82 y/o female respiratory distress

[rhan101277]

You are dispatched for the above call, when you arrive at the house you find the fire department is arriving the same time as you. Upon entering the house and making patient contact you find the patient sitting up in the bed in severe respiratory distress. You quickly place the patient on 15L NRB and assess lung sounds. Diffuse coarse crackles are noted, no pedal edema, really no stethoscope is needed to hear these crackles. pt aaox3, gcs 15, difficulty speaking due to the distress.

PmHx: HTN
Medications: Metoprolol

After further questioning this is an acute onset of breathing difficulty with no previous lung or heart problems. No recent n/v/d, skin p/w/clammy. Vitals are obtained.

BP: 103/90
HR: 133 (wide complex) no pacemaker
SP02: 92% on 15L NRB

Pt is loaded on a stair chair for extrication and re-vitalized

BP: 80/40 (still has good mentation)
HR: 140
SP02: 93% on 15L NRB

You have a 2 mile ride to the hospital, as you wonder what is going on with this patient.

What is going on and how would you proceed?

 

[Imacho]

Sound like a possibility of a PE.

 

[mycrofft]

No habla "Crackles". Inspiratory or exhalatory or both? (I'm guess "both").
A bilat lung auscultation enroute would be wise just in case. Nasty uncompensated drop in BP there, automated or manual? Pulse regularity ( EKG good for that)? Was a different sized cuff used on the pt between measurements? (I've seen a small cuff used from a jump bag on an emaciated little old lady get a higher BP than the larger one mounted to the vehicle's installed aneroid BP cuff).
Yeah, PE needs to be entertained. Usually get some sort of ℅ pain in those early on.

 

[Handsome Robb]

Can we have a 12-lead? Wide complex at 140 could be a lot of different things and could potentially cause her pulmonary edema.

I'm assuming diffuse coarse crackles is going to be bilateral rales.

Sounds like APE, probably secondary to an AMI. Seems like she's in cardiogenic shock and about to decompensate. She needs PPV but I'm hesitant to do it with her vitals. Inotropes would be nice, a small fluid bolus (yay frank starling), position her as upright as you can. Consider intubation if she starts to lose her mentation or airway. She also needs a cath lab I'm betting so let's go to a hospital that's capable.

Without more information it's tough to say, this is moving towards a lets boogy scenario though.

 

[mycrofft]

2 miles ride. How many minutes?

 

[Imacho]

Missed that part. Then ya flash edema would be primary impression. Pressure is too low for CPAP. Titrate dopamine to achieve 90 systolic.

 

[FLdoc2011]

Not sure what protocols would say but I wouldn't let an iffy BP stop me from using BiPAP/CPAP in a patient in resp distress which it appears this pt is in.

 

[Angel]

is she still wide complex @140?

2 miles isn't time to do a lot but id take another person and give her PPV, due to her BP cant use CPAP here.

Id get an IV and get base order for dopamine while assessing.

12 lead.

 

[NightShiftMedic]

I would want to get a good quality 12 lead ECG with a quickness, especially before resorting to dopamine or another vasoactive medication. We also need more history. Was she recently sick? Any recent infections, cough, cold, etc? My thoughts on treatment based on the given information are:

Continue the current oxygen therapy
12-lead ECG ASAP
be ready to intubate her should her GCS drop < 8
two (at least) well functioning IV's/IO's
small (IE 250 mL and no more!) fluid bolus
get her to the ER, preferably one that has a cath lab and is equipped to handle her

Currently my guess is that she's had a MI and is in cardiogenic shock. I would also guess that her wide complex rhythm is a bundle branch block due to the MI, however if we were to find VT or something like that on the 12 lead I would want to correct that before I would start dopamine, which can cause lots of ventricular ectopy.

Regarding CPAP or BiPAP, she may very well be preload dependent. With a pressure of 80 systolic, I wouldn't want put her on CPAP and reduce her preload even further.

I like this case!

 

[Angel]

For my own curiosity...why are so many people thinking MI?

 

[rmabrey]

For my own curiosity...why are so many people thinking MI?

MI sometimes cause APE. When ive seen It, its usually a sign of imminent death. Results may vary.

 

[NightShiftMedic]

For my own curiosity...why are so many people thinking MI?

Given what little info we have at the moment, it's a good place to start.

 

[jrm818]

For my own curiosity...why are so many people thinking MI?

It's an easy way to explain how a recently healthyish patient can suddenly have a miserable blood pressure and pulmonary edema. There aren't that many ways that happens quickly, and MI is probably the most common.

When we think about ACS or evaluating an MI, there are "anginal equivalents" that put your antennae up...sudden SOB/pulmonary edema is one, so that alone would make me wonder.

Arrythmias can obviously cause some of the same problems, and I don't really think any of us have a clear idea what is going on with the ECG in this scenario, seeing a 12 lead would help with that.


as rmabrey said, pulmonary edema + low BP is a very bad thing; much worse than the more typical acute pulmoary edema with hypertension.
For your listening pleasure:

http://emcrit.org/podcasts/cardiogenic-shock/

 

[Angel]

awesome site! thanks, and for the feed back too, guys.

 

[Handsome Robb]

Redacted

 

[FLdoc2011]

Whatever is going on here it's bad.

Acute Pulm edema is a good thought on what's currently happening, but the question would be from what? Acute MI/CHF/cardiogenic shock, viral illness/sepsis, alveolar hemorrhage, aspiration are all possibilities. Lots of other causes as well but they don't fit this scenario.

PE: also a possibility.... Tachycardic, hypoxic, hypotensive.

PNA: didn't say if she had a fever or not and shouldn't really be a completely acute onset but still a consideration. Would have to ask further questions on the days leading up to this and how she felt.

Arrhythmia: I'm still worried about that rate in an 82yr old. Don't have an ECG yet but would think about rapid afib/flutter causing hemodynamic instability or even vtach given wide complex noted, but a monitor/ECG should let us know there and after some supportive oxygen one of the first things that should be done and would probably dictate further management.

Clinically looking at her I would get an idea if she appeared fluid overloaded or dry. If not overtly overloaded and verified to be hypotensive could try a conservative bolus.

Without knowing more it's hard to agree it disagree with dopamine. On the surface I would be hesitant with that heart rate and note knowing what the rhythm was, though if truly in shock and that's the only pressor you have then I guess not much choice, but rarely is dopamine my first choice of pressor.

If work of breathing is increased where she is struggling and/or continued to be hypoxic would put on bipap/CPAP. Was ETCO2 done?

Could try some fluid, if pulm or mental status worsens then intubate.

 

[Handsome Robb]

Now that I'm on a computer I can be a bit more detailed. I think it's been pretty well covered why MI is on the ddx list. Another thought I had is VT could cause APE correct secondary to the poor cardiac output. It doesn't seem fast enough though unless left ventricular function was already compromised.

If it isn't VT It seems like dobutamine would be a good option if you have it.

I'd be pretty hesitant to ventilate her unless I absolutely had to. Any sort of PPV is going to cause an increase in intrathoracic pressure especially with PEEP. She's mentating, 92% on the mask and if the pleth form is good and she's not about to tucker out I'd like to let her ventilate herself until we can get her hemodynamically stable but if her airway starts to go I want to try and stay ahead of the game.

Can I add a question for discussion? If you had to RSI her what meds would you use? I'm thinking fentanyl, ketamine and sux. Ketamine has a good hemodynimic profile and can actually cause transient increases in BP, fentanyl has a good hemodynamic profile as well.

 

[NightShiftMedic]

Can I add a question for discussion? If you had to RSI her what meds would you use? I'm thinking fentanyl, ketamine and sux. Ketamine has a good hemodynimic profile and can actually cause transient increases in BP, fentanyl has a good hemodynamic profile as well.

I like your ideas of fentanyl and ketamine. I would probably use roc instead of sux so long as there's no predictors of a difficult airway. When given at the higher end of the dose range (1.2 mg/kg) it tends to have an onset similar to sux, but doesn't come with the risk of hyperkalemia.

If this patient gets RSI'd then likely we would need a pressor to support her BP.

 

[NightShiftMedic]

Although, I do understand that a lot of protocols only allow sux as the first paralytic unless it's a dialysis patient or something like that.

With my current protocols it would be etomidate and roc for the initial intubation then fentanyl and midazolam for continued sedation.

 

[NightShiftMedic]

If it isn't VT It seems like dobutamine would be a good option if you have it.

Or norepinephrine. I was just reading about this last night. Apparently there's less mortality with norepinephrine in cardiogenic shock.

I'd be pretty hesitant to ventilate her unless I absolutely had to. Any sort of PPV is going to cause an increase in intrathoracic pressure especially with PEEP. She's mentating, 92% on the mask and if the pleth form is good and she's not about to tucker out I'd like to let her ventilate herself until we can get her hemodynamically stable but if her airway starts to go I want to try and stay ahead of the game.

I'd definitely say this is the way to go.