Dyspnea

[systemet]

P waves look a litle p mitrale. So perhaps some LAE too? Also nice rS in Lead II, predominantly negative complex, the axis must be quite rightward. No STEMI. NSTEMI possible. Could be about to see STEMI on our next ECG.

Lack of any improvement with O2 and positioning isn't great. Combined with sudden onset, and prior DVT, the possibility of PE has just gone up. Do we know the last INR? Any sign of a current DVT?

CHF exacerbation remains possible, especially with HTN and JVD, but seems less likely if there are no other signs of volume overload. Patient producing urine? No hx of renal insufficiency? The dyspnea is paroxysmal, just about nocturnal, but doesn't improve with positioning. ACE inhibitors aren't new?

Spontaneous pneumo is possible, with diminished A/E, cyanosis, and JVD. But the patient still has a pressure.

I guess I'm leaning towards COPD exacerbation, and remain suspcious of an underlying infectious cause.

A few more questions:

Baseline GCS? Is he normally confused?

Temperature?

Should probably do a neuro exam as well.

[Just Plain Ruff]

so 20 minutes ago was onset? is the nursing home sure about that. I mean 2300 is shift change right? I think we need to dig a little deeper with the nursing home staff on onset.

I'll bet if we dig deeper we will find that the nurse who is giving you the info is really not his nurse but a nurse from another wing.

So do we have an actual onset time?

Edited May 25, 2012 by Captain ToHellWithItAll

[DwayneEMTP]

(Wait...you didn't do a refusal?..Heh..just kidding Brother. Inside joke for everyone else.)

Percussion of the thoracic cavity?

What does the ETCO2 look like?

Any signs of trauma or abuse?

What does the DNR state exactly?

I considered a PE also but the coincidence of that coinciding with the mostly silent lungs seems pretty big. I'm also very skeptical of this being new onset. I'd be willing to bet that the nursing staff has no idea of the actual onset.

Not bagging on the nurses. They can't be everywhere at once. Though I do hate the fact that I've never gotten a report from a nursing home nurse that said, "Last seen resting comfortable 4 hrs ago. Not sure of the onset." 25pts per nurse and yet they know what every single patient looked like 15 minutes ago?

We need to get another IV, this time without using a tourniquet, though I would be curious to see if another IV would blow also. I can't remember what, but it seems like someone explained here once that thinning/delicate veins is a sign of something...

Depending on the results of the Thoracic percussion I may have my partner set me up a half mg of Epi. Should the percussion return some hollow values then we need to consider decompressing this young fellow.

After trying to r/o a pneumo let's gently bag in an Albuterol neb and see if that creates any air movement.

How exhausted does this man look? Almost certainly a nasal intubation is going to be strongly considered. Is it possible that part of his respiratory rate and silent lung sounds is due to fatigue instead of completely caused by the primary pathology?

His weight seems about right for his height for a healthy-ish patient, so chronic COPD bumps down a bit on my differential for a patient of this age. At least a severe chronic case.

Top of my list right now is broncho constriction secondary to infection(?), spontaneous pneumo, though bilat seems unlikely, flash pulmonary edema, MI.

One thing for sure is that I'm either going to get some air into this guy, or he's going to code right where he is. I'm not going to stress this critical patient by trying to move him until we can get him at least slightly improved. There's just no advantage in it that I can see other than CYA.

[Bieber]

System, I agree with you on the P mitrale. There are labs available in the paperwork from yesterday showing an INR of 2. No signs of DVT on inspection of the extremities.

Patient is producing urine and no, the lisinopril isn't new.

Baseline GCS is 15, however it's difficult to ascertain the patient's true level of consciousness because they're unable to talk due to the hypoxia. Patient does respond to commands by squeezing his hand when indicated to.

Thermometer craps out, but the patient is warm to the touch.

Unable to complete a neuro exam due to the patient's level of distress.

Mike, I agree with you, however unfortunately the nursing staff insist that the patient didn't report any complaints to them until 20 minutes ago. When you probe deeper into the patient's general state of health recently, the nurse reports that "he isn't her usual patient".

Dwayne, percussion of the chest reveals hyperresonance throughout. No signs of trauma or abuse.

Waveform capnography shows a sharkfin morphology.

The DNR states that no resuscitation including chest compressions, intubation, medication therapy, or other invasive treatments shall be performed in the event that the patient's heart stops.

Good call on trying to get another IV, however as soon as you open the line (slowly, at that) that vein also blows. Another good call to bag in the albuterol--you do that and the patient's SpO2 gradually starts to increase. It's up to about 86% now and rising. Lung sounds are still diminished/absent however.

As far as the lung sounds go, he's taking big, deep breaths--you can see his entire chest wall move with each breath. He's holding strong for now, but he's obviously working to breathe at a rate which is non-sustainable long term.

So, considering epinephrine, what are you thinking, man? Patient's blood pressure is pretty high, plus the history of CHF. Oh, and you get a rhythm change on the monitor.

You get about fifteen seconds of this:

After fifteen seconds or so, patient reverts to the initial rhythm, with the occasional PVC.

[Kiwiology]

This guy is Really Fucking Super Crook^TM and needs much Intensive Caring for his COPD exacerbation

Do you have another set of obs and a temperature? I think he's got a respiratory infection (the most common cause of COPD exacerbations).

Have somebody put him on the floor, get a good jaw thrust going and preoxygenate him by passive insufflation through a bag mask that has a PEEP valve attached at 10cmH₂O

I'm going to shove an IO into his leg and get some drugs drawn up to tube him; I'd ordinarily go against my natural instinct to give everybody ketamine and use midazolam in this case because of the transient cardiovascular stimulatory effects of ketamine and he's already quite tachycardic and hypertensive (but this is probably just be normal as he has HTN)

[DFIB]

Thin, elderly, COPD, absent lung sounds. He sounds like a candidate for spontaneous Pneumothorax. I am not saying it is what is definitely has but I would be very suspect.

[Bieber]

Ben, right you are!

Next set of vitals are as follows:

HR: 135

BP: 192/110

RR: 24 labored

SpO2: 87% (after bagging in the initial albuterol treatment per Dwayne)

Temp: 100 F

Lung sounds are still diminished, but you're starting to notice a little bit of airflow apically and bilaterally. You've hear wheezes.

Patient's daughter and DPOA is on scene and requesting that the minimum amount of invasive treatments be performed to stabilize her father. With that in mind, do you want to continue with the IO and intubation, Ben?

DFIB, that's a good thing to consider. What do you want to do right now?

Everyone else, ideas? So far we're still on scene, we've had one episode of the tachycardic rhythm noted above, we're finishing up bagging in our first albuterol treatment, and so far we haven't managed to establish IV access.

What now?

[Kiwiology]

Patient's daughter and DPOA is on scene and requesting that the minimum amount of invasive treatments be performed to stabilize her father. With that in mind, do you want to continue with the IO and intubation?

A tricky one, without her there ordinarily I'd automatically say "yes" because his DNR only talked about cardiac arrest, which he is not yet in

With his daughter there I'd say something like "While I understand you don't want your dad to suffer and to have a dignified death right now he is not dying but is extremely sick and not getting much oxygen to his brain which if we don't treat he will suffer permanent draim brananage brain damage; what we'd like to do is put him to sleep and breathe for him, it's what they are going to do at the hospital anyway, how does that sound?".

[Bieber]

I hear you, man. Unfortunately, the daughter is pretty uncertain about what she wants done now. She said minimum treatment only, but Kiwi's persuasive New Zealand accent has her second guessing herself now. She isn't able to offer any better of an answer; she just says she's not sure what he would want.

Looks like it's up to you highly educated, highly experienced professionals to reach a solution to this ethical dilemma. What do the rest of you say? We're getting some response to the albuterol treatment and PPV. Do we want to tube the guy or try to improve his condition via less invasive ways?

Edited May 26, 2012 by Bieber

[Kiwiology]

She said minimum treatment only, but Kiwi's persuasive New Zealand accent has her second guessing herself now

LOL that would be something like "Far our cuz your dad is pretty nunngered as super crook eh I reckon we ought to shove a breathing tube down his gob cos he is getting stuff all oxygen up to his brainbox sound legend sweet as bro?"

I reckon we should tube him if it's 30 minutes to hospital and his SpO2 is still abysmally low, if his work of breathing keeps up he's probably going respiratory arrest anyway either from fatigue or hypercarboxaemia

Edited May 26, 2012 by Kiwiology