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Scenario: Another boring transfer


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Better hold off on the Hydralazine:

Some of the adverse effects related to hydralazine that have been reported in the literature include reflex tachycardia,

http://www.ncbi.nlm.nih.gov/pubmed/20687078

I am not sure we should be attempting to control the BP without a CT.


Since he is still under the care of the hospital staff, I would tell them to call back when pt is stable

That right there is how you kill people in the rural/remote setting.

Do you know what a rural GP Dr does when hes in over his head? He calls EMS!


I'd like to get some labs going NOW. CBC, CMP, Trop, ABG, coags to start.

How about D-Dimer? Would it be specific enough in this acute setting?

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I wish I knew what AMFYOYO meant haha

Adios my friend your on your own.

I see that obesity can be in issue with intubating in general but Im sure im missing something else.

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Since he is still under the care of the hospital staff, I would tell them to call back when pt is stable and request ALS or preferably CCT transport if they still want to go by ground. I would call dispatch and let them know what's going on and go back in service.

Until this pt is stable enough for transfer there is no way I'm BLSing a pt like this for two hours. Whoever requested BLS apparently has no idea what resources are needed. Sounds like a typical floor nurse scenario to me.

Ahhh... careful dissing on floor nurses.

So you would just ditch them and not continue to offer help? Neat.

Better hold off on the Hydralazine:

http://www.ncbi.nlm.nih.gov/pubmed/20687078

I am not sure we should be attempting to control the BP without a CT.

That right there is how you kill people in the rural/remote setting.

Do you know what a rural GP Dr does when hes in over his head? He calls EMS!

How about D-Dimer? Would it be specific enough in this acute setting?

Yeah, but if we don't do anything about the BP, seeing as he's missed his morning anti-hypertensive AND B-blocker, it's just going to keep going up and make the situation worse. I know hydralazine can cause tachycardia, but it also is very effective at lowering BP.

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Hello,

Lots of reading to catch up on.

Once we clear up his level of intervention/code status I think intubation is a reasonable step. He has had a general decline in his LOC. If I recall, his GCS is around 8/15. He has respritory failure (oxygenation and ventilation).

If there are no indicators of a difficult airway or difficult BVM I think RSI would be the best method. Propofol and Roc.

As for the HR. I would get the airway done first and then see how the HR and BP play out. If the monitor is showing a rapid A.Fib post intubation a loading dose of Amiodarone and a ggts could be an option. Sure, cardioversion could be an option. But, this won't last until the underlying medical cause is managed.

Maybe, with some post intubation sedation and ventilation support the BP might come down some.

Snap a quick CXR when the tech gets in.

Draw a ABG after 30 minutes or so to see how ventilation is going.

Sort out the logistics. As many poster have noted, perhaps CCT is in order.

Cheers

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I'm going to assume that since we can't get a head CT we also can get a chest, as someone mentioned a PE. Cxr is not helpful in diagnosing PEs (yeah you can see Westermark Sign or a Hampton Hump but those are usually only visible on the retrospectroscope). As cxr will tell us if there is heart failure, pneumonia, pneumothorax, an enlarged heart (possible pericardial effusion), or aortic aneurysm. Is is safe to assume we don't have a bedside US either? I'd like to get some labs going NOW. CBC, CMP, Trop, ABG, coags to start.

Chest Xray is negative for heart failure, enlargement, pnuemonia, pneumothorax, effusion, and aneurysm .

Ultrasound is not available.

There's some limit to what I can say for the labs, as I don't recall what they were! I didn't get to see them for more than a minute... But I also know how the scenario ends, so I can give you some idea what the results were (or would have been) to keep you on track. (I apologize for the lack of data here).

CBC will be within normal ranges, electrolytes are normal, creatinine and eGFR show slightly decreased renal function (nothing dramatic), Trops are negative, ABG was requested but never performed (actually). INR was slightly prolonged.

I don't want to make up the numbers, so I hope this manner of giving you rough answers will suffice for the sake of this scenario. I'll keep going as best as I can.

Can we get an ABG w/o a respiratory therapist?

We can certainly try! An ABG was requested at one point, but oddly enough no one seemed to do it!

How about D-Dimer? Would it be specific enough in this acute setting?

D-Dimer negative

Yeah, but if we don't do anything about the BP, seeing as he's missed his morning anti-hypertensive AND B-blocker, it's just going to keep going up and make the situation worse. I know hydralazine can cause tachycardia, but it also is very effective at lowering BP.

For sake of discussion, can you think of anything else you could use to bring down HTN in this situation?

What would you like to do for the rate?

Is there any other symptoms present that we can treat right now?

And the last Q to ponder; what came first? How did this cycle begin?

Hello,

Lots of reading to catch up on.

Once we clear up his level of intervention/code status I think intubation is a reasonable step. He has had a general decline in his LOC. If I recall, his GCS is around 8/15. He has respritory failure (oxygenation and ventilation).

Just for recap, Eyes remain closed, he is not answering questions, he withdraws from pain (and I should note, makes purposeful movements) but does not follow commands, and is making incomprehensible sounds (which isn't a substantial drop from the significant aphasia he had when you saw him yesterday). There is a decline in LOC that you can notice, but also a significant increase in distress.

If there are no indicators of a difficult airway or difficult BVM I think RSI would be the best method. Propofol and Roc.

There are some moderate signs of difficult airway, but you're a pro and I believe in you. Lets tube this sucker.

You visualize the cords, pass the tube, secure, confirm lung sounds bilat, and visualize waveform capnography that resembles this:

http://i3.photobucket.com/albums/y59/Jeyface/tmp2A94_thumb2221.jpg

As for the HR. I would get the airway done first and then see how the HR and BP play out. If the monitor is showing a rapid A.Fib post intubation a loading dose of Amiodarone and a ggts could be an option. Sure, cardioversion could be an option. But, this won't last until the underlying medical cause is managed.

Maybe, with some post intubation sedation and ventilation support the BP might come down some.

Snap a quick CXR when the tech gets in.

(see above)

Draw a ABG after 30 minutes or so to see how ventilation is going.

Sort out the logistics. As many poster have noted, perhaps CCT is in order.

Cheers

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I'm good with just a beta blocker and see how it does, I'm good with adding a nitro drip and seeing how that goes. I'm really thinking this is more cardio/respiratory than neurological at this point.

I'm hesitant I address the lung sounds because everything we have in our arsenal can increase HR and BP.

There may be a small bleed in the brain from the tPA that could have started this sequelae but we also might never know since I don't think this buddy had a very favorable outcome given all the obstacles to his care.

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I like to go against the grain.... So I'm gonna stick with my plan.

I believe the V/Q mismatch at this point is due to PE.

I want to attempt the cardioversion prior to RSI. I don't expect it to change the resp status, but I'd feel a lot better about giving anything vasoactive if he was back in his sinus rhythm. I see above where someone states the rhythm will probably convert back.... although I tend to agree, but at this point it is all about scale tipping. I want as much weight on my side as possible for the RSI. If the guy stays in a sinus rhythm for 15min, that is enough time to get him RSI'd, and start an antihypertensive..... though I am not sold we should be doing that.

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When trying to control afib/tachy/htn I like to stick with what the pt is already on, especially if they missed their dose. I'd give some extra beta-blocker, consider an esmolol drip. You can get a "withdrawal" tachycardia from missing doses of beta-blockers. As for the ABG, the doc or a nurse can draw it. You don't need to have RT. Someone mentioned a d-dimer. It would not be useful in this situation. Although it has been stated it was negative, I would place money on it being positive. It is a very nonspecific test that will be elevated for thousands of reasons. It is only useful to r/o PE when your pre-test probability is low, which with this pt's history it is not low (see PIOPED study and Wells Criteria). As for airway control, I'd try to stabilize the HR/BP first to see if the mental status improves but have everything ready to drop the tube.

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