Protoman2050

The reason the CVT has his US machine w/ him is b/c it's a portable Phillips CX50 that can be stashed in a large laptop bag. And he works at different physician offices, and brings his machine along. SaO2 is 90%. Digoxin would not be good, b/c it slows the heart rate...slow heart rate worsens MR. Tachycardia in beneficial in acute MR. And tachycardia will keep his CO at an acceptable level. Are we agreed to simply run a slow infusion of fluids, and give aspirin PO, oxygen, and IV NTG. And transport to the hospital ASAP. This guy needs an intra-aortic balloon pump/Impella, PCI, and MVR surgery. Fast. IA=intra-arterial.

Well, the Afib can wait, and PVCs aren't actually dangerous. But, the mean pulmonary artery pressure is 6 mmHg, which is half of normal, and the pt. is hypotensive. Something has to be done, b/c a MAP of 63.33 is just above the minimum necessary to maintain end-organ perfusion. We can't let him run dry while we rush him to the hospital. Perhaps IA fluids?

Here's an interesting scenario. Reason I'm asking this is b/c I'm a CVT student, and I keep imagining I find myself in this scenario. I hope I don't! The guys on EMTLife think this is an interesting scenario, and they referred me here to get some input from paramedics. Scenario: A cardiovascular technologist who contracts with the local hospital and uses his own equipment, is eating his lunch on a park bench. He is chatting with a middle-aged man, who suddenly starts having angina and dyspnea. He is sweating, his skin is cool to the touch and pale, and his jugular veins are distended. The CVT activates EMS, gets in contact with medical control, and asks for an ambulance and permission to perform an 18-lead EKG and a transthoracic echocardiogram. He also performs a physical exam. You, a paramedic, arrive to the site, and the CVT shares his findings with you: Symptoms and physical findings: Angina and dyspnea. He has slight wet rales, and he has a holosystolic murmur from S1 to S2. Patient also has severe jugular vein distension. VS: BP: 90/50, RR: 18, HR: 100 bpm, Temp: 37 degC EKG: 18-lead EKG shows large Q-waves and 5 mm of ST elevation in leads II, III, avF, V1-3, V3R, and V4R. Afib and PVCs are also noted. ECHO findings: Severe acute MR due to torn papillaries causing flail leaflets. LVEF is 45%. There is a severely hypokinetic left and right inferior wall. There is flattening of the interventricular septum during systole. Mean pulmonary artery pressure is 6 mmHg. RVEF is 30% He says that the pulmonary edema is less then he thought it would be, but that's only because the diminished LV preload isn't giving much for the MV to regurgitate into the lungs. He says that RV is severely overloaded, because of the systolic septal flattening. You activate the cardiac cath lab, and page the on-call cardiac surgeon at the local hospital. How would you stabilize this patient? Would you put the patient on CPAP, administer 0.5 mcg/kg/min of dobutamine and 0.5 mcg/kg/min of Nitropress to augment the patient's cardiac output and reduce the afterload of the ventricles. How would you maintain LV preload without throwing the patient into FPE? What would you do about the Afib and PVCs? 150 mg amiodarone over 10 minutes? Would you start Activase to attempt to restore perfusion? Thanks, Doug