chbare Posted August 4, 2006 Author Share Posted August 4, 2006 Medic429 & AZCEP; - + JVD. - Lung sounds; coarse crackles to the bases bilat. (you note very harsh sounds at a rate of about 110 when listening over the left anterior chest for lung sounds) - 1+ bilat pedal pitting edema. -Abd soft and non tender. -O2 15 LPM via NRB---> Remains pale and diaphoretic, continues to C/O dyspnea, SAO2- 93%. -BGL 142 mg/dl -12 Lead shows Q waves in leads V1-V4 (old infarct?) with very poor R wave progression and some non specific ST changes in V1-V4. -IV access is obtained. -Transport is 25 minutes. Anything else? Take care, chbare. Link to comment Share on other sites More sharing options...
AZCEP Posted August 4, 2006 Share Posted August 4, 2006 Capnography? What is the rhythm on the ECG? What is the frontal axis? Where does the QRS become mostly positive in the chest leads? Are the radial pulses equal? Are pedal pulses palpable, and are they equal? Any carotid bruits noted? Link to comment Share on other sites More sharing options...
rocket Posted August 4, 2006 Share Posted August 4, 2006 Do we have CPAP on this rig? -Trevor Link to comment Share on other sites More sharing options...
chbare Posted August 4, 2006 Author Share Posted August 4, 2006 AZCEP, the rhythm is sinus tachycardia with the occasional unifocal PVC and borderline 1st degree AV block. Further evalution of the ECG will not really help with the diagnosis. The very poor R wave progression may help. Radial pulses are equal bilat. You can palpate bilat pedal pulses. Co2 is 22. No carotid bruits noted, however, you can hear a loud harsh systolic murmur. Rocket, your in the land of OZ. What you want is what you get! The patient is now very lethargic, only reaponds to a sternal rub. He is very pale and diaphoretic with a systolic pressure of 70/P. His RR is 33 and shallow with a SAO2 of 87% on NRB. Pulse is 128 and very weak. Take care, chbare. Link to comment Share on other sites More sharing options...
AZCEP Posted August 4, 2006 Share Posted August 4, 2006 Correct me if I'm wrong, but isn't CPAP only used if the patient is responsive? This patient just bought himself a tube/vent combo plate. Since we have the cool guy unit today, let's get an ABG and a chest CT Link to comment Share on other sites More sharing options...
chbare Posted August 4, 2006 Author Share Posted August 4, 2006 AZCEP, you are correct. CPAP was a good idea while the patient was awake, however, he now requires more aggressive airway management. (yes I know CPAP is used for sleep apnea) Intubated with 8.0 ETT and on vent with whatever setting you like. Placement confirmed. ABG machine just went down. It seems bio med is moonlighting for Never Never Land and has been slack on maintenance in the Land of OZ. Radiology states he cannot do a CT because you do not have a BUN and CREAT. Is there a less invasive test you could consider? Take care, chbare. Link to comment Share on other sites More sharing options...
rocket Posted August 4, 2006 Share Posted August 4, 2006 Correct me if I'm wrong, but isn't CPAP only used if the patient is responsive? That is what I understand as well. This protocol (from Wisconsin) isn't from my home state but it does a good job of describing the indications/contraindications/etc: http://dhfs.wi.gov/ems/system/PDF_files/CPAP_Protocol.pdf As we have now learned that this patient has gone deeper into the rabbit hole I agree that we are now out of the realm of use for CPAP. tube 'em, spock!! 8) -Trevor Link to comment Share on other sites More sharing options...
AZCEP Posted August 4, 2006 Share Posted August 4, 2006 Okay patient intubated, capnography in place, value should come up here shortly. Due to the pressure, get some Dopamine running. Start at 5 mcg/kg/min, watch for better perfusion, prevent excess tachycardia. Consider some Tridil and Bumex, once we get the pressure up to the mid-90's. Might want to place a foley to watch how well the kidneys are perfused. With that done, a CXR, A/P and Lateral. Want to see how full the lungs are, and since our CT is out, we will have to imagine the third dimension. Might also consider an echocardiogram, or bedside ultrasound eval to see what the left ventricle is doing, since it apparently isn't pumping much blood. Link to comment Share on other sites More sharing options...
chbare Posted August 4, 2006 Author Share Posted August 4, 2006 AZCEP; Chest X ray indicates pulmonary edema with properly placed ETT. Foley is in with very little output. EtCo2=19. Ahhh, nice call on the echo. Here you go. Please note that if you look at the apex all you can see is black. If you bring the doppler down a little the apex is visible. However the bright colored divider between the right and left ventricle remains open about half way down. Left ventricular ejection fraction is.....not good. Dopamine is started. What do you think now? Take care, chbare. Link to comment Share on other sites More sharing options...
MedicRN Posted August 4, 2006 Share Posted August 4, 2006 HOw about general labs........ CMP, CBC, BNP, Mg, Phos, Cardiac Enzymes 2D Echo, Transesophageal Echo Working Dx = pericarditis vs CHF (though doubtful) Edit: oops... a bit late with the post...... looks like a ventricular septical defect... possible ruptured ventricular septum? Link to comment Share on other sites More sharing options...
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