whit72 Posted July 8, 2007 Posted July 8, 2007 This one is odd. We are dispatched to a person not feeling well. On arrival we find a unresponsive 70ish male pale, cool and diaphoretic, absent radial pulses, carotid of 40s and irregular. Resps of 8 and shallow. Wife states he has had bilateral shoulder pain for two days. Extensive cardiac HX. Cabg, multiple caths. Call for an intercept We quickly load him place him on a NRB for a trip down the stairs. We get him on the stretcher, into the truck, drop a NPA and begin to assist ventilations. Spo2 of 80%, lungs clear bilat. Fire drives. Unable to obtain blood pressure. BGL is 116, we place the AED pads on him. (if your going to do this, don't attach to the machine) We are transporting in 5 minutes. We meet up with ALS approximately 3 minutes later. I give him the rundown, they throw a line in him, connect our pads to their monitor, do a 12 lead. The medic is ready to switch places with me to attempt intubation. I look down and the guys eyes are wide open. I say hello, and he answers me, I ask him his name and he tells me. I ask him if anything hurts, he has pain in his chest and that he states about a 5/10. This is in the hospital parking lot. He pinks up, spo2 come up to 98%, we place him on a NRB. His heart rate is in the 70's and irregular, we get a BP of 92/54. Now we called this in as an unresponsive, with a cardiac hx, HR in the 40s. No BP. We walk in this guys talking with somewhat stable vitals. Come to find out this guy was having a huge septal wall MI, I believe they stated septal rupture, with a right wall dissection. I am not completely sure if thats correct but its in the ballpark. My question. How in the hell did this guy just wake up, pink up, and his vitals stabilize? I was certain this was going to be a CPR in progress when we arrived at the hospital.
AZCEP Posted July 8, 2007 Posted July 8, 2007 If it was a septal rupture, perhaps the slow rate and low blood pressure happened for long enough to allow some scar tissue to form, sealing the hole. Definitely an unusual progression.
Ridryder 911 Posted July 8, 2007 Posted July 8, 2007 I have seen aneurysms have an increased perfusion when lay them down.. ( as in when you were going to intubate) as well they may not have much pressure but the stroke volume is able to compensate (for a short period of time). R/r 911
whit72 Posted July 8, 2007 Author Posted July 8, 2007 Well we had him supine from the time we got him, till we brought him into the ER. Maybe 13 minutes. Would that increase the perfusion, in that short amount of time to stabilize his vitals? It was just weird all around. They thank us for everything we did as we are leaving. Sometimes its better to be lucky then good.
Dustdevil Posted July 9, 2007 Posted July 9, 2007 Definitely an interesting case. I'd say it is possibly good for the patient that ALS didn't make the scene. If this was truly a septal rupture, pressors and chronotropes (wow, I used that word twice today!) could have resulted in a fatal blowout. The "shock" in this case probably saved his life.
Sdowler Posted July 10, 2007 Posted July 10, 2007 Dust are you saying that cardiogenic shock saved the pt due to other complications?
Dustdevil Posted July 11, 2007 Posted July 11, 2007 Dust are you saying that cardiogenic shock saved the pt due to other complications? I am saying that might theoretically be the case. We have long known that some forms of shock begin as a compensatory mechanism. This is why we don't use MAST and pressors in hypovolemic shock. The same theory would seem to apply here, where a raised pressure may have resulted in fatal problems. There are a lot of questions that would have to be answered to determine if this were true, but it is something to think about. This is why it is so important to have the education to actually understand pathophysiology, and not just memorise protocols to be blindly followed. Every patient is different, and few of them are following our protocols.
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