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usmc_chris

Dizziness with Fall

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Gag reflex intact. You are able to assist ventilations; his SpO2 returns to normal. You now arrive at the hospital.

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Hello,

Thank you for an interesting scenario Chris.

SAH and other catastrophic neurological events can cause a profound dilated cardiomyopathy. A neurosurgical unit I worked at many years ago saw a few 'stunned hearts' from SAH.

Also, a year or so ago, a women came into the ED with a SAH (grade III) was hypotension despite and impressive ICP. However, I have never seen or heard of QRS prolongation from a SAH.

In addition, it is fairly common to have ST elevations with SAH as well. Why this happens........who knows!!!!......I have never found an adequate answer nor received one the many keen people I have asked.

Overall, I can not think of anything to add treatment wise. Fluid and a Levophed or Epi to support the BP.

Chris, I am interested to hear what the outcome was.

Cheers,

David

Edited by DartmouthDave

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Hello,

Posting the follow up now.

He was transported to the Level III trauma / PCI center. My system places great emphasis on customer service / destination requests, the transport time difference between the two facilities was minimal, and the facility he was transported to should have been able to handle the patient's condition. The final ECG printed as he was taken into the ER is attached.

Upon arrival at the hospital RSI is performed, pressors are finally successfully hung, and the patient is sent to CT. Cerebral hemorrhage and cervical spinal compromise are ruled out with CT.

After about 90 minutes in the ER he is finally sent to the cath lab. They identified a 100% proximal LAD occlusion but were unable to open the occlusion prior to the patient going into cardiac arrest. Unfortunately he was not able to be resuscitated.

I posted this case for a couple reasons:

1) Neither myself or any of my coworkers had ever seen ST elevation as severe as this patient had in the anterior leads, and I thought it would be interesting to share it.

2) I learned some things here, and wanted to continue to learn from this case. First, I may be beating myself up, but I feel I was a little too complacent on this case. We respond to a lot of "done fell out" at church on Sunday and what I was presented with was absolutely NOT what I was expecting. I wish I had brought more "stuff" to the patient's side, and I wish I had been more proactive with obtaining additional help in the back. Our first responders are normally good about riding in with us, but I honestly had no idea where they went once we got into the ambulance. In addition, given that it was "off" / weekend hours, the Level I may have been more promptly equipped than the facility he was transported to. Obviously, hindsight is 20/20, but the day we stop learning is the day we need to get off the truck.

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You know, your case brings me back to a poor dude who was a classic MI if we've ever seen one.

Lead elevation in II, III and AVF along with reciprocol changes were some of the worst myself and my partner had ever seen.

Every time we laid him even back a little, to get him out of his house or even to move this guy, any movement, nearly put him in arrest. Strange seeing him lucid one minute and then nearly unresponsive the next until you sat him straight up.

We landed the helicopter in this guys field and put him on the helicopter all the while knowing that he would not survive the 70 mile flight. Fortunately he did survive the flight but he did not survive the attempt to open his 100% occluded arteries and there were two others that were 95% occluded.

He was so grey in color that we turned on additional lights in the house to verify that it wasn't just te lighting in the house.

We prepared his wife and mother for the worst outcome which in the end came true.

The receiving hospital as well as the helicopter crew were excellent but sometimes people are too far gone to be saved.

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I think we've ALL had a patient that as soon as we make contact , You just know they are having the "big one".

They present with the death pallor and you don't need any equipment other than the mark 1 eyeball to tell they are circling the drain or shortly will be.

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