggressive treatments and just go code to the ER. She is in a wide-complex tachycardia, which we'll have to assume is VT, but her rate (130-150) isn't what you'd expect with VT. She is stable and in fact, as you say, her LOC, skins, and BP have not changed with this change in rhythm. Since she's stable, I wouldn't cardiovert, and I would be very hesitant to give lidocaine due to the fact that she was brady before. Like I said, if I was close to the hospital, I would hold off on aggressive treatments as long as nothing changed. I would also consult with my base, which in my protocols is actually required for stable VT. Great scenario! Link to comment Share on other sites More sharing options...
AnthonyM83 Posted November 3, 2007 Share Posted November 3, 2007 So what's the rest of the scenario!? What are we missing? Link to comment Share on other sites More sharing options...
Freaknuggetz_chick Posted November 5, 2007 Share Posted November 5, 2007 ventricular rhythm, decreased loc may be from hyperglycemia, BP still stable, i just took ACLS this weekend...next step: expert comsultation!! but as usual, i assume that the phones are down.... support ABC's, reassess q5min have combo-pads on and at the ready query fluid bolus for hyperglycemia; lets go 250, cautious with fluid overload. fax 12-lead (dont suppose there was one prior to the tachycardia?? hard to see elevation with tach) treat with amiodarone, 150mg over 10-20 minutes i would also like to know about fluid intake/output had there been previous edema in the legs in the last week or so? i agree with above comment concerned about sepsis. again, expert consult would be my best option at this point. what are the VS now? LOC Airway open? Breathing rate? SpO2? Pulse rate? can she answer as to whether or not she has chest pain? rhythm check? BP? reassess BGL? pull blood for labs in some services. JVD? Trachea midline? Lung sounds? abdominal assessment (colour, firm/soft, masses, bowel sounds, incontinence, pain?) Link to comment Share on other sites More sharing options...
akroeze Posted November 5, 2007 Author Share Posted November 5, 2007 I'm so sorry folks, I completely forgot about this thread! Listen, I need to leave in like 2 minutes so I can drive the 3.5hrs to get to my ACP class but as soon as I can I will continue on with this. Does nobody suspect that the 12 lead shows sinus tach with BBB? Link to comment Share on other sites More sharing options...
AnthonyM83 Posted November 10, 2007 Share Posted November 10, 2007 Anyone? Link to comment Share on other sites More sharing options...
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