Case: Difficulty in breathing

[Asysin2leads]

Okay, well, now that we have some answers, here's what happened. First off, the glucometer wasn't hers, it was one of her family members. She didn't take insulin, and according to her family was not diabetic, however, once at the ER, her BGL was 365. Anyway, I prepped to intubate with the BVM, while my partner got the IV, in preparation for transcutaneous pacing. After securing the tube and ventilating @ 12bpm, I noticed her heartrate is now an irregularly irregular 146, a recheck of the blood pressure produces 120/86 and she starts to fight the tube, so we sedate with 5mg diazepam and transport, lung sounds now produce audible rales, and a 12 lead showed some ST depression in II, III, and aVF. I have yet to do a follow up on this woman to find the final diagnosis, I'm not sure if it was purely a respiratory problem or there was some cardiogenic origin, but, the moral of this story is that her bradycardia, evidently, was caused by hypoxia. Prior to this, I was aware that bradycardia in children is almost always caused by a respiratory problem, and that of course hypoxia is one of the five H's in ACLS bradycardia/PEA algorithm, but this is the first time I had seen it manifest like this. The other thing that I wondered about in this case was her initial rhythm, it was a narrow complex bradycardia without P waves. Now, when her heartrate came back up, as I said before, it looked like a rapid A-fib, so I wondered if she was one of our elderly types that usually walks around in a-fib, is it possible a slow a-fib would look like a junctional rhythm? Maybe if I cook Doczilla some bolognese he can tells us the exact relationship between hypoxia and bradycardia and if I'm right about the EKG.

[fiznat]

...and how was the pasta!??!?!

[Asysin2leads]

...and how was the pasta!??!?!

Well, for whatever reason, my sauces always taste better reheated the next day, anyway...

[canuckEMT]

Hmmmm..well it looks like I totally missed that one. Dopamine would have had some very negative effects with the a-fib.

[bozzie22]

First thing I would do is check for a valid and active DNR lol

[brentoli]

Well, for whatever reason, my sauces always taste better reheated the next day, anyway...

Marinated and aged, yum.

[hammerpcp]

I actually had a pt who presented almost exactly like this scenario. I bagged her up while my partner prepared to intubate and her HR came right up as well as her BP and spontaneous respiratory rate. I can't remember what happened with this pt or what her final dx was either. Too bad. The only difference with this pt is that she continued to tolerate being intubated even with her improved vital signs. I think we were suspecting a CVA with other respiratory complications.

So, although the answer has already been provided I was thinking one of two things for this pt. First I would try ventilating her, plain and simple. Then I was going to ask about Parkinson’s meds. I have had another pt who had just taken his levodopa and levocarb (I think it was) and who's BP abruptly dropped into his boots. He was also on beta blockers so there was no compensatory HR increase. A fluid bolus did it for this gentleman. No atropine, Dopamine or anything.

It goes to show that there is no teacher like experience.

I am learning that often the toughest call to make is whether to treat aggressively or conservatively. Neither is right in all situations.

[CBEMT]

After securing the tube and ventilating @ 12bpm, I noticed her heartrate is now an irregularly irregular 146, a recheck of the blood pressure produces 120/86 and she starts to fight the tube, so we sedate with 5mg diazepam and transport

Well that would've been an unpleasant development. :evil:

I have to call for Valium or anything else that needs to be locked up. :roll:

[Novisen]

Bad preload gives a Bezold-jarisch reflex with bradycardyia, hypotension, slow breathing. Seen this one time. Gave atropin and fluid and the patient went back to normal HR, bloodpressure and breathing. The problem is that I can´t find anything about BJR and atrial fibrillation on the net. The underlaying problem can be a stunned myocard like the 12:lead showed. (Inferior)