Congestive Charlie

[Kiwiology]

I would be dubious about nitrates in his present state or really at all as it'll just make his cardiogenic shock worse.

Agree he needs an inotrope rather than a chronotrope so some dopamine should be in order here.

My treatment plan would be a dopamine and CPAP with no GTN or frusemide.

[melclin]

I'm not sure that dopamine is a good idea given its chronotropic affects and I don't think its worth the risk - the pt isn't ill enough to warrant dopamine in the prehospital environment. I don't think he's at the blood pressure at all cost stage yet and I wouldn't be comfortable giving a drug that affects his heart significantly, while not knowing exactly whats wrong with his heart. Is dopamine indicated for endocarditis/mycarditis? I would have thought you'd want all inotrope and no chronotrope for that sort of thing.

Maybe if we had noradrenaline.

I would move up to CPAP only if I couldn't get good oxygenation from ~100% and frusemide is best left for when fluids I/O and electrolytes can be monitored and managed, if at all. As for GTN, I don't feel like killing a man today, so I'll keep that safely tucked away

The MD, did he ever find those chest films?

Edited January 22, 2010 by melclin

[Kiwiology]

Dopamine could be out because of its chronotropic effect perhaps isporel or something else might do the trick however I think we are starting to get into tunnel vision of over-treating the patient.

I think the best thing we can do here is oxygen and transport.

[DartmouthDave]

Hello,

This patient has constrictive pericarditis. I am sure it is exudative in nature. A histroy of feeling unwell for five days and an elevated temp.

- Any treatments aimed towards AMI or acute CHF is a very bad idea here (No NTG No MSO4). Reducing preload isn't a good idea at all. Drop the RVEDP and the CO will tank.

- If he is dry from being ill for 5 days Lasix is a very bad idea. Again, a big drop in RVEDP will kill this fellow.

- ACE inhibitors. I am not keen on this as well.

- CPAP. The PEEP and pressure support would increase the cardiac worklaod.

- Dopamine. The heart can not stretch. This guy has systolic as well as diastolic failure due to the effusion.

- Amiodarone. If his heart is irritable from treatment. Stop the treatment. If his heart is irritable due the effusion leave it.

Keep it simple. IV, O2. maybe some fluid, and off to the ED. An echo or a FAST will give us the answer we need quickly (...effusion, valves, EF {if an echo is done}, what the myocardium is doing).

If he has a bad pericardial effusion (...moving towards a tamponade...) a pericardial tap followed by a drain will (should) have a crowd pleasing effect. Improved CO and a resolution of his congestion.

Oddly, as of late, we have had a trio of bad effusions come through the ICU. All looked like hell until drained.

So, in effect......I am parrot here and repeating much of which has all ready been said. =)

Thank you,

David

[Aussieaid]

Actually we really need a few more assessment points here. Not convinced that it is a tamponade without more answers.

What is his SpO2? (Pre and post albuterol if that was actually given).

You said you didn't listen to heart sounds? At all? So we don't know if they were muffled or if there was a gallop or rub?

Were there signs of pulsus paradoxus? (eg. pulse weakening when the pt breaths in)

Did he have hepatomegaly?

What is his medical history and what medications is he on?

I had a few more but I will have to come back to it later.

[DartmouthDave]

Hello,

Looking back at the orginal post I noticed this bit of information:

"The doctor is trying to find some chest films he took and it'll take a minute or two."

What dose it show? Is the CXR new or old? Better yet a new and old one.

So, looking back on this thread our list of possible dx are:

1. Sepsis

2. Pneumonia

3. CHF

4. Endocarditis with an effusion

All solid answers IMHO.

These all can be dx clinically. But, if you are wrong you could make things much worse. Supportive care and get to the ED. Do a quick U/S (FAST)and CXR. If this guy walked in to the ED it he would get supportive care and an U/S, labs, ABG, 12-lead, and a CXR done to figure out what is going on.

Besides, these case studies always have Zebras lurking =)

Cheers,

David

[Kiwiology]

Actually we really need a few more assessment points here. Not convinced that it is a tamponade without more answers.

No it's not tamponade

What is his SpO2? (Pre and post albuterol if that was actually given).

This patient never got salbutamol; his SPO2 was ~92% on O2

You said you didn't listen to heart sounds? At all? So we don't know if they were muffled or if there was a gallop or rub?

Heart sounds should have been taken but here at least they are not taught and while I agree it might be useful some sparky ambo would find some way to screw it up, kill somebody by blowing out thier scene time and it'd be taken away agian.

I am an elephant keeper not a horse whisperer; I dont think Stanley will be galloping anything he is much to large I mean when is the last time you saw an elephant running? That's like tubbo infront of you at McDonalds ordering a salad then going for a jog!

Were there signs of pulsus paradoxus? (eg. pulse weakening when the pt breaths in)

No

Did he have hepatomegaly?

No

What is his medical history and what medications is he on?

He has no history to speak of except has been feeling sick and fluey for the past 5 days.

I'm more interested in seeing how we would manage this patient than a concrete diagnosis because most of what he presents with would catch a few ambo's I know off gaurd and they might do silly things like GTN and frusemide and end up on the fast track to a lawsuit without much support!

[Aussieaid]

Ok, so with a slightly clearer picture here and looking at his vital signs my prehospital plan would be 2 IV's one with fluids TKO (ready for a bolus if needed) and one TKO, O2, HOB elevated and boogie to the ER. In the hospital the previous treatment plan is what I would be looking at as the goals remain the same. Also in the hospital you have a few more drug choices that would be better for this patient. (i.e. milrinone verus dopamine but still may need some dobutamine or dopamine to support the BP so you can give the afterload and preload reducers). This pt still needs GTN but prefer to have a higher BP before using it. If he starts to deteriorate then inotropes, fluid, CPAP/BiPAP and possibly fluid bolus are what he needs.

Lasix is pretty much on the way out as most of these patients are actually dehydrated and since this guy has been sick with a fever for a few days he most likely needs fluid but first his heart needs help moving the fluid in the right direction. If you gave too much fluid right now he would probably deteriorate pretty rapidly.

And leave Stanley in the pasture as this guy most likely has a horse (or zebra) galloping around in his chest rather than an elephant sitting on it! If Stanley develops pachydermitis let me know as I know a few people who know a few people...if you know what I mean! (nudge, nudge, wink, wink!)

[Mateo_1387]

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.

I am not following you about ACE inhibitors and inotropy. Could you please explain?

Dopamine could be out because of its chronotropic effect perhaps isporel or something else might do the trick however I think we are starting to get into tunnel vision of over-treating the patient.

Not following you either Kiwi. I cannot find the drug Isporel, which I assume is Isuprel. If that is the case I will say this...

You cannot use Dopamine for the chronotropic effects, but what about the chronotropic effects of Isuprel?

Heart sounds should have been taken but here at least they are not taught and while I agree it might be useful some sparky ambo would find some way to screw it up, kill somebody by blowing out thier scene time and it'd be taken away agian.

So, I am not getting this either. How can you screw up heart tones, then kill somebody with heart tones? How can listening to heart tones extend your scene time dramatically? How can they take away heart tones? Doesn't make much sense to me...

[chbare]

There are a few potentially exciting studies out about ACEI's and acute CHF treatment. The results show rather substantial hemodynamic improvements over traditional modalities such as nitroglycerine. I am talking class III and IV CHF. While the base of evidence is still rather small, I suspect this to become very popular with subsequent studies of large numbers. Perhaps large studies now exist? ACEI's are also very popular for AMI salvage type therapy. Even more so than beta blockers. In fact, beta blockade is being somewhat emphasized as an immediate core measure in the ER management of the AMI patient. The evidence is so compelling, my medical direction and clinical gurus are looking at a possible ACEI guideline to be integrated into our practice.

I agree, the pressor debates are all over the place and I am not sure I would consider a pressor or adrenergic based agent with any of the given blood pressures. I guess if you really had a hardon for increased B1 effects for the patient with a systolic B/P in the 90's, you could look at dobutamine; however, I am more of a conservative fella. Yet, the argument of augmenting inotropic activity and perhaps augmenting coronary perfusion is valid when considering dobutamine or even variable doses of other agents such as dopamine.

Take care,

chbare.