DartmouthDave

Hello, It isn't uncommon in severe sepsis to have myocardial dysfunction due to immune/inflamatory response. Typically, once the patient is fluid loaded and pressor (Levophed) is started we watch for three outcomes; (1) a decreasing lactated level (2) a VBG sat >75%. (3) Slowly correcting pH If this isn’t the case a second agent is added to improve cardiac output. Like Dopamine or Doubatamine for example. As for fluids. How much? This is a hard case. But, with poor perfusion and poor urine output more fluid seems reasonable. Switching to RL or a solution with a higher pH (Normosol ect…) is also helpful if you have been giving lots of NS. Excessive NS will give you a hyperchloremic acidosis which you want to avoid. SCANCRIT is an excellent critical care blog. Here is a study they posted about the benefits of beta blockers in selected septic patients with cardiac dysfunction. http://www.scancrit.com/2012/09/28/%CE%B2-blockers-give-survival-advantage-sepsis/ “Early stage sepsis results in a cathecholaminergic overdrive that could result in myocardial injury or dysfunction. Septic patients who get cardiac dysfunction or injury have a two- to fourfold increase in mortality.” Also, Dr, Rivers published an excellent sepsis article in 2001 I think. It is worth a look on PubMed. EMCRIT has three pods casts featuring Dr. Rivers that is worth the time. I am not sure about the Dex and steroids. I would hold off until a good pressor is online. Cheers

RSI a decompensated patient is courting disaster. A little light sedation for the combative hypoxic and hypercapnic in most situations works like a charm. Put on nasal cannulas and pop in an OPA and a NPA and use good two-person BVM technique with some PEEP. Once you get the sats up and some more fluid in you can secure the airway. It also gives you some time to do an airway assessment (if you haven’t done one yet). The beauty of this approach is if you can’t pass the tube then you just start bagging again and try plan B (change blade, bougie, et al.) Keep bagging until the sats are back up and you are ready with your plan B. Plan B fails then insert an LMA or a King LT. Or, just keep using a two-person BVM approach. The AIME text book by Kovacs and Law is an excellent progressive source: http://aimeairway.ca/ The Levitian and Winegart article on apneic ventilation is also useful. The EMCRIT site has some podcast on it as well. http://www.annemergmed.com/article/S0196-0644%2811%2901667-2/fulltext I find this approaches makes airway management and ventilation less of a crisis. I have seen countless intubations in the ED, ICU, ward, and with EMS and this makes a difference in most cases. Thank you for your time, David

Hello, I agree with a little light sedations as a means to preoxygenate the patient before intubation is a great idea. The nasal cannulas for apneic ventilation is an other good idea. I also like Kiwi idea of a LMA. As of late, I have been reading about the concept of sedation and ventilation with an LMA or King LT. I think the term is 'rapid sequence airway'. Personally, I have no experience with this. Kiwi, do you use this as a bridge to intubation? Cheers

Hello, Good case study. I am thinking septic pneumonia. Poor pain control, fractured ribs, and hypoventilation could be the cause. Also, it has slowly developed over three days. I would also like a repeat EKG as well. Also, I would check her skin out to see if their are any red spots. Fat embolism is a remote possibility. A PE is an other possibility. But, if a PE is big enough to cause profound hypotension I would think her SpO2 would be much lower. Cheers

Hello, IV access is needed. Depending on your protocols go for a femoral line or an EJ. Then, if you need it, an I.O. The question that needs to be answered is: Is the I.O. ok for the cath lab? I assume it is...but I am not sure. Also, I would like to roll thinghs back a little. I assume this case study is in rural Alberta. You need to get to the cath lab. But, there is nothing wrong is stopping at a local Emergency department first. They could put in a central line (maybe they have U/S), run a quick set of labs. Take a look at the heart with the u/s to see what is going on. A quick u/s can help with some of the DDx that can mimic a AMI. Such as pericarditis with an effusion, atypical balloning, CNS bleeding, LV aneurysm from an old MI and a number of other that i can not recall right now. Second, with a line, she can be managed better during the transfer. She has had ASA,Plavix and PO Zofran. Some NTG IV would be nice. Also, if their isn't too much delay a Head CT to make sure all is well. I have seen enough STEMI to know standard medical management (ASA,Plavix,IV NTG, Heparin or Lovenox)can have patients's pain free and somewhat stable for the trip to the cath lab. A little more on CNS bleeds being a STEMI mimic. I have seen SAH/CVA cause ST elevations. Usually, their isn't pump failure and cornary blood flow is uneffected. In some cases, the CNS bleeding caused a stunned myocardium (Dilated Cardiomyopathy). The tell tale sign in these cases is a HYPOTENSIVE neuro patient. This is big trouble. Recently, in the local ED, there was a fit 30 year-old women with a ST elevations and a Grade IV SAH. Her pressure was in the 70's despite an incresed in ICP. As for the seizure. Maybe here Dilantin level is low or their is a medabolic cause. I must admit that the seizure is worrysome. But, if here LOC is good (14-15/15) with no abnormal finding (weakness) I would be more reassured. She is hypertensive. She has a histroy of HTN. I would expect her BP to be much higer if their was a CNS bleed or clot. So, if here LOC is good I would: 1. Get a line of some type 2. Zofran IV 3. NTG IV 4. Fentanyl IV Cheers

Hey Moby, You better make the next scenario a paracarditis! =)

Hello, I wonder about and IO and TNK? I am sure it is fine but I have never thought about it, until now. So, we have a medical clinic and an ED 30 minutes away? Cheers

Hello, I would get her on the stretcher, monitor, get a line and put her on some o2. I think the EKG is worrying. I would lean away from Pericarditis because their hasn't been a preceding illness (i.e. flu, ect). Also, it my understand that any ischemic changes rules out Pericarditis. She had risk factors for CAD: - Smoked 1/2 pack x 25 years - Dyslipemia (taking Atrovastin) - Lack of physical activity (watches TV) - Hyperglycemia - Age She has the look and the symptoms: gray, unwell, and pain in her right elbow The EKG shows Q-waves (I think), ST elevation in V1,2,3,4,5 and V6. ST depressions in II and III Plus, spike T-waves in a few locations Also, the wide QRS morphology with spike 'T' waves could be caused by electrolytes which can minic an AMI, especially hyperkalemia / hypokalemiia. Hyperkalemia can produce very odd looking EKG. Maybe, she has some renal inefficiency that has progressed? Enough rambling. I would: 1. Do a 12/15 lead EKG 2. Get bilateral BP's (as noted above) 3. Give her an antiemetic like Zofran IV or SL 4. Give small doses of Fentanyly for the arm pain (25mcg PRN) 5. Give NS 500 6. Watch her LOC for any changes 7. Give the N+V time to settle then give ASA PO 8. Transport to the local ED for some more assessments and labs (mainly lytes and BUN/Cr/Tn-I). A stop here is a good idea before a long transfer. I would like to know: 1. How long has she been feeling unwell? 2. Temp? 3. Why is she on Ropinirole? I looked it up and it is for Parkinson Disease and Restless Leg Syndrome. 4. Any rash? 5. Stiff neck? Still back or legs? 6. Splinter hemorrhages in the hands and feet? 7. Decreased voiding? Cheers I

What do you take?

Hello, Excelelnt discussion. Back to Swe112 comments on Propofol and the agitated patient. It use is gaining popularity for non-intubated patients with delerium and agitation. Typically, a low dose infusion is hung until standard PO medications have time to take effect (Clonadine/Seraquil ect...) In fact, are published case now of low dose Propofol used in palative acre as well. However, as most poster here will quickly point out this can not be generalized to the pre-hospital environment. But, what is interesting is the use of Propofol in transporting (fixed wing/HEMS) psychotic patients to Regional Medical Centers from small communities. As well as Ketamine gtts. Dr. Minh Le Cong blog has lots of good information on it. There was even a case of a very dangerious psychotic patient (in New Zealand) that was sedated with Remifentinal/Ketamine and the inserted an LAM and connected it to a t-piece. Interesting stuff. We covered this in great depth at my service recently. I just wish I had a copy of the power point to put up. We tried a Propofol gtts once for an non-intubated agitated patient. It worked well. However, in the end, we have decidied to go with standard therapy (Haldol/Zyprexa/Benzo) because the services in these case studies are Physician based and can not be generalized to a non-physician based team. Cheers, My rambling post in done.....too many Starbucks coffee today! http://prehospitalmed.com/about/

Hello, I would stay away from a CCB in this a most situations. A constant, non-varying rate of 280 in a otherwise healthy 35 year-old male makes me think a reentry or assessory pathway is at work here. So, slowing AV conduction could cause a paraadoxical increase in the heart rate. It could be an ugly time. I still think a trial of Adenosine is worth an effort. It may convert the tachycardia. Or it may show you what you have. See what the PRI is and so forth. Or, slow down the EKG speed so their is more space to see what is going on. I have seen this work nice of 1:1 flutters and such. Have the pads ready just in case. Thank you, David

Hello, His GCS is 15 and he has a good pressure and SpO2. So, he is stable at the moment. I am not saying that you do nothing and drive slowly to the hospital. But, if you have a time to assess and think about the situation you should take it. Get a 12-lead, give something for the anxiety and ask a few questions. Give some Adensosine IV and see if it converts or if it shows us what is going on. Why? Well, I have seen S.Tachycardia cardiovert by EMS because it was a narrow rapid tachycardia and the patient was deemed 'unstable'. Or, a hyperthyroid induced tachycardia that was zapped a few times. Plus, a few rapid 1:1 or 2:1 A.Fibs as well. Most recently, a septic lady. She had a temp (39), a low pressure (80's) and an alterted LOC (GCS 12-13). But, look, a rapid norrow tachycardia on the monitor......this is an unstable tachycardia..the patient is unstable...cardiovert. I have seen bad things happen in the hospital as well. It isn't just EMS. Thank you, David

Hello, I agree that he is stable-ish as well. He has an anxiety disorder. I has been worse over the pat 3-4 months. These worsening episodes of anxiety could be cardiac in nature (as suggested by numerous posters) or their could be some other internal medicine type cause such as hyperthyroidism. It is hard to say. This is my weak point. But, I though WPW had a shortened PR intervial? We can not see the PRI due to the rate. But, if we change the EKG speed we may be able to see if their is a P wave. I have seen Cardiology do this trick before. I would load him on the cot, connect the monitor and get a line going. Give him some Ativan SL or IV and get the Adenosine ready. Cheers

Hello All, No wheezing are noted in the lung fields. Just course (rhonchi). The swollen ankles are a long standing problem and they don't seem any worse than normal. The son has no idea what was prescribed. His mother went to see her GP and was given the Rx with a follow up booked in a week. You transfer to the ambulance, start and IV, give fluid and reassess: GCS 13-14 HR 140-150 A.Fib BP 70/40 SpO2 89-90% on 15 lpm Cheers

Hello, The patient is 79 years-old and a full code. Some information from the son; His mother has been unwell for a week. She had a lung infection and has been taking pills for it. He is unsure of his mother's medical history because she is a private person. But, he sure she has high blood pressure and swelling of the ankes. She quit smoking 10 years ago and has troubles with her sugars. That is all he knows. He picked up his mother today at her home for a family dinner. She was weak but insisted on coming to see the grandkids. He wanted to take her to the clinic to see her Family Dr. You transfer her to the strectcher and do your assessment. Here is what you discover; -->GCS 13/15 (E3 V4 M6) confused, mumbling words, able to follow simple commands -->Pupils: 4mm and reactive -->Arms: weak (no drift) -->Legs: weak -->Lungs: very course -->Skin: very hot to the touch, diaphoretic, swollen ankles (+1 edema) --> You are unable to get any useful history or information from the patient due to her mental status VS: HR 150's A.Fib with narrow QRS and occassional PVC BP 80/30 Temp: 39.7 O2: 87% on room air (creeps up to 90-91% on o2) BGL: 14 mmol/L (252 mg/dl)

Hello, You are dispatched to a suburban home for a 'sick person'. On arrivial you are greeted by the patient's son. He says his mother is acting funny and hasn't been well for the last week or so. He ushers you into the kitchen. The patient is sitting at the table looking pale, weak and is having trouble sitting up in the chair. He breathing is laboured. Two of her grandchildren are supporting her. Thier is panic in the air. Cheers

Hello, Are S1 and S2 normal? Muffled heart sounds? New mummur? Stomach soft? Maybe, she repture a cardica valve or repture a cardiac aneurysm? However, I am leaning towrda a repture AAA or a thoracic aneurysm with the sudden onset, lower back pain, and frank hypotension. I would drop in 1L bolus and start to package her for transport. maybe with a better pressure her LOC will imporove. I would also get ready for a tube if need be. Cheers

Hello, It could be an incompleted spinal cord injury: Central Cord Syndrome. He was punched and hyperextensed his neck backwards. A collar with the HOB 15-30 degrees should be adequate for transport. Cheers

Hello, I have used Octreotide in the emergency management of bleeding gastroesophageal varices in patients with cirrhosis. However, I just transfer a patient with upper GI bleeding (throat and nose) from cancer (not sure of type). He was on a Panto gtts and an Octreotide gtts. There was no history of cirrhosis. I am not sure if the Ocreotide was indicated? I was wondering if other have had expereince with this situation? Cheers

Hello, NP.......I forgot to include the units in my post with the lab values. This always causes issues with blood sugars (...the US and their odd measurements...lol) and hgb. Cheers

Hello, Hgb 64 g/L (110-160) ed1040 says, "A rare complication of a femoral CVC is an abdominal hematoma" You are correct on this. I have never seen this until recently. A patinet had a large retroperitoneal bleed from multiple femoral line attempts. So, I figure it would be a nice concept for a scenario. Island syas, "As far as the leaking tube, Put in a gum bougie and install new tube over that with plenty of lube. reverify with CXR." Yes, the cuff keeps deflating. You exchange the tube with a bougie without complications and the portable CXR is on the way. Do they have the capability to type & crossmatch? Yes they do but it will take some time. They have 4 units of O -ve that can be transfused now. Cheers

Hello, His CXR showed an ET tube that was too high (...which has been corrected...) and well aerated lungs with no pathological findings. His lungs are clear and his is easy to ventilated. He had a CNS infection in his late 20's and developed a seizure disorder after that. I was (until now) well managed with Dilantin T.I.D. Some questions: So, why do we have a burn patient with a low Hgb that is looking like a hypovolemic shock? Why is he more distended and firm? (Despite decompression with an OG) (The second leak in this scenario) What is the plan for the leaking cuff? Cheers

Hello, An OG is insert and it dose not stop the gurgling. The abd is more distended as well. Cheers

Hello Mobey, Island, ed1040 and et al...., Sorry, ATL in my world means ''...at the lip..." =) A CXR was done and it shows the cuff is just.....barley.....below the cords. The pilot ballon is soft to the touch. You advance the tube and add air to the cuff but the leak soon returns. They did not do an ABG because of his burns and not enough time. He is on a transport vent (AC 12x550 FiO2 100% PEEP +5). He is riding the ventilator. He has been given 2000cc NS so far. No LR. Parkland works out too 11,520cc in 24 hours. With a goal of 5760 in the first 8 hours...around 725cc/hr. He is cold (Temp 35) so you cover him with dry burn sheets. When they inserted the central line they drew labs. They are back now: Lytes: K 4.2 Na 145 Mg .6 Phos .9 Profile: Hgb 64 CBC 22 His current VS: HR 140 (well sedated) BP 75/50 O2 100% Temp 35.1 Urine 10 cc in 2 hours His abd seems a little bigger. The ED is anxious for you to leave ASAP. =) Cheers

Hello Island and Mobey, Also, he has a foley in situ with 10cc of dark urine noted. Cheers