jonas salk Posted January 21, 2010 Share Posted January 21, 2010 any dependent edema? Was a 15-lead performed? Are the PVC's multifocal or unifocal? Link to comment Share on other sites More sharing options...
Kiwiology Posted January 21, 2010 Author Share Posted January 21, 2010 any dependent edema? Was a 15-lead performed? Are the PVC's multifocal or unifocal? No 15 lead and PVCs are unifocal. Pedal edema and mid/basalar crackles. Link to comment Share on other sites More sharing options...
melclin Posted January 21, 2010 Share Posted January 21, 2010 (edited) Please clarify something for me. Charlie's temperature is 38 point 5 degrees? Either he is hypothermic, as the temperature is below 80 degrees, normal being 98 point 6, or someone forgot to indicate Fahrenheit versus Celsius. Sorry, I'm used to working with the Fahrenheit scale. I think you can reasonably assume that it would be Celsius. Other than the fact that pretty much everywhere in the world uses Celsius, I would imagine a patient with a temp of ~3 degrees C (38.5F) would probably not be 'complaining' of anything. Seeing as though, I've seen this on another thread, I won't give away the answer - but these were my first thoughts when it over at the Life. The apparent sepsis, minus a tachy and with an ECG showing me a heart in a bad mood - I thought one of the carditis' or maybe pneumonia causing some kind of secondary ischaemic heart troubles (as with secondary UA). I would consult for appropriate use of ceftriaxone although I don't think he's sick enough to warrant it in the pre-hospital setting. Other than that I would load and go with a couple of liters depending on the pulse ox I reckon. Who asked for salbutamol? That seems like a silly thing to do. Edited January 21, 2010 by melclin Link to comment Share on other sites More sharing options...
DartmouthDave Posted January 21, 2010 Share Posted January 21, 2010 Hello, Ah...brain gym at 0200hrs. Sepsis (...moving toward severe sepsis or septic shock) is a solid dx. The temp and the histroy point to this. However, the DBP is still quite good for sepsis and the pulse pressure is quite narrow as well (for both pressures given). For example, 96/86 has a tight pulse pressure of 10. Something is at play here. Add in signs of congestions and a new one set block and an angery strip. I would lean to endocarditis with a weaker inclanation towrads pericarditis (...no ST changes....not that they are always there)with a bad pericardial effusion. Jonas asked about edema and there is perpherial edema and crackes. What about JVD and heart sounds as well? Distant? Mummurs? The valuves may have taken a hit. Any odd skin leasons? Red spots on the arms, hands or feet (Roth lesions I think is the name...not sure)? Any splinter lesion in the nails? Supportive is the main treatment here. Get him to the ED and get a FAST done. Oh...a CXR as well. Thank you, David Link to comment Share on other sites More sharing options...
Kiwiology Posted January 21, 2010 Author Share Posted January 21, 2010 There is noticable JVD, but unsure of heart sounds sorry Nothing else remarkable Link to comment Share on other sites More sharing options...
DartmouthDave Posted January 21, 2010 Share Posted January 21, 2010 (edited) Hello, Slow night here. I just put NaHC03 and CaCl togeather in a bag of NS. I am waiting to see if calicum carbonate will form in there. =) Ok....I am going to go with infective pericardia effusion. If I was in an urban or suburban area with short transport times I would put IV x 2, oxygen and transport. If I had a longer transport time I would dig deeper as to the patient's fluid status. Any N+V? Eatting? Drinking? How long he has had a fever/chiils? I would also see about end organ perfusion. Making pee? --If the SBP maintained above 90 and he was making some urine I would sit on my hands. --If the SBP maintained above 90 and he wasn't making urine I would be worried but I would still sit on my hands. A little pre-renal failure would (should) correct nicely once the cardiac issue is corrected. --If the SBP started to fall (RVEDP too low) and he made some urine I would give NS 250. Increase the filling pressure. --If the SBP started to fall (RVEDP too low) and he was anuric I would give NS 500. Increase the filling pressure. The risk/benefit here is very tight. David Edited January 21, 2010 by DartmouthDave Link to comment Share on other sites More sharing options...
Kiwiology Posted January 21, 2010 Author Share Posted January 21, 2010 OK, so .... to ask a conspiciously leading question (yes I have an alterior motive here) Simply put this guy has classic "chest pain and short of breath with rales" what do we not want to give him and why? Link to comment Share on other sites More sharing options...
Niftymedi911 Posted January 21, 2010 Share Posted January 21, 2010 Breaking it down Kiwi..... If you were to follow that SOB/CP/Rales protocol, it would indicate the use of NTG, Lasix, and CPAP. NTG is contradinicated to begin with..... But with the indicated heart failure due to poss pericarditis, he's dependent on pre-load. You give him NTG, you kill him plain and simple. Also, if you were also going to be doing CPAP, you will be increasing the intrathoracic pressure in the chest. With someone who's already suffering from an increase pressure on the heart, more pressure would also send him to asystole. Tx: (In this order) High Fowler's Positon on stretcher 15 LPM NRB and prepare for DAI Diesel IV x2 (Still kinda of leaning to giving this guy a fluid challenge, I'll start a 200 cc bolus and see how things change.) Continous NIBP,Cardiac, 12 lead, SPO2, ETco2 monitoring Radio report Offload to ED Link to comment Share on other sites More sharing options...
Aussieaid Posted January 21, 2010 Share Posted January 21, 2010 This is definitely a tricky one and treatment is kind of a tight rope walk. This guy has more of a cardiomyopathy picture versus septic shock and whether it is from a virus, an infection or some other cause the treatment pre hospital will still have the same goals. Goals are to reduce preload, afterload, increase contractility and improve oxygenation. This is where it gets tricky because his BP is on the lower side for the drugs that he needs so you may need to counteract the effects of some drugs with other drugs to be able to balance on the tightrope here. He needs nitrates and CPAP or BiPAP to reduce the preload, afterload and to oxygenate. You may need to give a little fluid challenge or start an inotrope to help with his BP. If you start giving a little fluid without the CPAP/BiPAP you may just make him worse. So if you start to give some fluids and he gets worse stop the fluids and get the inotrope started. Now he also need some inotropic support. If you have an ACE inhibitor that would be ideal but you may have to make do with dopamine if that is all you carry. The problem with the dopamine is that it could make him worse with tachycardia or cardiac irritability. He has a fairly slow heart rate at least so hopefully we have some room to move. I would be reluctant to use it but if he starts doing any worse arrhythmias I would give him amiodarone. I would not be giving lasix. Leave that up to the hospital. He more than likely needs some fluids but we have to be cautious with them as the state his heart is in currently it cannot handle any more fluid. Sounds like he really needs an IABP at least. Interesting case. Link to comment Share on other sites More sharing options...
Richard B the EMT Posted January 21, 2010 Share Posted January 21, 2010 Other than the fact that pretty much everywhere in the world uses Celsius, I would imagine a patient with a temp of ~3 degrees C (38.5F) would probably not be 'complaining' of anything. Thank you for making my admittedly minor point for me. Link to comment Share on other sites More sharing options...
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