BushyFromOz Posted July 24, 2013 Posted July 24, 2013 Its kind of hard to have a go at this without seeing an ECG, i mean it is possible that the adenosine was given in error. Having said that, the last haemorrhagic stroke i was directly involved in became agitated, B/P went to 240/140, SVT in the 160's, cheyne stoking and then brady'd out to an idioventricular rhythm of 20 in space of about 3 minutes, but that was a very samll time frame in the 2+ hours they had been symptomatic. I have no idea what the territory is on beta blockers / nitrates / anti hypertensives in acute haemorhagic stroke, i imagine that messing with a hypertension thats supporting CPP is counter productive, but that is nothing more than a guess I cant remember what the other guys said for management, but of they're agitated ill manage for pain as well as the usual stuff.
Happiness Posted July 24, 2013 Posted July 24, 2013 You and your partner are working in a rural community, about 2 hours from any major centers You are called to your local health center for a BLS transfer of a 60 year old male, going for a Head CT. It's a patient you've already been acquainted with, since two days ago one of the other crews brought her to the nearby stroke facility (~75 km away) for a suspected CVA, and after being given TPA and receiving 24hrs of monitoring, you and your partner brought her back for continued care. It's been ~48 hours since TPA was given. Thrombolytics were unsuccessful, and the patient was left with right-sided paralysis and significant aphasia (he can only say "Yes", "No", and something that sounds like "bipisa"). When the nurses came this morning to give the patient his AM meds, the patient was found to have lost the ability to swallow or chew (new finding), and seemed increasingly confused. The attending physician has now requested a repeat head CT at a center ~1.5 hours away. When you arrive at the nurses station to receive a report, you find that all of the nurses are missing. When you look around, you discover that all of the nurses are in the room where your patient currently is. They're moving around frantically, and they've just finished administering adenosine. The patient appears significantly distressed, is not responding to questions, and appears acutely ill. He's on a NRB at 15 lpm, has a 20g IV in his left wrist running at 75 ml/hr, and has cardiac monitoring showing a rate of ~190bpm. What would you like to know? What would you like to do? What do you think is going on? I would like to ask why you did this as a BLS Transfer. Most of us have stated that BLS would not be transferring this pt. and if ALS was not available I would be taking a Doc on car with me. Personally with this pt I am picking up the air vac crew and be the taxi driver along with being extra hands if need. I am not touching this pt. with a ten foot pole.
runswithneedles Posted July 28, 2013 Posted July 28, 2013 BLS transfer. Im AMFYOYO. In a ALS crew. Granted we have suspicion for another stroke but im rather curious if this is a possible pulmonary embolus. Chest x-ray would be nice to rule that out real quick. RSI and place on vent to bring up the SPO2. Initiate a second IV 18 ga or largest possible set to TKO. What was the result of the initial attempted cardioversion. Did it rhythm change after the initial dose of adenocard. After the intubation did the SPO2 improve. If nothing improves than request for a medevac. 2 hours is way too long for a patient in that condition and is still deteriorating.
Jaymazing Posted July 28, 2013 Author Posted July 28, 2013 First and foremost, I have to apologize for the incredible delay in me getting back to this scenario! I wont make excuses, but I've had a very interesting week to say the least. But without further delay, Getting back to it! For those requesting ECG's, I have several for you. Following an initial 6mg, followed by 12mg Adenosine administration, this was the rhythm. No flutter waves were witnessed. http://i3.photobucket.com/albums/y59/Jeyface/ecg/photo1.jpg For anyone who might want to see an ECG from yesterday, you don't even have to ask....http://i3.photobucket.com/albums/y59/Jeyface/ecg/yesterday.jpg
Jaymazing Posted July 28, 2013 Author Posted July 28, 2013 What/when was the last CBC, PT/INR? What rhythm does it look like at that rate? Any response to the adenosine? What dose of the adenosine? Possibility of cardioverting? (See above for ECG) CBC was normal, PT/INR was within normal ranges, Adenosine failed to cease the tachycardia, doses were 6mg and 12mg respectively, and you tell me if there's a possibility of cardioverting...do you want to cardiovert right now? Why are there no physicians in the room??? A RRT should have been called and a stroke alert at the first notice of change in symptoms...but I'm guessing this is a small hospital with no such resources which brings me to the question of why in the world would he be brought back to podunkville just 48 hours after tPA?!? He should have been in a major hospital with CT capabilities... The physician is currently at the nurses station, on the phone. You are correct in guessing that this is a small hospital. The attending physician is only 1 of 2 working in the community today, and they are also dealing with a chest pain patient in the emergency department as we speak. As a meager minion of our healthcare system, I can't really say why the patient is back in podunkville so soon. I agree, he should be somewhere with CT capabilities, but sadly, he is not. So goes life in Podunkville, some days. On to care.... I'd like to get that BP down, so like IV beta blocker to get that pressure and heart rate down... What would you like to give? Anyone else feeling like RSI and knocking this patient down for a bit? With the O2 saturation decreasing and his altered LOC, I'm not too happy with him controlling his own airway as he's stroking out and possibly going to code on us with a BP and HR that high. Is there anything else you'd like to do/ask/know before pursuing the RSI route? He's likely having another ischemic stroke (doubt hemorrhagic d/t pressure)... What meds is he on? What have his vitals trended? Meds include several antihypertensives, beta blockers, lasix, ventolin/atrovent MDI, spiriva MDI, budesonide MDI, levothyroxine, ativan PRN, desvenlafaxine, ASA, acetaminophen, and some more that i unfortunately cannot recall. He is normally poor compliance with his meds at home. Vitals have been increasingly tachycardic, tachypnic, hypertensive, sats were initially 96% this morning (about 3 hours ago) and have been coming down since. If you'd like more specific numbers, I can try to track them down. ETA: Any presence of corotid bruits? Patient Temperature? Negative for carotid bruits. Temperature is 37.5 celcius. You said the heart rate on the monitor is 190...what is it on his wrist? Too fast to count, but it seems to correspond with the QRS complexes on monitor. Bounding, grossly irregular. Hello, First, thank you for posting a scenario. It is a little crazy that a CVA patient was transfer back to a small community hospital from the stroke centre so fast. I concur! Thrombolytic CVA can convert to a hemmorrhage hemorrhagic at the 24-48 hour mark. Basically, the ischemic tissue dies and a bleed can result. This is the same reason the ischemic changes do not show on a Head CT for the first 24 hours. This could explain the new neurological finding and the HTN. HR=190 What dose the monitor show? http://i3.photobucket.com/albums/y59/Jeyface/ecg/photo1.jpg Also, what is the code status/ level of intervention? There is no advanced directive for this patient. But I'm glad you asked! lastly, this is not a BLS transfer. I concur again! Thank you, Thank you! Well... hopefully you can cancel from the job since the patient has deteriorate but is in hospital and it’s not what you’ve been called for… If they want your involvement then: Is he maintaining his airway? If not, triple airway manoeuvre and OPA as primary intervention. I’d like to provide positive pressure ventilation with an SP02 of 91% on high flow oxygen with a GCS of 8. He is maintaining his airway, but its very labored. But he resists the BVM. Would you like to try anything else? What are pupils doing? ERL, 4mm What’s happening on ECG? Are they giving adenosine for SVT? http://i3.photobucket.com/albums/y59/Jeyface/ecg/photo1.jpg What’s BGL doing? 9.7 mmol/ml I’d like bigger IV access than a 20g at this stage. Done. 18g in the opposite forearm. A total summary of IV fluids. Total of 150ml normal saline today, running at 75cc/hr Recent pathology results. No labs have been done today, but they were good yesterday! Further respiratory status assessment, auscultation, skin colour etc.? Grossly laboured at about 30/minute, coarse inspiratory/expiratory wheezing in the apices with no entry to the bases, cyanosis to the lips Were the doc? Elsewhere Can we get a better history on the situation, how long ago did the symptoms start, has there been a rapid deterioration, what treatment has the patient received since being admitted to the rural hospital including what the nurses have done since the patient started to deteriorate? I’d still like to get a full past history and list of current or new medications. Today when the nurses came in to administer the patient's morning meds (approx 3 hrs ago), they found that the patient wasn't swallowing and appeared to be increasingly agitated and not responding to questions. They moved the patient to a bed with telemetry and initiated an IV and NRB, and began organizing ground transport to a facility with CT capabilities. The nurses say that the symptoms came on gradually at first, then dramatically got worse when the family arrived to visit her this morning. PmHx includes HTN, A-Fib, Hypothyroid, asthma/COPD, CHF, depression/anxiety, arthritis, and obesity. He reportedly has very poor compliance with his HTN and AFIB meds. Meds include several antihypertensives, beta blockers, lasix, ventolin/atrovent MDI, spiriva MDI, budesonide MDI, levothyroxine, ativan PRN, desvenlafaxine, ASA, acetaminophen, and some more that i unfortunately cannot recall. Treatment is really dependant on what your skills level is and what the hospital can provide? I concur. Sounds like the patient will need to be intubated… So question.... why would this be hemorrhagic vs ischemic? Just based on the history of tPA? I didn't think you would see a BP THAT high with hemorrhagic. I'm not really seeing any signs of cushing's triad either indicating to me that the ICP isn't rising as it would with a hemorrhagic right? Very good point I'm just trying to work my brain on this one... I just have a very narrow experience with strokes so understanding more of the pathophys of all this can only help? Sorry dont apologize! this is how we learn! I'm glad you're participating I would like to ask why you did this as a BLS Transfer. Most of us have stated that BLS would not be transferring this pt. and if ALS was not available I would be taking a Doc on car with me. Personally with this pt I am picking up the air vac crew and be the taxi driver along with being extra hands if need. I am not touching this pt. with a ten foot pole. It was dispatched as a BLS transfer, but as I'm sure you know, dispatch information can vary immensely from actuality. Unfortunately, air medevac is not available. You're more than welcome to be an ALS provider in this scenario. I apologize for not making that more clear in the initial information. BLS transfer. Im AMFYOYO. In a ALS crew. Granted we have suspicion for another stroke but im rather curious if this is a possible pulmonary embolus. Chest x-ray would be nice to rule that out real quick. RSI and place on vent to bring up the SPO2. Initiate a second IV 18 ga or largest possible set to TKO. What was the result of the initial attempted cardioversion. Did it rhythm change after the initial dose of adenocard. After the intubation did the SPO2 improve. If nothing improves than request for a medevac. 2 hours is way too long for a patient in that condition and is still deteriorating. I wish I knew what AMFYOYO meant haha I like the diffDx! get those gears turning. Adenocard administration showed brief asystolic pause, no flutter waves visible, with prompt resumption of tachycardia. This was the same for both 6mg and 12mg doses. And I'll let you intubate, but you may wish to review some of the new information first.
scubanurse Posted July 28, 2013 Posted July 28, 2013 (edited) So, he didnt get his am meds? IV hydralazine for the pressure IV furosemide Stats cxr Does this hospital have an ICU? Respiratory therapists? Respiratory status likely due to not receiving his asthma, copd/asthma and chf. BP/HR likely d/t missing his AM beta blocker/antihypertensives. Probably totally off on this, but it may stabilize him long enough to get a bird available or get a critical care team to ground transport to a ct hospital. Edited July 28, 2013 by scubanurse 1
Jaymazing Posted July 28, 2013 Author Posted July 28, 2013 So, he didnt get his am meds? Correct! IV hydralazine for the pressure Would you give this as a front-line antihypertensive? Would the heart rate be of concern? Would you like to do anything about the tachycardia? IV furosemide Done. Stats cxr Pending. The technician is being called in from home. Does this hospital have an ICU? Respiratory therapists? Negative on both counts! Respiratory status likely due to not receiving his asthma, copd/asthma and chf. BP/HR likely d/t missing his AM beta blocker/antihypertensives. Very interesting! We should pursue this futher Probably totally off on this, but it may stabilize him long enough to get a bird available or get a critical care team to ground transport to a ct hospital.
ERDoc Posted July 28, 2013 Posted July 28, 2013 I'm going to assume that since we can't get a head CT we also can get a chest, as someone mentioned a PE. Cxr is not helpful in diagnosing PEs (yeah you can see Westermark Sign or a Hampton Hump but those are usually only visible on the retrospectroscope). As cxr will tell us if there is heart failure, pneumonia, pneumothorax, an enlarged heart (possible pericardial effusion), or aortic aneurysm. Is is safe to assume we don't have a bedside US either? I'd like to get some labs going NOW. CBC, CMP, Trop, ABG, coags to start.
Bill5508 Posted July 28, 2013 Posted July 28, 2013 Since he is still under the care of the hospital staff, I would tell them to call back when pt is stable and request ALS or preferably CCT transport if they still want to go by ground. I would call dispatch and let them know what's going on and go back in service. Until this pt is stable enough for transfer there is no way I'm BLSing a pt like this for two hours. Whoever requested BLS apparently has no idea what resources are needed. Sounds like a typical floor nurse scenario to me.
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