DartmouthDave Posted August 20, 2010 Author Share Posted August 20, 2010 Hello, Sorry for the slow response. Got tied up at work. The wife can not find the pacemaker information card. She says it is for when his heart beats too fast it zaps him and speeds things up when his heart is too slow. It was inserted after his MI because his heart got 'too big' and would 'go to fast' and the patient would 'pass out'. The Dr told the husband and wife that his scopy was normal for his agen and no bleeding was noted. He was given so 'white stuff' and some pain medications. He recovered quicky and was discharge home. The wife also add that Walter felt a funny 'zap' in his chest on the way home. Since then his troubles have started. His medications are: ->Ferrous Sulfate/Levothyroxine/Glyburide/Atrovastin/Sprilactone/Lasix/Ramipril/Metoprolol Your partner inserts an IV and connects the patient to your monitor while you conduct a more detailed physical exam. The physical assessment notes: ->course crackles BL ->no edema ->skin: cool and diaphoretic ->BGL:12.6 ->EKG: Sinus Tachycardia @ 120-130 Cheers... Have to run..... Link to comment Share on other sites More sharing options...
HERBIE1 Posted August 20, 2010 Share Posted August 20, 2010 (edited) OK, so this guy clearly has cardiomyopathy, CHF, apparently gout, diabetes, HTN, GI bleeding issues, MI's- he has a pretty bad ticker. I'm not familiar with the units being used for the blood glucose level, so I'll just assume it's normal. I'd want a 12 lead EKG- he could easily be having another MI. Based on his vitals, he appears to be in cardiogenic shock. I'd consider Dopamine and some diesel therapy. He's a sick puppy. Ooops- just saw his BP, I retract my cardiogenic shock statement. I still think he is having a cardiac event, based on the vitals, and the fact that his ICD fired again. Edited August 20, 2010 by HERBIE1 Link to comment Share on other sites More sharing options...
chrissym6 Posted August 20, 2010 Share Posted August 20, 2010 The "white stuff" and pain meds tell me he was given propofol for the scope which if memory serves can, albeit rarely, cause tachycarida and tachypena. Looking at his med list I'm also starting to worry about possible drug intereactions especially if he was med compliant prior to the procedure, he hasn't taken them for at least two days at this point and I don't know how long they stay in the system but I know that ACE inhibitors can react with diuretics and thyroid hormone can react with iron supplements etc. The fact that he is dehydrated and hypoglycemic are just going to make any interactions that much worse. I would like to give him something for the hypoglycemia (oral glucose as a basic and D50W if I were a paramedic) to try and see what's being casued by that and what is being caused by something else. The zap he felt on the way home has me concerned as well, is his pacemaker malfunctioning or is there so much going on that the best it can do is bring his heart rate down to 120-140? What does his 12 lead look like? Link to comment Share on other sites More sharing options...
DartmouthDave Posted August 20, 2010 Author Share Posted August 20, 2010 (edited) Hello, The BGL is in mmol/dl so the blood sugar is elevated. Sorry, I forgot to include the units. Herbie1 don't run away from the cardiomyopathy (CM) call. You hit the nail on the head so to speak. So, what type of CM dose this fellow have? His wife said his heart was 'big' and 'floppy'. Also, what is in importance of the 'zap' he felt on the way home? The patient nor his wife had had this happen before. Lastly, a slight omission, I forgot to add that he was on PO Amiodarone. Sorry. Lots of distractions these days. I will do a follow up post here in a little while more vitals and information. Need to go for a coffee run..... Cheers Edited August 20, 2010 by DartmouthDave Link to comment Share on other sites More sharing options...
HERBIE1 Posted August 20, 2010 Share Posted August 20, 2010 Hello, The BGL is in mmol/dl so the blood sugar is elevated. Sorry, I forgot to include the units. Herbie1 don't run away from the cardiomyopathy (CM) call. You hit the nail on the head so to speak. So, what type of CM dose this fellow have? His wife said his heart was 'big' and 'floppy'. Also, what is in importance of the 'zap' he felt on the way home? The patient nor his wife had had this happen before. Lastly, a slight omission, I forgot to add that he was on PO Amiodarone. Sorry. Lots of distractions these days. I will do a follow up post here in a little while more vitals and information. Need to go for a coffee run..... Cheers Couple more questions. What is his ejection fraction like? I still think it's his ticker. I think he might be a candidate for an LVAD- his heart simply cannot adequately pump anymore. Link to comment Share on other sites More sharing options...
DartmouthDave Posted August 22, 2010 Author Share Posted August 22, 2010 (edited) Hello, The fellow is look quite sick. His SpO2 is falling and he is becoming confused and agitated. Also, the monitor shows are run of VT that is converted by his ICD back to sinus tachycardia. GCS 13/15 (E4 V4 M5) BP 92/60 SpO2 84% Rate 30's with assessory muscle use Lungs course+++ Coughing up frothy secretions. Jeepluv77: He went in for a day procedure and had procedural sedation with Fentanyl and Diprivan. He was recovered for a couple of hours and sent home. Chrissym6: His pacemaker is set to pace a slow rate and to defib lethal arrhythmias such as VT and VF. The wife was he has had no issues with the pacemaker. Also, he was NPO since the night before for the scope. He just got home from the hospital and started to feel weak very quickly and SOB. 4C6 and other who have asked: No evidence of a lower GI bleed seen on the scope or bloody stool since. Nor any c/o abd pain. The patient has had chronic low hgb and the scope was an investigation by the pt GP. Cheers.... Nice work... Edited August 22, 2010 by DartmouthDave Link to comment Share on other sites More sharing options...
mobey Posted August 23, 2010 Share Posted August 23, 2010 Hmmm, I don't really know what is causing all the commotion, but I would definatly run in 150mg Amiodarone. I am sick of fighting with O2 sats and BP is too low for CPAP, so RSS/RSI it is, Ketamine will be my choice for this one, hopefully we see a rise in BP. Notify recieving hospital, start organizing air transfer. I am not going with Dopamine right off the bat, now that I have intubated I may give a small fluid bolus, and see how he reacts wih the ketamine and repaired hypoxia. I am sure since we have started PPV dopamine will be indicated though. Oh Ya before we do all that..... DNR?? Link to comment Share on other sites More sharing options...
Chief1C Posted August 23, 2010 Share Posted August 23, 2010 Yes.. No evidence during the procedure, but I've transported a patient that ended up bleeding rather badly after (the patient) had the procedure. (The patient) was on the side of hypovolemic shock that you don't want to be on at a rural location. In fact, I put the MAST on (the patient) and (the patient) got a chopper ride. It was bad, no stool, just semi-viscous clumps of coagulated blood. Link to comment Share on other sites More sharing options...
DartmouthDave Posted August 23, 2010 Author Share Posted August 23, 2010 Hmmm, I don't really know what is causing all the commotion, but I would definatly run in 150mg Amiodarone. I am sick of fighting with O2 sats and BP is too low for CPAP, so RSS/RSI it is, Ketamine will be my choice for this one, hopefully we see a rise in BP. Notify recieving hospital, start organizing air transfer. I am not going with Dopamine right off the bat, now that I have intubated I may give a small fluid bolus, and see how he reacts wih the ketamine and repaired hypoxia. I am sure since we have started PPV dopamine will be indicated though. Oh Ya before we do all that..... DNR?? Hello, Solid plan. RSI is what the ALS crew did for this patient. Also, CPAP was not an option. Ketamine and a cardiac patient? I have heard pros and cons from numerous people on its use on patients with CAD. According to Up-To-Date: Ketamine appears to have beneficial effects on stunned myocardium in vitro [53]. When used prior to myocardial oxygen deprivation, ketamine resulted in better recovery after reperfusion. Contractility may also improve with ketamine use [52]. Clinicians must weigh ketamine's potential cardiovascular benefits against its potential to induce cardiac ischemia in patients with significant coronary disease. Ok...the patient is intubated and copious amounts of frothy secretions are in the ET tube. The patient is hard to ventilate. Pressure is even softer and the patient is cool and toxic looking. The loading dose of Amiodarone has settled the VT issue. VS are as follows: BP 60/p HR 110 Sinus Tachycardia SpO2 90% So, the next issue is what to do about the pressure? Fluid or Pressor? Cheers Link to comment Share on other sites More sharing options...
uglyEMT Posted August 23, 2010 Share Posted August 23, 2010 This almost sounds like what my father went through recently... OK BP is falling but rate is up sounds like hypovoliemic. Push fluids start with 2 units saline. If possible check with hospital to see what, if any, vasodialators he was given. Check to see if they would react to his precription meds. If hes had this kind of history the meds would be in his system long after 24hrs. Might be looking at a reaction and severe vasodialation which due to his weakend heart is making the volume drop thus the low BP and s&s of shock (note he hasnt lost blood but doesnt pump enough through the system to maintain healthy BP) The frothy sputem in the tube sounds like a PE. Could be a result of the procedure. The "shock" he felt on the ride home could be indicitive of a arythmia caused by the developing PE. From my BLS experience I would say suction, get the fluids going to get the BP up, notify receving facility of updates, major diesil bolus. Link to comment Share on other sites More sharing options...
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