# A train wreck of usals proportions.



## abckidsmom (Oct 9, 2012)

Dispatched for a 68 yom complaining of difficulty breathing.  The additional says he has no medical history and has had difficulty breathing all night, now is unable to speak.

On arrival, he's upstairs in the back bedroom with a fan blowing on his face, tripoding, gasping for air, generally looking gray, with purple lips.  He's an overweight guy with a huge belly, varicosities, and clubbed fingernails.  

One glance tells you that you want to get out of the house immediately.  The partner is sent for the stair chair and you call back to the station to let them know you're going to be picking up an additional provider on the way to the hospital.

While the partner is getting the stair chair, you throw him on a non rebreather.  

Initial vitals:

BP: 280/150
HR: 200
RR: 40
SpO2: 72%

Lungs sound wheezy throughout, with minimal air movement, and sound coarse in the bases.  There is lots of accessory muscle use, and the patient is very anxious, with no other complaints.  He specifically denies chest pain, nausea or vomiting.  He also denies any medical history, says he hasn't been to the doctor in years, no known allergies.

On the monitor, he's got an EtCO2 of 48, with a shark fin wave form, and the 12 lead shows afib with RVR, no elevations or signs of ischemia on the 12 lead.  

You throw him on the CPAP at 7.5 of PEEP, he settles into that pretty well.

5 minutes later the vitals go like this:

BP:  168/80
HR: 190
RR: 44
SpO2: 97%
EtCO2: 46

You're working on getting access, struggling to find a vein, and trying to think up a plan.  What's your plan?  What are you thinking?


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## usalsfyre (Oct 9, 2012)

"No medical history" means "I haven't a clue the horrible medical mess I am" in this case...

I'm going to get an EKG and depending on the results, dump 1.2mgs of NTG under his tongue, ask him to chew up some ASA, start an NTG drip/throw on some paste if I can't get a line, reevaluate the waveform and do an inline neb as needed. Consider diltiazem if my rates still >150 after I get some preload off. I'd stick an EJ for access PRN. Primary differential is a CHF exacterbation, be alert for renal failure though.


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## VFlutter (Oct 9, 2012)

I am assuming it is an acute exacerbation of something chronic. Clubbed fingernails do not happen over night, he has been dealing with hypoxia for sometime. It could be any number of undiagnosed conditions since he has not been to the doctor in for a while. 

Shark fin waveform = bronchospasm

And we have the A Fib RVR and HTN

The tricky part will be treating one without worsening the other. 

What are your drug options? Atrovent, Theophylline, Albuterol?

If the HR does not come down soon I would consider Cardizem or Amnio

I am hoping that controlling the respiratory distress will bring down the HR/BP


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## Anjel (Oct 9, 2012)

Holy moly. I don't know where you guys get your abundance of knowledge. I feel so inadequate. I'm only replying so I can subscribe and see what happens with this.


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## abckidsmom (Oct 9, 2012)

usalsfyre said:


> "No medical history" means "I haven't a clue the horrible medical mess I am" in this case...



I called for a phone consult with the attending of the receiving ER.  She didn't hear the humor in my voice when I said that and was all, "What do you mean, no history?"



> I'm going to get an EKG and depending on the results, dump 1.2mgs of NTG under his tongue, ask him to chew up some ASA, start an NTG drip/throw on some paste if I can't get a line, reevaluate the waveform and do an inline neb as needed. Consider diltiazem if my rates still >150 after I get some preload off. I'd stick an EJ for access PRN. Primary differential is a CHF exacterbation, be alert for renal failure though.



EKG:  Afib with RVR with nothing really of note.  

Next set of vitals:

BP: 70/50
HR: 200
RR: 34
SpO2: 98, on CPAP at 7.5
EtCO2: 28


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## Aidey (Oct 9, 2012)

usalsfyre said:


> "No medical history" means "I haven't a clue the horrible medical mess I am" in this case...
> 
> I'm going to get an EKG and depending on the results, dump 1.2mgs of NTG under his tongue, ask him to chew up some ASA, start an NTG drip/throw on some paste if I can't get a line, reevaluate the waveform and do an inline neb as needed. Consider diltiazem if my rates still >150 after I get some preload off. I'd stick an EJ for access PRN. Primary differential is a CHF exacterbation, be alert for renal failure though.



Pretty much this. Except I would have to give the nitro .4 at a time, and I don't have diltiazem.


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## abckidsmom (Oct 9, 2012)

ChaseZ33 said:


> I am assuming it is an acute exacerbation of something chronic. Clubbed fingernails do not happen over night, he has been dealing with hypoxia for sometime. It could be any number of undiagnosed conditions since he has not been to the doctor in for a while.
> 
> Shark fin waveform = bronchospasm
> 
> ...



Drug options:  Albuterol, Atrovent.

Other med options:  Metoprolol, Amio.

The CPAP setup is not immediately conducive to in-lining a neb.  You are privately cursing the backwards leadership of your EMS-based Fire Department who have heard you railing on the impossibility of providing excellent EMS without the backup of excellent equipment.

They really just want quiet medics who drive people to the hospital at $10/mile.

/rant


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## Aidey (Oct 9, 2012)

I think at this point he has earned himself a cardioversion. I don't have any medication options to manage his HR, so that would be my only choice.


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## abckidsmom (Oct 9, 2012)

Aidey said:


> I think at this point he has earned himself a cardioversion. I don't have any medication options to manage his HR, so that would be my only choice.



So if you cardiovert him, the rate drops to 130 for about 2 minutes, then revs back up to the 200 range.  It's way more irregular now, flipping in and out of A flutter, a fib, and having more runs of VT.

BP: 70/42
HR: 200 ish
RR: 34
SpO2: 98, CPAP at 7.5
EtCO2: 26


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## Aidey (Oct 9, 2012)

Urgh, of course. Back of the PEEP to 5, and hang amiodarone.


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## usalsfyre (Oct 9, 2012)

I suspect he's got mega 'lyte problems from renal failure. How's his T's look? Have we considered some calcium?


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## Aidey (Oct 9, 2012)

I'm suspecting the same thing. I would be concerned about his T's not being diagnostic due to the rate and due to the stunted EKG changes in slow raising K+.


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## abckidsmom (Oct 9, 2012)

Aidey said:


> Urgh, of course. Back of the PEEP to 5, and hang amiodarone.



I'm going to just go ahead and let him die, if we do this.  His pressure went from 280/150 to 70s/50s after only 10 minutes on CPAP.  He does not have the cardiac wherewithal to continue dealing with that PEEP.



usalsfyre said:


> I suspect he's got mega 'lyte problems from renal failure. How's his T's look? Have we considered some calcium?



Ts look fine.  For conversation's sake, let's say that his urine output has been ok.  Let's have a glimpse into the future and see this gas:

pH 7.0
pO2 78
pCO2 68
Bicarb 39


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## usalsfyre (Oct 9, 2012)

Did he forget to mention his 200 pk/yr history?

Neb him...fever or other signs of infection?


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## firecoins (Oct 9, 2012)

Where is the hospital in relation to the pt?


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## abckidsmom (Oct 9, 2012)

usalsfyre said:


> Did he forget to mention his 200 pk/yr history?
> 
> Neb him...fever or other signs of infection?



Haha, 60 pk/yr history.  

At this point, his mental status declined to the point that we drilled him for IV access and started ventilating him with a BVM.

No fever, no obvious signs of infection.  Family says he's been having SOB spells for the last couple of weeks, with DOE, but this is the worst (duh).


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## Aidey (Oct 9, 2012)

abckidsmom said:


> I'm going to just go ahead and let him die, if we do this.  His pressure went from 280/150 to 70s/50s after only 10 minutes on CPAP.  He does not have the cardiac wherewithal to continue dealing with that PEEP.
> 
> 
> 
> ...



The PEEP on our CPAPs doesn't go under 5, so yeah.


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## abckidsmom (Oct 9, 2012)

firecoins said:


> Where is the hospital in relation to the pt?



Says the guy with the helicopter in his avatar.  

Initially pt was 45 minutes from the hospital.  Now we're fully 10 minutes out.  And since we had an extra minute or two, we drew up the code drugs, just to ward off evil spirits.

RSI is not an option.


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## usalsfyre (Oct 9, 2012)

abckidsmom said:


> RSI is not an option.



Brutane? 

Realistically? The guys hosed. I'm going to guess multiple untreated comorbidities got tipped over by the exacterbation of one. Cue the lengthy ICU stay, trach, and heavy duty rehab with accompanying reduction in quality of life.


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## abckidsmom (Oct 9, 2012)

usalsfyre said:


> Brutane?
> 
> Realistically? The guys hosed. I'm going to guess multiple untreated comorbidities got tipped over by the exacterbation of one. Cue the lengthy ICU stay, trach, and heavy duty rehab with accompanying reduction in quality of life.



Snicker.  You are so funny.

I considered nasally intubating him, but it had been so long since I did it, and we basically had his airway under control BLSish, that I left it off.  

My initial indecision- primary cardiac or primary pulmonary?  Let's shock him and find out....but I really didn't want to have to do CPR that long- was more than made up for when the attending took one look at him and debated with herself on whether she would cardiovert first or intubate first.  

They shocked him that one time (I never did) and got the response above.  The afib was a symptom, not the problem.

That insane acidosis, didn't help either.

Gas exchange was inhibited by his PE (D-dimer 1580)

and his pneumonia

and his biventricular heart failure.  

His heart was freaking enormous.  I was shocked that he managed to stay away from the doctors for as long as he did...


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## NYMedic828 (Oct 9, 2012)

Wish I had CPAP to begin with.

We don't even have diltiazem anymore.

My only options are nitro, ECG 3/12 monitoring and cardioversion/amiodarone if it was warranted after nitro/nebulizer treatment.


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## VFlutter (Oct 9, 2012)

That is a stampede and a half of zebras. Well not by themselves but all together is just crazy.


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## usalsfyre (Oct 9, 2012)

I'm gonna forgo the APACHE II survival to determine how this guy does. 

Dana, I want to know one thing to predict his future morbidity/mortality...what was his tooth to tattoo ratio?


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## FLdoc2011 (Oct 9, 2012)

Was it a confirmed PE by CT angio or some other study?    An elevated d dimer in a guy like this isn't terribly specific.


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## 46Young (Oct 10, 2012)

@ OP, you mentioned that the pt had wheezing and also "shark-fin" waveform on the ETCO2. My understanding is when a pt has a total loss of alveolar plateau as above, CPAP will cause additional air trapping, since the pt cannot eliminate it due to the severe bronchoconstriction. Is it possible that the CPAP caused increased intra-thoracic pressure, and created a tamponade effect? If so, the earliest sign could be the ETCO2 trending downward, particularly south of 30-35, since ETCO2 values are dependent on venuous return. When the pt's pressure starting dropping, so did the ETCO2.

No in-line neb availability sucks, but then again there are systems, sometimes large systems, that don't even carry CPAP.


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## Melclin (Oct 10, 2012)

At first glance, I'd think this to be an infective COPD exacerbation, pushed into some level of failure by said infection. What was this dude's temp?

Intensive care back after I first laid eyes on him.
Neb'd Albuterol, atrovent.
Aspirin
0.6mg GTN SL. 

Pads on, two lines, hang a bag TKVO, draw up IV albuterol, dexamethasone, 1:1000 and 1:10,000 adrenaline, amiodarone. Fent and midaz ready for cardioversion or tube. 

Depending on availability of Intensive care backup, I would be disinclined to move this guy before I got him a bit more stable. Going on the working dx above, I would really hate to take this guy out into the cold and have him peg out on me with no access and no drugs on board. I would be heavily criticised if I loaded this pt without doing anything for him first. Interesting comparison between the systems.


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## Handsome Robb (Oct 10, 2012)

I would've CPAPd him with an inline neb since our units are designed to make inline nebs easy-peasy 

I will usalsfyre, this guy is going to be in a hospital bed for a long time to come, possibly for the rest of his life.


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## abckidsmom (Oct 10, 2012)

usalsfyre said:


> I'm gonna forgo the APACHE II survival to determine how this guy does.
> 
> Dana, I want to know one thing to predict his future morbidity/mortality...what was his tooth to tattoo ratio?



Tooth:tattoo=3:0

Make of that what you will.


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## abckidsmom (Oct 10, 2012)

46Young said:


> @ OP, you mentioned that the pt had wheezing and also "shark-fin" waveform on the ETCO2. My understanding is when a pt has a total loss of alveolar plateau as above, CPAP will cause additional air trapping, since the pt cannot eliminate it due to the severe bronchoconstriction. Is it possible that the CPAP caused increased intra-thoracic pressure, and created a tamponade effect? If so, the earliest sign could be the ETCO2 trending downward, particularly south of 30-35, since ETCO2 values are dependent on venuous return. When the pt's pressure starting dropping, so did the ETCO2.
> 
> No in-line neb availability sucks, but then again there are systems, sometimes large systems, that don't even carry CPAP.



I still regret missing that Bob Page class. Good info. I'll be learning more about it. Thanks!


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## abckidsmom (Oct 10, 2012)

Melclin said:


> At first glance, I'd think this to be an infective COPD exacerbation, pushed into some level of failure by said infection. What was this dude's temp?
> 
> Intensive care back after I first laid eyes on him.
> Neb'd Albuterol, atrovent.
> ...



There was no staying in this house. It bordered on hoarders-level clutter, and we barely had room to turn him around in the stair chair to get out. 

I agree with drawing up meds before you need them, though. It's a good method to keep Murphy at bay.


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## BandageBrigade (Oct 10, 2012)

usalsfyre said:


> I'm gonna forgo the APACHE II survival to determine how this guy does.
> 
> Dana, I want to know one thing to predict his future morbidity/mortality...what was his tooth to tattoo ratio?



I prefer the degree of stained his tank top(wifebeater if you prefer) is, with 0 being semi clean (dingy white) and 10 being call a hazmat truck x beer cans on floor and # of ash trays - trash cans actually in use.


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