Colonoscopy & SOB

[DartmouthDave]

This almost sounds like what my father went through recently...

OK BP is falling but rate is up sounds like hypovoliemic. Push fluids start with 2 units saline. If possible check with hospital to see what, if any, vasodialators he was given. Check to see if they would react to his precription meds. If hes had this kind of history the meds would be in his system long after 24hrs.

Might be looking at a reaction and severe vasodialation which due to his weakend heart is making the volume drop thus the low BP and s&s of shock (note he hasnt lost blood but doesnt pump enough through the system to maintain healthy BP)

The frothy sputem in the tube sounds like a PE. Could be a result of the procedure. The "shock" he felt on the ride home could be indicitive of a arythmia caused by the developing PE.

From my BLS experience I would say suction, get the fluids going to get the BP up, notify receving facility of updates, major diesil bolus.

Hello UGLyEMT,

Airway management and rapid transport is an excellent plan.

His VS could reflect hypovolemic shock. However, this fellow has cardiogenic shock or pump failure. His volume may be normal or elevated but the heart can not 'pump' it effectively. If he was more stable NTG SL or IV would help the heart pump more easily increasing vasodilation. Or, in some case, after careful assessment, Lasix to reduce the volume the heart needs to pump.

However, this fellow needs something to help his heart pump more effectively. For example, as suggested by Mobey and Herbie1 Dopamine may be an options.

These types of patients are very difficult to manage in any setting; hospital or in the field.

Cheers....

Edited August 23, 2010 by DartmouthDave

[uglyEMT]

Thanks Dave. I stay away from the meds side being a BLS provider but at least I know I have my ABCs in order. Thanks!

Copy on the cardiogenic shock. Thats a new one to me, I had to look it up. Thanks for giving the answer as to the low BP. Its something I will look out for now.

As for the frothy sputum Im asuming that was caused by the blood backing up the pulminary artery due to the decreased heart function.

Edited August 23, 2010 by UGLyEMT

[HERBIE1]

Hello,

Solid plan. RSI is what the ALS crew did for this patient. Also, CPAP was not an option.

Ketamine and a cardiac patient? I have heard pros and cons from numerous people on its use on patients with CAD.

According to Up-To-Date:

Ketamine appears to have beneficial effects on stunned myocardium in vitro [53]. When used prior to myocardial oxygen deprivation, ketamine resulted in better recovery after reperfusion. Contractility may also improve with ketamine use [52]. Clinicians must weigh ketamine's potential cardiovascular benefits against its potential to induce cardiac ischemia in patients with significant coronary disease.

Ok...the patient is intubated and copious amounts of frothy secretions are in the ET tube. The patient is hard to ventilate. Pressure is even softer and the patient is cool and toxic looking. The loading dose of Amiodarone has settled the VT issue. VS are as follows:

BP 60/p

HR 110 Sinus Tachycardia

SpO2 90%

So, the next issue is what to do about the pressure? Fluid or Pressor?

Cheers

I know it sounds counterintuitive, but I actually had my medical director tell me to push fluids on a cardiogenic shock patient- Hypotensive, pink frothy sputum, tachycardia.

I certainly would not do it without a doctor's authority. I cannot recall the details, but for some reason there was a good possibility the person was hypovolemic. I questioned the doc about pushing fluids(supposedly a no-no with a person in failure) but he explained later that 200cc's or so will make essentially no difference to the patient in terms of fluid overload, but if they are fluid deprived, it can help stabilize their BP. In my case, it did work. In field, we cannot be certain if it's a pump failure issue or hypovolemia, so I would go with pressors unless told otherwise.. Based on the patient's history in this scenario, his heart was clearly in bad shape, so pump failure would be a good bet, although hypovolemia is still a possibility. Obviously we do not have the benefit of Hg, Hematacrit, or other blood values.

I reiterate my thinking that this person is probably a good candidate for an LVAD- probably permanent- since it does not sound like he's a good candidate for a transplant..

[mobey]

Fluids or pressors? Well, I say both.

Suction that tube.

Now that we have RSS'd we have made a "relative hypovolemia"... kinda, let me explain my thoughts.

By starting PPV we increase the pressure in the thorax, and specifically the major venous return vestles (vena cava) as well as the right atrium, thereby reducing preload. Hence the drop in BP seen with intubation. We have taken the "prime" out of the pump, so we must fill it again before we cas shrink the container with a pressor.

Yes the patient is in pump failure and dobutamine would be nice, but in reality, we don't see it much prehospitally.

I would give some fluid for sure, not a big bolus, but maybe 500ml (kinda gotta see the patient) then start Dopamine at 5mcg/kg/min, and adjust prn. Epi drip is a big gun and could be used later if needed.

Ventolin shall be used after some fluid is taken out of the lungs and the wheezes are heard (you know thier gonna be there).

I disagree with lasix, this patient is not a fluid overload, although if there was a catheter in place with no output, I would give some to help them recover from any shock they may be suffering from the hypotension.

I will continue with Ketamine for now, but if things do not straighten up with the fluid... or I see changes on the 12 lead indicitave of ischemia, I would switch to fentanyl.

Good scenario

[DartmouthDave]

Fluids or pressors? Well, I say both.

Suction that tube.

Now that we have RSS'd we have made a "relative hypovolemia"... kinda, let me explain my thoughts.

By starting PPV we increase the pressure in the thorax, and specifically the major venous return vestles (vena cava) as well as the right atrium, thereby reducing preload. Hence the drop in BP seen with intubation. We have taken the "prime" out of the pump, so we must fill it again before we cas shrink the container with a pressor.

Yes the patient is in pump failure and dobutamine would be nice, but in reality, we don't see it much prehospitally.

I would give some fluid for sure, not a big bolus, but maybe 500ml (kinda gotta see the patient) then start Dopamine at 5mcg/kg/min, and adjust prn. Epi drip is a big gun and could be used later if needed.

Ventolin shall be used after some fluid is taken out of the lungs and the wheezes are heard (you know thier gonna be there).

I disagree with lasix, this patient is not a fluid overload, although if there was a catheter in place with no output, I would give some to help them recover from any shock they may be suffering from the hypotension.

I will continue with Ketamine for now, but if things do not straighten up with the fluid... or I see changes on the 12 lead indicitave of ischemia, I would switch to fentanyl.

Good scenario

Hello,

In summary, this fellow was tubed and brought in to the ED ten ICU. He was dx with Cardiogenic Shock. Two theories of the cause were:

1 ---> Off his medications for the scope caused him to go in to VT (according to the pace maker clinic he was defib at total of 5 times for VT). This stunned his heart and resulted in the rapid development of failure (an echo showed an EF of 15%).

2 ---> He was slipping into failure and the stress of the scope caused the VT, the shocks (x5) and the cardiogenic shock.

Personally, I think it was a little of option 1 and 2.

He was quite sick. He require Doubtamine and Levophed for a couple of days. There was talk of transfer to a large center but he started to come around. He was extubated by day 4 and up to the ward by day 5.

Mobey,

I agree with your statement about Lasix. Hers is what I should have said:

"Or, in some case, after careful assessment in hospital, Lasix to reduce the volume the heart needs to pump."

Cheers...

Excellent work....

[HERBIE1]

Hello,

In summary, this fellow was tubed and brought in to the ED ten ICU. He was dx with Cardiogenic Shock. Two theories of the cause were:

1 ---> Off his medications for the scope caused him to go in to VT (according to the pace maker clinic he was defib at total of 5 times for VT). This stunned his heart and resulted in the rapid development of failure (an echo showed an EF of 15%).

2 ---> He was slipping into failure and the stress of the scope caused the VT, the shocks (x5) and the cardiogenic shock.

Personally, I think it was a little of option 1 and 2.

He was quite sick. He require Doubtamine and Levophed for a couple of days. There was talk of transfer to a large center but he started to come around. He was extubated by day 4 and up to the ward by day 5.

Mobey,

I agree with your statement about Lasix. Hers is what I should have said:

"Or, in some case, after careful assessment in hospital, Lasix to reduce the volume the heart needs to pump."

Cheers...

Excellent work....

Fascinating stuff. Thanks for sharing.

Any idea what his situation will be post discharge? Any changes in the management of his situation- new meds, new Tx, etc?

[DartmouthDave]

Fascinating stuff. Thanks for sharing.

Any idea what his situation will be post discharge? Any changes in the management of his situation- new meds, new Tx, etc?

Hello,

Like noted above there was talk of transfer the patient to a CVICU/CCU. As luck would have it, he started to come around and was transfer to the ward. Currently, he is doing very well and has return to his normal level of activity.

The one new medication that was added was an ACE inhibitor (Ramipril I think). As it turns out he was on an ACE but he stopped taking it because of a dry cough (common side effect).

No new treatments. However, improved patient teaching. As the years go on I see this as a critical part of an patient care plan (for EMS and hospital). A part that is often neglected.

CHF and DCM was explained to the patient. The importance of daily weights. Simple stuff like that may prevent future episodes of failure.

Cheers

[Doczilla]

I'll add in here that the colonic prep for the procedure may cause significant fluid shifts, which may not be well tolerated in the elderly with fragile cardiovascular status. Patient may become fluid overloaded or dehydrated. Various preps include:

Golytely or colyte, which is a gallon of fluid with electrolytes and polyethylene glycol. This should be the safest with regards to fluid shift, but it can still happen.

Mix a bottle of Miralax (polyethylene glycol) with a bottle of Gatorade

Fleets phosphosoda

Castor oil

Usually a laxative such as bisacodyl (dulcolax) is included in the above regimens, and they're usually followed with enemas.

'zilla

Edited September 6, 2010 by Doczilla

[HERBIE1]

Hello,

Like noted above there was talk of transfer the patient to a CVICU/CCU. As luck would have it, he started to come around and was transfer to the ward. Currently, he is doing very well and has return to his normal level of activity.

The one new medication that was added was an ACE inhibitor (Ramipril I think). As it turns out he was on an ACE but he stopped taking it because of a dry cough (common side effect).

No new treatments. However, improved patient teaching. As the years go on I see this as a critical part of an patient care plan (for EMS and hospital). A part that is often neglected.

CHF and DCM was explained to the patient. The importance of daily weights. Simple stuff like that may prevent future episodes of failure.

Cheers

I think you bring up a very important point- patient education. We, as EMS providers can play a crucial role in this process. I am always amazed at how little patients know about their medications, their diseases, and how to properly take care of themselves. We all know about the diabetics who may KNOW about proper diet but CHOOSE to be noncompliant. What we do not know is how much has been explained to them, or more importantly, how information much they retain. Often times newly diagnosed diabetics end up hospitalized because they were in DKA, they were having kidney problems, or gawd knows what else. Think of all the information they will get before they are discharged- new medications, doctors explaining how the person must now watch their diets, etc, a dietician may come in, but often times these folks are on information overload. Explaining the importance of regularly checking their glucose levels, of taking extra caution with wound care, and how vigilance may keep a person from having problems down the road.

Folks need to be reminded- especially the elderly- of the dangers of carbohydrates. People will SWEAR they have not eaten sugar, but admit to having a major liking for bread or pasta and wonder why their glucose is always elevated. We need to educate folks about these things and not simply assume someone else already has done it.

Simple things like taking their meds at the proper times, about therapeutic levels of drugs, about taking some meds with food, about why someone with chronic a-fib is at risk for blood clots and strokes, etc. Even simple "BS" calls can be teaching moments and the patient can only benefit from the information. We should never assume that a person who has had a disease for a long time is doing what they should. Maybe they are getting forgetful, maybe they are getting lazy, maybe they are getting depressed and giving up. Just a few questions can shed light on a problem before it gets out of control.