Protoman2050 Posted October 5, 2009 Posted October 5, 2009 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
mobey Posted October 5, 2009 Posted October 5, 2009 I definatly would stay away from dobutamine since this episode seems to be MI/UA related, I really do not need to put anymore stress on the heart. The rate of 100bpm certaintly does not speak to a rate induced cardiogenic shock type situation, so cardioversion is out. As far as dealing with the A-Fib & PVC's prehospitally, you would be pretty hard pressed to find a provider around here who is going to start an antidysrythmic based on the case presented here. With a RR of 18, I am not too worried about the pulmonary edema, the patient is not a candidate for CPAP in my eyes. MY Tx would be: ASA, O2, large I.V. TKVO. Transmit ECG & begin rule in/out on thrombolytics.
Protoman2050 Posted October 5, 2009 Author Posted October 5, 2009 I definatly would stay away from dobutamine since this episode seems to be MI/UA related, I really do not need to put anymore stress on the heart. The rate of 100bpm certaintly does not speak to a rate induced cardiogenic shock type situation, so cardioversion is out. As far as dealing with the A-Fib & PVC's prehospitally, you would be pretty hard pressed to find a provider around here who is going to start an antidysrythmic based on the case presented here. With a RR of 18, I am not too worried about the pulmonary edema, the patient is not a candidate for CPAP in my eyes. MY Tx would be: ASA, O2, large I.V. TKVO. Transmit ECG & begin rule in/out on thrombolytics. 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?
mobey Posted October 5, 2009 Posted October 5, 2009 IA fluids?? Sorry, no speaky this abbreviation. This is a double edged sword for the paramedic in a prehospital setting. Yes, the patient is hypotensive. However, 90/50 is.... well..... low..... but, still condusive with life. The problem is, the guy is infarcting and anything we give to counteract the cardiogenic shock carries the risk of increasing the size of the infarct as well as inducing a lethal arrythmia (PVC's are present already). Really, the first line Tx for this dude is probably a small fluid bolus (watching the lung fields) then possibly a Dopamine drip at 5mcg. Seems retarded to even discuss fluids and Dopamine in a RVI infarct..... But we will have to do what we can. May also consider digoxin for it's inotropic properties.
chbare Posted October 5, 2009 Posted October 5, 2009 Fibrinolytic therapy is not really indicated at this point. Cardiogenic shock associated with MI does not typically respond well to fibrinolytics. Additionally, this patient will be on his way to an intervention soon. CPAP may actually worsen his condition with increased intrathoracic pressures. A statement that carry with me applies: What is the enemy of good? Better is the enemy of good. This guy is hanging tough for the moment, he is doing good in spite of the underlying problems. Sometimes, we make the situation much worse in our pursuits of better. Nothing much we can do for his regurgitation or RVI at this point. Perhaps consider judicious fluid administration. The guy is awake with rather acceptable vital signs given the fact he could be much worse. Do you really want to screw with that? Benign neglect is the word of the day until the surgical team arrives. Take care, chbare.
tniuqs Posted October 5, 2009 Posted October 5, 2009 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 Ok the CVT is packing a US in his back pocket on his lunch break ? ... ok maybe is it just me that thinks this senario is a bit over the edge .... or they were watching too much "Trauma" on the TV. I believe I would get him off the bloody park bench and transport to the ER were he could get some definitive assistance, double tropes in the field without an art line or swan ??? With a low B/P nope agreed no CPAP..... what's SpO2 and dont put a cart before the horse. His level of C was what again ?? What medications is buddy on ? O2, Line, small bolus of fluid ... think about Dopamine (and if you don't have a pump) don't even spike the bag. TRANSPORT and let the CVT student do the patch .... cheers.
Protoman2050 Posted October 5, 2009 Author Posted October 5, 2009 Ok the CVT is packing a US in his back pocket on his lunch break ? ... ok maybe is it just me that thinks this senario is a bit over the edge .... or they were watching too much "Trauma" on the TV. I believe I would get him off the bloody park bench and transport to the ER were he could get some definitive assistance, double tropes in the field without an art line or swan ??? With a low B/P nope agreed no CPAP..... what's SpO2 and dont put a cart before the horse. His level of C was what again ?? What medications is buddy on ? O2, Line, small bolus of fluid ... think about Dopamine (and if you don't have a pump) don't even spike the bag. TRANSPORT and let the CVT student do the patch .... cheers. 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 fluids?? Sorry, no speaky this abbreviation. This is a double edged sword for the paramedic in a prehospital setting. Yes, the patient is hypotensive. However, 90/50 is.... well..... low..... but, still condusive with life. The problem is, the guy is infarcting and anything we give to counteract the cardiogenic shock carries the risk of increasing the size of the infarct as well as inducing a lethal arrythmia (PVC's are present already). Really, the first line Tx for this dude is probably a small fluid bolus (watching the lung fields) then possibly a Dopamine drip at 5mcg. Seems retarded to even discuss fluids and Dopamine in a RVI infarct..... But we will have to do what we can. May also consider digoxin for it's inotropic properties. IA=intra-arterial.
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