# CVT student's nightmare



## Protoman2050 (Oct 4, 2009)

Here's an interesting scenario. Reason I'm asking this is b/c I'm a CVT student, and I keep imagining I find myself in this scenario. I hope I don't!

Scenario:

A cardiovascular technologist who contracts with the local hospital and uses his own equipment, is eating his lunch on a park bench. He is chatting with a middle-aged man, who suddenly starts having angina and dyspnea. He is sweating, his skin is cool to the touch and pale, and his jugular veins are distended.

The CVT activates EMS, gets in contact with medical control, and asks for an ambulance and permission to perform an 18-lead EKG and a transthoracic echocardiogram. 

You, a paramedic,  arrive to the site, and the CVT shares his findings with you:

Symptoms and physical findings: Angina and dyspnea. He has slight wet rales, and he has a holosystolic murmur from S1 to S2. Patient also has severe jugular vein distension. 

VS: BP: 90/50, RR: 18, HR: 100 bpm, Temp: 37 degC

EKG: 18-lead EKG shows large Q-waves and 5 mm of ST elevation in leads II, III, avF, V1-3, V3R, and V4R. Afib and PVCs are also noted. 

ECHO findings: Severe acute MR due to torn papillaries causing flail leaflets.  Severely hypokinetic left and right inferior wall. Mean pulmonary artery pressure is 6 mmHg. 

He says that the pulmonary edema is less then he thought it would be, but that's only because the diminished LV preload isn't giving much for the MV to regurgitate into the lungs. 

You activate the cardiac cath lab, and page the on-call cardiac surgeon at the local hospital.

How would you stabilize this patient?

Would you put the patient on CPAP, administer 0.5 mcg/kg/min of dobutamine and 0.5 mcg/kg/min of Nitropress to augment the patient's cardiac output and reduce the afterload of the ventricles. 

How would you maintain LV preload without throwing the patient into FPE?

What would you do about the Afib and PVCs? 150 mg amiodarone over 10 minutes?

Would you start Activase to attempt to restore perfusion?

Thanks,
Doug


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## Jersey (Oct 6, 2009)

This seems like a test question to me with 'paramedic' thrown in....


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## Protoman2050 (Oct 6, 2009)

Jersey said:


> This seems like a test question to me with 'paramedic' thrown in....



Test for whom? Definitely not me. I'm a CVT student...my tests are nothing like this. 

I made this up, b/c we're learning about myocardial infarctions and how an inferior wall infarct can cause MR or right ventricle infarction, and I wondered how a patient who had both would be medically managed while en-route to the OR for stat CABG and MVR.


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## Shishkabob (Oct 6, 2009)

The pathological q waves mean that this guy's had an MI before... that tissue is already gone.   Those q-waves didn't form instantly from the time it took you to see the guy in pain, to doing the strip.  The ST elevation is what we have to worry about now.



How far is the nearest cath lab?  
MD's hard limit on mmHg for vasodialators, 90 or 100?


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## Protoman2050 (Oct 6, 2009)

Linuss said:


> The pathological q waves mean that this guy's had an MI before... that tissue is already gone.   Those q-waves didn't form instantly from the time it took you to see the guy in pain, to doing the strip.  The ST elevation is what we have to worry about now.
> 
> 
> 
> ...



Nearest cath lab is 45 minutes away. Limit for vasodilators is 90 mmHg. 

But, since the guy's papillary muscles tore, and he has MR and is going into HF (hence the slight wet rales due to pulmonary congestion, and cool skin due to vasoconstriction), he needs a vasodilator to reduce the afterload of the LV to decrease the regurgitant volume and increase it's EF. This will also increase the EF of the RV. 

Perhaps a dopamine drip is in order, perhaps in combo with dobutamine. 7.5 mcg/kg/min of dopamine sound right?


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## Dominion (Oct 6, 2009)

I dunno if that dose was right.  I was always taught to run dopamine wide open till they started siezing and then back off till it stops and you have your dose of dopamine.


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## usalsfyre (Oct 7, 2009)

Fluid load, and start the pt on a conservative dose of IV NTG, titrated up as B/P and patient condition can stand. Fentanyl to treat any C/P.  If I was feeling really hinky, I might think about starting dobutamine after chatting with a physician.


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## Protoman2050 (Oct 7, 2009)

usalsfyre said:


> Fluid load, and start the pt on a conservative dose of IV NTG, titrated up as B/P and patient condition can stand. Fentanyl to treat any C/P.  If I was feeling really hinky, I might think about starting dobutamine after chatting with a physician.



But won't fluid loading cause the MR to spit it back into the lungs? Hw fast of an infusion are you thinking; I think it needs to be slow. 

If only you guys could plug it into your simulated patient mannequin. Then we'd have an interesting learning experience.


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## daedalus (Oct 7, 2009)

I'm not buying it. Is there not a cardiovascular technology forum where this can be discussed? I am really trying not to be rude, but this is not even a remotely likely scenario. A tech will not be getting "medical control orders" for procedures in an emergency, and a tech will not be assisting the patient once the paramedics arrive.

If you were to try and preform such procedures you would be practicing medicine without a license. Also, this scenario has been discussed before in a thread I posted in this subforum a few months ago. (acute pulmonary edema secondary to papillary muscle rupture and valve failure).


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## Protoman2050 (Oct 7, 2009)

csmmedic said:


> I'm not buying it. Is there not a cardiovascular technology forum where this can be discussed? I am really trying not to be rude, but this is not even a remotely likely scenario. A tech will not be getting "medical control orders" for procedures in an emergency, and a tech will not be assisting the patient once the paramedics arrive.
> 
> If you were to try and preform such procedures you would be practicing medicine without a license. Also, this scenario has been discussed before in a thread I posted in this subforum a few months ago. (acute pulmonary edema secondary to papillary muscle rupture and valve failure).



I've looked for a forum. Obviously, I couldn't find one.  It's not practicing without a license if a physician gives you a verbal order to perform a diagnostic test within your scope of practice. 

Besides, wouldn't you want help from a person who deals with cardiac patients every day to assist you in your patient care? 

If I were to get up and leave, I'd be depriving the paramedics and patient of my valuable expertise. Is that not unethical?


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## daedalus (Oct 7, 2009)

Still no. If you use your equipment on a patient in the park, yes you will need an order from a physician. Only, there is not a physician in the world who would give you this order. No doctor will allow a random cardiology technician to work up a random patient that the doctor does not know, under his license.

It is not your job description to provide emergency cardiac care in the field. Don't get me wrong, I can tell your a smart guy, but if you want to be preforming EKGs and examining emergency heart patients in the field, become a paramedic. If you want to do echos on people who are already in the hospital than work in your current capacity.

You have the mind of a good paramedic and I can see you will easily pass through a paramedic program if that is a desire of yours.


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## usalsfyre (Oct 7, 2009)

*I should have said...*

...carefully add fluids. This guy is gonna be a balancing act of preload vs MvO2 vs pulmonary edema. I like CPAP, but be ready for it's hemodynamic effects. This pt is very likely going to need ventilatory and pressor support just to make it to the ED, and even then might not. I would skip SL NTG and jump straight to an infusion for greater control, if I could get the B/P to where I could use it at all. Control his pain with narcotics as much as his respiratory drive will allow, pain is doing him no favors.

The other, simpler aproach is Fentanyl for pain, C/BiPAP for pulmonary edema, pressors as needed and tincture of deisel or Jet A...


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## Protoman2050 (Oct 7, 2009)

csmmedic said:


> Still no. If you use your equipment on a patient in the park, yes you will need an order from a physician. Only, there is not a physician in the world who would give you this order. No doctor will allow a random cardiology technician to work up a random patient that the doctor does not know, under his license.
> 
> It is not your job description to provide emergency cardiac care in the field. Don't get me wrong, I can tell your a smart guy, but if you want to be preforming EKGs and examining emergency heart patients in the field, become a paramedic. If you want to do echos on people who are already in the hospital than work in your current capacity.
> 
> You have the mind of a good paramedic and I can see you will easily pass through a paramedic program if that is a desire of yours.



Thanks for the comment on my mental skills? What exactly is "the mind of a good paramedic", though? Isn't paramedic school really hard, as hard as my program? Like basically 30% CVT, 30% RRT, and 30% RN? I can't believe you think someone with only a few weeks of CVT training (I'm just beginning my 22 month program) would make a good paramedic. 

Though I do eventually want to earn my BS, go to med school, and become a cardiologist. 

Yeah, I'll be happier in a hospital Coronary Care Unit, where I can perform (and, depending on the hospital, provide the initial report) EKGs, contrast-enhanced ECHOs, TEEs, and stuff like that, with immediate access to a MD. 

Have you ever done a 21-lead EKG, with both the posterior and right precordial leads in addition to the standard setup?


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## Protoman2050 (Oct 7, 2009)

usalsfyre said:


> ...carefully add fluids. This guy is gonna be a balancing act of preload vs MvO2 vs pulmonary edema. I like CPAP, but be ready for it's hemodynamic effects. This pt is very likely going to need ventilatory and pressor support just to make it to the ED, and even then might not. I would skip SL NTG and jump straight to an infusion for greater control, if I could get the B/P to where I could use it at all. Control his pain with narcotics as much as his respiratory drive will allow, pain is doing him no favors.
> 
> The other, simpler aproach is Fentanyl for pain, C/BiPAP for pulmonary edema, pressors as needed and tincture of deisel or Jet A...



His RV is probably pressure-overloaded as well, since it can't pump out the blood coming into it from the RA. Nitropress will dilate the veins, reducing preload, as well as the arteries, reducing afterload. 

Why don't we do this:

Dobutamine 7.5 mcg/kg/min + Nitropress 3 mcg/kg/min + D5W 250 ml/hr + Fentanyl 1 mcg/kg/hr + CPAP starting at 5 cmH20 and titrate upwards prn. 

If only protocol and paramedic training allowed for field Swan-Ganz catheters...


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## VentMedic (Oct 7, 2009)

Protoman2050 said:


> Thanks for the comment on my mental skills? What exactly is "the mind of a good paramedic", though? Isn't paramedic school really hard, as hard as my program? Like basically 30% CVT, 30% RRT, and 30% RN? I can't believe you think someone with only a few weeks of CVT training (I'm just beginning my 22 month program) would make a good paramedic.


 
I guess your assumption is a compliment to Paramedics.

However, in most states here in the U.S., the Paramedic is only a few hundred hours of training with no college level prerequisites required.  Only one or two states require a 2 year degree and only recently did it have to be in Paramedicine.  

At this time there is very little comparison between the Paramedic training and that of either an RN or RRT when it comes to education.  

College level A&P, hemodynamics and pharmacology are not taught at any great length or depth in the technical schools or college certificate programs for the Paramedic.    

If it was difficult it would not be possible to make Paramedics out of almost every Fire Fighter in some FDs so easily and quickly.


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## Protoman2050 (Oct 7, 2009)

VentMedic said:


> I guess your assumption is a compliment to Paramedics.
> 
> However, in most states here in the U.S., the Paramedic is only a few hundred hours of training with no college level prerequisites required.  Only one or two states require a 2 year degree and only recently did it have to be in Paramedicine.
> 
> ...



Ah. That's highly disturbing. How can I trust paramedics who have such little training if I'm involved in an MVA, and I have a epidural hematoma, rib fractures, tension pneumothorax, mitral regurgitation, and pulmonary and cardiac contusion?

Btw, did you read my PM? Are you willing to chime in on how to manage this case?


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## Summit (Oct 7, 2009)

So there you are... sitting in the park with your very own 18 lead and echo...

I blame you for his condition.


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## VentMedic (Oct 7, 2009)

Protoman2050 said:


> Btw, did you read my PM? Are you willing to chime in on how to manage this case?


 
I made a promise to a few of the CLs that I would refrain from offering too much educational information on this forum.    I hate to waste time typing a long informational post and then have it deleted.


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## Shishkabob (Oct 7, 2009)

Protoman2050 said:


> That's highly disturbing. How can I trust paramedics who have such little training if I'm involved in an MVA, and I have a epidural hematoma, rib fractures, tension pneumothorax, mitral regurgitation, and pulmonary and cardiac contusion?



I hope that was a poorly worded jest?

There's nothing a medic can do for an epidural hematoma, mitral regurgitation, and pulmonary / cradiac contusions... let alone be able to detect them and confirm them in the field... 2 year college degree or not.


But hey, tension pneumo?  We can dart you till your face turns blue! (Which hopefully doesn't happen...)


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## usalsfyre (Oct 7, 2009)

Protoman2050 said:


> His RV is probably pressure-overloaded as well, since it can't pump out the blood coming into it from the RA. Nitropress will dilate the veins, reducing preload, as well as the arteries, reducing afterload.
> 
> Why don't we do this:
> 
> ...



Most of the time you aren't going to see a Swan outside a cath lab or ICU unless a transport team is moving it around. Floating something through the RV in a non-sterile environment is generally a bad idea.

 Why nitropress instead of straight nitro?


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## Protoman2050 (Oct 7, 2009)

Linuss said:


> I hope that was a poorly worded jest?
> 
> There's nothing a medic can do for an epidural hematoma, mitral regurgitation, and pulmonary / cradiac contusions... let alone be able to detect them and confirm them in the field... 2 year college degree or not.
> 
> ...



You can *suspect* epidural hematoma if my LOC starts going down and I become confused. Also, if I'm bradycardic and have an increased pulse pressure, that's a sign of increased ICP. If that happens, please administer furosemide and hyperventilate me, for that will decrease the amount of blood in my vessels, and cause the cerebral vessels to constrict. 

Also, if you use your stethoscope, MR will be a loud holosystolic murmur. Management is Nitropress to reduced afterload and decrease regurgitant fraction. 

Pulmonary contusion will cause painful breathing, decreased SaO2, dry rales, and decreased breath sounds. 

Cardiac contusion will cause sternal pain and possibly arrhythmias. 

Yes, this was sort of a joke.


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## Protoman2050 (Oct 7, 2009)

usalsfyre said:


> Most of the time you aren't going to see a Swan outside a cath lab or ICU unless a transport team is moving it around. Floating something through the RV in a non-sterile environment is generally a bad idea.
> 
> Why nitropress instead of straight nitro?



Nitropress is less selective than NTG for veins. This guy needs stat afterload reduction.


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## Shishkabob (Oct 7, 2009)

With those ones that I named, you're merely treating the symptoms / staving off the inevitable in the field (granted, that's what a lot of what er do is).  The real fixing is going to be done in the OR.


Hearing a heart murmur at the scene of an MVC... good luck with that 

The fact that you already have broken ribs makes differentiating between fx ribs and a pulmonary contusion next to impossible. Sure, chances are you bruised something with the broken ribs, but again... there's nothing we can do to confirm it in the field.

As for the cardiac contusion, many things can manifest as substernal chest pain and some can lead to dysrhythmias... and the two are not mutually exclusive.  You can have someone with acid reflux and SVT ^_^



Aside from that, many places around here prefer mannitol for ICP as opposed to furosemide.  

And it's not really hyperventilation... it's more of a "Keep the EtCO2 at the low end of normal", ie 30ish.


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## Protoman2050 (Oct 7, 2009)

Linuss said:


> With those ones that I named, you're merely treating the symptoms / staving off the inevitable in the field (granted, that's what a lot of what er do is).  The real fixing is going to be done in the OR.
> 
> 
> Hearing a heart murmur at the scene of an MVC... good luck with that
> ...



Yes, but if you guys didn't do those interventions while the pt is en-route to the OR, the pt would be going to the mourge, not the hospital. 

Btw, why don't EMS medical directors have admitting privileges at the hospitals in their jurisdiction, so they can directly admit patients to the MICU/Cath lab/CCU/OR?


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## Dominion (Oct 7, 2009)

Protoman2050 said:


> Yes, but if you guys didn't do those interventions while the pt is en-route to the OR, the pt would be going to the mourge, not the hospital.
> 
> Btw, why don't EMS medical directors have admitting privileges at the hospitals in their jurisdiction, so they can directly admit patients to the MICU/Cath lab/CCU/OR?



I'm not sure what you mean by this?  If we have a patient in need of cath lab we frequently bypass the ER and transport that patient directly into the cath lab.  If we have a patient in need of stroke care we bypass the ER and go straight into the care of the stroke team.

Additionally while finding all that information is all well and good, and yes many services are looking at mannitol for ICP.  Our protocols locally are if ICP is suspected keep ETCO2 where it needs to be if monitoring it is available (yes not all services in the state have ETCO2 capabilities, some have 1/2 capability.  Some of our services still use LP10 or LP11's)

Search through the educational threads on here and you'll get a better grasp of what it takes to be a paramedic.  I can think of two programs off the top of my head locally that are just a few months long with the bare min. of contact hours required.


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## Aidey (Oct 7, 2009)

Also, how many non-Critical care Ambulances have nitropress? (Serious question here). I know nowhere I have ever worked has had it.


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## daedalus (Oct 7, 2009)

Aidey said:


> Also, how many non-Critical care Ambulances have nitropress? (Serious question here). I know nowhere I have ever worked has had it.



I have never heard of it myself as well. This guy sounds like a troll or something, trying to make a pass at prehospital medicine.


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## daedalus (Oct 7, 2009)

Protoman2050 said:


> Btw, why don't EMS medical directors have admitting privileges at the hospitals in their jurisdiction, so they can directly admit patients to the MICU/Cath lab/CCU/OR?



*head desk*


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## Aidey (Oct 7, 2009)

I've heard of it, just not on a "regular" ambulance.


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## Protoman2050 (Oct 7, 2009)

csmmedic said:


> I have never heard of it myself as well. This guy sounds like a troll or something, trying to make a pass at prehospital medicine.



I'm not a troll, I'm just not intimately familiar with what drugs are carried on an ambulance. 

Remember, I am a Cardiovascular Technology student, not an EMT student.


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## Protoman2050 (Oct 7, 2009)

Dominion said:


> I'm not sure what you mean by this?  If we have a patient in need of cath lab we frequently bypass the ER and transport that patient directly into the cath lab.  If we have a patient in need of stroke care we bypass the ER and go straight into the care of the stroke team.
> 
> Additionally while finding all that information is all well and good, and yes many services are looking at mannitol for ICP.  Our protocols locally are if ICP is suspected keep ETCO2 where it needs to be if monitoring it is available (yes not all services in the state have ETCO2 capabilities, some have 1/2 capability.  Some of our services still use LP10 or LP11's)
> 
> Search through the educational threads on here and you'll get a better grasp of what it takes to be a paramedic.  I can think of two programs off the top of my head locally that are just a few months long with the bare min. of contact hours required.



That's what I meant.


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## Dominion (Oct 7, 2009)

Protoman2050 said:


> I'm not a troll, I'm just not intimately familiar with what drugs are carried on an ambulance.
> 
> Remember, I am a Cardiovascular Technology student, not an EMT student.



Ok typically here are some of the more common drugs an ambulance will carry: (this is not a definitive list)

Epi 1:10000
Epi 1:1000
Lidocaine
Adenosine
Atropine
Vasopressin
D50
Dopamine
Narcan
Benadryl
Morphine
Ativan
Bicarb
Phenergan
Albuterol
Atrovent

These are what we carry with them trying to get permission to carry Fentanyl.

This is not a definiative list and every service will carry different things.

Also like someone pointed out, you are not going to hear murmurs prehospital.  I mean it's POSSIBLE but very unlikely.


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## usalsfyre (Oct 7, 2009)

This guy does need afterload reduction, which the dobutamine will help provide. Nitropress is a *BIG* gun to pull out, with the posibility of serious hypotension and lots of nasty toxicologic side effects. I'd rather start with NTG and see where that takes us.

Bottom line at this point we're looking at someone who's going to be lucky to walk out of a hospital with this amount of cardic injury.

Giving lasix to a trauma pt is generally going to go in the bad idea section. Manitol is probably what your thinking and studies have shown it not to make much difference in outcomes when given in the field. Diuresing folks is generally very tricky business and in all truth should probably be left to the pros who can monitor I/O and even hemodynamic parameters as needed way more closely than us


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## wvditchdoc (Oct 8, 2009)

Protoman2050 said:


> I'm not a troll, I'm just not intimately familiar with what drugs are carried on an ambulance.
> 
> Remember, I am a Cardiovascular Technology student, not an EMT student.


 
And you are posting (rather smugly I might add) on an *EMS Forum*. EMS, Emergency Medical Services, Pre-hosptial care, something you admittedly want nothing to do with???:wacko:


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