Kaisu Posted August 8, 2012 Share Posted August 8, 2012 I don't hate you. I don't note JVD in the field and don't use it for clinical signs. It points towards cardiac tamponade ( or any filling of the right ventricle). Do you have a decreasing pulse pressure? I think you mentioned muffled heart sounds earlier. Don't tell me you did a pericardiocentesis? I would be sooooo jealous. Link to comment Share on other sites More sharing options...
paramatt_ Posted August 8, 2012 Share Posted August 8, 2012 Very poor prognosis if we are talking about a rupture as Kaisu stated....which dose fit with the tamponade. My inital thinking was along the lines of conservative fluid management as not to aggravate the dissection, however, it seems like we've past this point and are in need of bolus fluids. And lets go for 100mcg fentanyl...no harm making her comfortable. Link to comment Share on other sites More sharing options...
scott33 Posted August 8, 2012 Share Posted August 8, 2012 How are you arriving at you MAP numbers? Link to comment Share on other sites More sharing options...
Kaisu Posted August 8, 2012 Share Posted August 8, 2012 And lets go for 100mcg fentanyl...no harm making her comfortable. fentanyl can and often does decrease MAP. This patient cannot tolerate that. Anectodal though it may be, I find that pain and discomfort often support BP. Link to comment Share on other sites More sharing options...
rock_shoes Posted August 8, 2012 Share Posted August 8, 2012 Pericardial effusion with a non-traumatic cause? Any cancer history with this patient? Recent illness? Sent from my SGH-T989D using Tapatalk 2 Link to comment Share on other sites More sharing options...
mobey Posted August 8, 2012 Author Share Posted August 8, 2012 I was a pericardial efusion, leading to tamponade (Obstructive shock). No, I didn't needle it, though if I could not have gotten her a plane, I definatly would have called for standing orders in case of an arrest. MAP is calculated by the LP15. Not the most scientific, but better than BP alone IMHO. 100mcg Fentanyl is a little much, I was giving her 25mcg increments, which took the edge off. So... anyone want to run Dopamine? Or should we run fluids? Link to comment Share on other sites More sharing options...
fakingpatience Posted August 8, 2012 Share Posted August 8, 2012 I would attempt a 250cc fluid challenge. If no improvement with the fluid bolus (not expecting improvement), I would consider presser agents (dopamine). Get her pressure high enough that she is perfusing end organs, and I can give pain management. I don't know the proper dosage for fentanyl (we only carry morphine out here). In your setting, I would definitely want to be flying this patient. Link to comment Share on other sites More sharing options...
BEorP Posted August 8, 2012 Share Posted August 8, 2012 Thanks for the case! I'm a bit late, but curious. You mentioned in the initial post that the ECG showed sinus tach with a narrow QRS and no T or ST changes. Not that it is something we're normally looking for, but was there any PR segment depression? Link to comment Share on other sites More sharing options...
ERDoc Posted August 8, 2012 Share Posted August 8, 2012 Why would you wait for this woman to code before you drain the fluid? You can prevent that from happening if you drain it now (though I realize you had to do what your standing orders/medical control says). This is a case where prehospital ultrasound would be great. I will admit that given the scenario, I'd be hesitant to needle her without some confirmation that she indeed has tamponade. Link to comment Share on other sites More sharing options...
Kaisu Posted August 8, 2012 Share Posted August 8, 2012 Excellent case - thanks for posting.... Question - Is the pressure/pain radiating to lower back typical of tamponade? in women? Link to comment Share on other sites More sharing options...
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