Case: It is cardiogenic shock

[Asysin2leads]

Here's a patient I had that I think we all could learn from.

Called to a clinic for a report of difficulty breathing. Arrived to find a 36 year old male in obvious respiratory distress with audible rales laying on examination table, on O2 10lpm via NRB. Examining physician states that patient reported not feeling well for several days, came in for check up, was found in current state. Patient speaks no English. Using paramedic's limited knowledge of Spanish, patient complains of difficult breathing, and minor, midsternal, non radiating sharp pain, 4/10. Denies nausea, vomiting, diarrhea, headace. Only history is asthma, uses albuterol pump.

Vitals: BP:60/P, HR 130, SP02: 94% on 100% O2, GCS: 15.

PE: Patient is pale, cool, perrl, negative cyanosis, trachea midline, negative JVD, positive accessory muscle use, equal chest expansion, bilateral rales auscultated in all fields, abdomen soft, non-tender, negative incontinence, motor, sensory present x 4, unable to palpate peripheral pulses, negative edema.

EKG: Sinus tachycardia, rate 130.

Presumptive diagnosis: cardiogenic shock.

Patient has very poor periphery, as partner attempts external jugular cannulation, I contact telemetry. Without getting into too much discussion of the specifics, the telemetry doctor disagreed with my diagnosis and did not feel comfortable with my request for a dopamine infusion, and ordered normal saline only. Luckily we were less than five minutes away from the hospital.

A follow up with the ER physician listed the diagnosis as cardiogenic shock secondary to constrictive endocarditis.

So here's my question: Would the dopamine have helped? If you had the carte blanche to do anything with this patient in the field, what would you have done?

[spenac]

Find a better person to translate.

What were his heart sounds?

Heres just a little especially as only 5 minutes to hospital. Why stay and play? He needs definitive care.

BLS: Keep high flow O2, Keep warm but not hot to avoid vasodilation, elevate head and shoulders to reduce pressure caused by fluid backing into lungs

ALS: For starters would want 2 large bore IV's. With description sounds like 1 may need to be IO. These primarily for meds. Careful with fluid to avoid flooding lungs. 12 lead.

By this point should have been at hospital 10 minutes ago. Turn care over to the local rent-a-doc.

Hey I may have to move to the city, didn't even have time to get into my drugs.

[678 Responding]

Here's a patient I had that I think we all could learn from.

Called to a clinic for a report of difficulty breathing. Arrived to find a 36 year old male in obvious respiratory distress with audible rales laying on examination table, on O2 10lpm via NRB. Examining physician states that patient reported not feeling well for several days, came in for check up, was found in current state. Patient speaks no English. Using paramedic's limited knowledge of Spanish, patient complains of difficult breathing, and minor, midsternal, non radiating sharp pain, 4/10. Denies nausea, vomiting, diarrhea, headace. Only history is asthma, uses albuterol pump.

Vitals: BP:60/P, HR 130, SP02: 94% on 100% O2, GCS: 15.

PE: Patient is pale, cool, perrl, negative cyanosis, trachea midline, negative JVD, positive accessory muscle use, equal chest expansion, bilateral rales auscultated in all fields, abdomen soft, non-tender, negative incontinence, motor, sensory present x 4, unable to palpate peripheral pulses, negative edema.

EKG: Sinus tachycardia, rate 130.

Presumptive diagnosis: cardiogenic shock.

Patient has very poor periphery, as partner attempts external jugular cannulation, I contact telemetry. Without getting into too much discussion of the specifics, the telemetry doctor disagreed with my diagnosis and did not feel comfortable with my request for a dopamine infusion, and ordered normal saline only. Luckily we were less than five minutes away from the hospital.

A follow up with the ER physician listed the diagnosis as cardiogenic shock secondary to constrictive endocarditis.

So here's my question: Would the dopamine have helped? If you had the carte blanche to do anything with this patient in the field, what would you have done?

After all basic interventions have been applied I would have done some ALS if I had time without delaying transport to the hospital. I don't think dopamine would have hurt. The patient has a pump problem, and I dont see why it wouldnt have helped the patient. If you had it, I would have opted to go for dobutamine due to it's mostly inotropic effect, and less chronotropic effect of dopamine since the patient is already tachy and dont want to increase myocardial oxygen demand by increasing the heart rate anymore. But, my personal opinion is that even though the patient has endocarditis, its complicated with cardiogenic shock (according to your assessment) and that needs to be treated immediately. If you're less than 5 minutes from the hospital, I dont think starting a dopamine or dobutamine infusion is going to fix the patient that tremendously since you'll be rolling into the ER just as you hang it. Nice case though.

[sladey67]

From the information given appears to be cardiogenic shock to me. Would be interested to see his 12 lead - acknowledge the short tx time.

I imagine the ER doc may have had difficulty accepting your diagnosis given the pts age. I bet if you'd said 76yo he'd have been more comfortable with it

My only pharmacological option would be for an adrenaline infusion (think you guys call it epi?). However with the information given not sure I would give it (always difficult not having the pt in front of you). Provided he was not deteriating (sp?) would probably do the basics (posture, O2, IV access, monitor) and get this guy to definative care quickly. Sometimes it better to not mess with what you've got - while his presentation is not ideal it could be a lot worse. I'd be a bit concerned about pushing his hr up with adrenaline.

Curious how did the hospital rx him?

[northernmedic]

Interestingly enough last week I had a pt presenting with nearly identical signs and symptoms (and age) who was severely septic. With such a short transport time I would start a fluid bolus if I could and just hit the road. By the time you get your dopamine infusion initiated you could be at the hospital.

[AZCEP]

The problem that I see with using the vasopressors (dopamine, epinephrine, Levophed) would be the effects they will have on the "constrictive" mechanism. Seems to me that the action you would want to have would be more ventricular filling, not a more forceful contraction of an empty chamber.

Fluid boluses to maintain the pressure, and transport to a cardiac center that can do a pericardiocentesis would be the best option.

[678 Responding]

The problem that I see with using the vasopressors (dopamine, epinephrine, Levophed) would be the effects they will have on the "constrictive" mechanism. Seems to me that the action you would want to have would be more ventricular filling, not a more forceful contraction of an empty chamber.

Fluid boluses to maintain the pressure, and transport to a cardiac center that can do a pericardiocentesis would be the best option.

Exactly what I was thinking about, but I had something else in mind. Dobutamine (as I am being taught in class) is more of a contractility increasing drug (inotropic and dromotropic), with little to no alpha effect so you're not squeezing an empty tank, but trying to make the pump more efficient, along the same lines of Digitalis. Levophed isnt what id want, as that really isnt the problem here since that is nothing but alpha effect and doesnt work where we want it to. Adrenaline or Epinephrine infusing is out of the question as this would sky rocket the heart rate, decreasing ventricular filling and making the problem even worse. I would be cautious with fluid boluses since the heart is already overloaded, and more fluid would put it into even further failure. Trying to increase the force of contraction of the heart in my personal opinion (opinion only) would be the best course of action. There is enough fluid, it just needs to be circulated better. If you increase the force of contraction, the pump becomes more efficient thus increasing the blood pressure to a more comfortable level without increasing heart rate or oxygen demand all that much. My reasoning behind this is that the low BP and rales are due to poor circulation and LV failure, so we most likely have enough fluid, just not enough "umph" from the pumper. Thats just my $.02 Have a nice day.

[mrmeaner]

If you're less than 5 minutes from the hospital, I dont think starting a dopamine or dobutamine infusion is going to fix the patient that tremendously since you'll be rolling into the ER just as you hang it. Nice case though.

Why wait for the ER staff to make an intervention? Even if you're pulling into the garage, the infusion is still running while you unload the patient, give report, nurse does an assessment, nurse calls doc, doc does assessment, etc. Is there something I'm missing?

[678 Responding]

Why wait for the ER staff to make an intervention? Even if you're pulling into the garage, the infusion is still running while you unload the patient, give report, nurse does an assessment, nurse calls doc, doc does assessment, etc. Is there something I'm missing?

Oh no, by all means if you can get the drip started prior to getting in the ER, thats awesome. I'm just saying that since he is so close to the hospital, that by the time he gets his assessment done, and gets on the road which I trust is very quick due to the severity of the patient and gets orders for an infusion, setting it up, I can only imagine that he'll be hitting the "Run" button on the pump as he rolls the stretcher into the ER. So, why do that when they're going to switch over everything to their own stuff in 2 minutes anyway. I'm just trying to keep time along with practicality in mind.

[sladey67]

The problem that I see with using the vasopressors (dopamine, epinephrine, Levophed) would be the effects they will have on the "constrictive" mechanism. Seems to me that the action you would want to have would be more ventricular filling, not a more forceful contraction of an empty chamber.

Fluid boluses to maintain the pressure, and transport to a cardiac center that can do a pericardiocentesis would be the best option.

I understand and accept your point, however my belief is that adrenaline (epi) in low doses acts first on B1 receptors and you only start to get the alpha effect (constriction) as the dose increases.

Adrenaline infusion is my only option for cardiogenic shock and our protocol calls for 5mcg - 15mcg/min. At this dose we are taught you're getting predominantly B1 effects - increased HR (not so good) and increased force of contraction (some good)