82 yo Male C/C Shortness of Breath

[Handsome Robb]

You're an ALS unit (medic/intermediate) kicked out of your fancy hard post at 2200 for a Priority 1 shortness of breath, responding with an ILS FD. It's about a 12 minute code 3 response which puts you about 20-25 minutes by ground from three capable hospitals, one being a Level II TC the others are you're standard community hospital with interventional cardiology on call.

Upon arrival you find an 82 year old gentleman seated in a lounger in his living room in mild distress speaking with FD personnel already on scene. Pt is A&Ox4. Pt began having SOB and worsening weakness about 1 hour prior to your arrival while watching TV. Pt states he has had "minor" SOB all day but it just recently "got bad". Pt speaks in full sentences but does stop to catch his breath between sentences. Pt denies any recent changes in medications, illness, trauma, chest pain, palpitations, diaphoresis, dizziness, N/V/D or any other associated symptoms. Pt states he has felt this before 2 weeks prior and spent 3 days in the hospital "because there was fluid around my heart".

Fire immediately shoves a 4 lead into your hand showing A-flutter at a 3:1 conduction with an atrial rate of 140 BPM and a ventricular rate of ~45 BPM.

12-lead confirms A-flutter + RBBB, no ST elevation noted (I'll try to post a picture in a bit, I don't have a scanner). Conduction seems to be changing between 2:1 - 4:1 mostly staying at 3:1 though, lowest ventricular rate noted is ~30. Continuous alarms from the MRx ranging from low SpO2%, multiple PVCs, VT and SVT alarms. You notice what some may argue what appear to be occasional multifocal PVCs, my partner said bigeminal PVCs, I said it was a 2:1 A-flutter.

Vitals:

150/94
HR as noted above, pulse matches the ventricular rate on the monitor and is difficult to palpate.
95% on 2 lpm which the patient wears "all the time", breath sounds clear in all fields
CBG 208 mg/dl

Physical exam is generally unremarkable other than the pt appearing to be pale and appears to becoming more diaphoretic throughout your assessment. Pt is ~6'2" and ~120 kg.

Pt states he would like to be transported for evaluation and of course requests the furthest of the three facilities, about 25 minutes away by ground.

Hx - A-fib, CHF, HTN, Hyperlipidemia, IDDM, RBBB, non-smoker, non-drinker and you find discharge paperwork on the counter that says the pt was released with a dx of a pericardial effusion 2 weeks prior and had radiologically guided pericardiocentesis which resulted in ~900 cc being drained off.

A - NKA/NKDA

M - Amiodarone, diltiazem, lisinopril, lasix, K++, lantus, humalog and a few others I can't remember off the top of my head

My question is what do you want to know and what are your interventions? I'll tell you what I did after I hear some input, I'll tell you now though it wasn't very exciting. Well it made me take a bite out of my boxers but other than that...

This one confused me a bit. I knew what was going on but from the treatment standpoint I was having some trouble deciding where I was going to go.

 

[Handsome Robb]

Top is fire's 4 lead, middle two are alarm strips my monitor auto-printed showing II, V1 and V2 in that order, bottom is my second 12-lead...first one somehow got both copies left at the ER but there weren't any differences that I noted between the two which were captured about 10 minutes apart.

Pardon the cans of chew an the crappy phone picture

 

[Anjel]

With the ventricular rate that low, and the atrial rate high, I would consider pacing? Maybe? Haha

How were his heart sounds? Muffled at all?

 

[VFlutter]

With the ventricular rate that low, and the atrial rate high, I would consider pacing? Maybe? Haha

How were his heart sounds? Muffled at all?

The heart rate really isn't that low and the patient does not sound hemodynamicly unstable. His symptoms are not due to the HR but rather (Most likely) a reoccurrence of the effusion. Increasing the HR would not help with that. I wonder if the effusion would alter the ability to capture during pacing?

I would transport in position of comfort, HOB up. Can't really think of any interventions.

Any indication why he had an effusion in the first place?

Did he tamponade during transport?

 

[Anjel]

The heart rate really isn't that low and the patient does not sound hemodynamicly unstable. His symptoms are not due to the HR but rather (Most likely) a reoccurrence of the effusion. Increasing the HR would not help with that. I wonder if the effusion would alter the ability to capture during pacing?

I would transport in position of comfort, HOB up. Can't really think of any interventions.

Any indication why he had an effusion in the first place?

Did he tamponade during transport?

Ya just thought I would throw that out there. He isn't symptomatic really. But if his BP was to drop, or level of consciousness. Then maybe?

And 30 is really low in my book.

 

[VFlutter]

Ya just thought I would throw that out there. He isn't symptomatic really. But if his BP was to drop, or level of consciousness. Then maybe?

And 30 is really low in my book.

I personally would avoid pacing. I would assume the pacing threshold would be higher on a patient with a pericardial effusion and I think it would just be problematic. Also 900ml is a significant effusion so assuming this may be happening again I would not want to work the heart anymore than it already is.

And the way it sounded to me the patient was mostly sustaining 45ish with drops to the 30s. If they sustained 30 then I may get concerned. But the patient is on amino and dilt so it is somewhat expected.

Do you carry Dopamine/Dobutamine? That would be a better alternative IMO

 

[Anjel]

Ah ok.

I haven't really learned too much about effusions yet. Thanks for explaining that.

 

[VFlutter]

In order for someone to have >500ml in the pericardium then it is most likely a chronic condition (Pericarditis). The heart can not accommodate rapid accumulations and as little as 200ml can cause a tamponade.

Normal volume is around 30-50ml

 

[Anjel]

Oh geez. I forgot what the normal volume was.

I would still like to know how his heart sounds were. Just out of curiosity.

And rob... You should of called for orders for a pericardiocentisis.

 

[Handsome Robb]

So his pressure trended downward throughout transport and his pulse pressure narrowed. Last pressure I got was 106/82. Mentation and complaint never changed although he did look "sicker" by the time we got to the hospital. Heart tones were tough to hear but we were also bumping down a wonderful country road when I listened, no JVD though.

 

[Melclin]

Speed him up with adrenaline and then sync cardiovert him after you needle his chest.

I would do nothing. He's obviously pretty crook but I think this requires consideration by someone who knows what they're doing better than I. Intensive care backup if it doesn't delay, but I don't think they'll be doing much either. I think this guy needs to be in a resus cubicle soonish.

 

[Handsome Robb]

Speed him up with adrenaline and then sync cardiovert him after you needle his chest.

I would do nothing. He's obviously pretty crook but I think this requires consideration by someone who knows what they're doing better than I. Intensive care backup if it doesn't delay, but I don't think they'll be doing much either. I think this guy needs to be in a resus cubicle soonish.

I like it!

I had the same thought, he was definitely sick and needed someone much smarter than myself. I'm hoping to make it back to that hospital today to follow up on him.

Mr fast65 and myself were talking about overdrive pacing but I'm not sure that'd be in our scope of practice or even doable with the MRx. If I understand it correctly I'd have had to have gotten the pacer rate above the atrial rate, gotten capture then slowed it down. That's my basic understanding of it and hence why I did absolutely nothing other than VOMIT + fluids.

I'm still interested to hear what the smarter ladies and gents on here have to say.

 

[VFlutter]

I may be totally wrong on this but here is my rationale. The main problem is a reduction of volume in the LV due to compression which results in a decreased CO. Kind of like a restrictive cardiomyopathy situation? Stroke volume x HR = cardiac output. So i guess pacing may improve the situation, if you could actually capture, but if that did not work I would start thinking about inotropes (Dopamine) to increase the heart rate and force of contraction and hopefully maintaining enough output until you can get the patient to the ER.

 

[FLdoc2011]

Pacing isn't the answer here, and certainly not overdrive pacing. I've seen some papers describing some uses in afib/flutter but the only time I even seen it used/mentioned is in the context of an ICD's overdrive pacing to abort vtach.

Others have already mentioned it but recurrence of pericardial effusion is high on the list if worries here and that needs to be evaluated in ER with an ECHO.

But not much more I would do with this besides supportive care in the meantime. If he does start to crash on the way in and you suspect tamponade then a fluid bolus would be needed.

 

[Handsome Robb]

Pacing isn't the answer here, and certainly not overdrive pacing. I've seen some papers describing some uses in afib/flutter but the only time I even seen it used/mentioned is in the context of an ICD's overdrive pacing to abort vtach.

Others have already mentioned it but recurrence of pericardial effusion is high on the list if worries here and that needs to be evaluated in ER with an ECHO.

But not much more I would do with this besides supportive care in the meantime. If he does start to crash on the way in and you suspect tamponade then a fluid bolus would be needed.

I was able to follow up and he was admitted for observation, echo and cxr were clear and showed no signs of another effusion. I'm really interested to find out what the final diagnosis is.

For what it's worth doc all I did was supportive care. I'm the first to admit though that had he continued to go south on me I'm not sure what I would have done, our flight crews can do pericardiocentesis and it crossed my mind to call for them for that exact reason because an effusion was my number one ddx, time wise I elected not to due to them not being simultaneously dispatched with us.

The only thought I had was upgrade to code 3 and more fluids, I gave him a total of 500 cc over about 20 minutes.

Per protocol a-flutter is treated with cardioversion, we don't carry CCBs and I don't think either would be appropriate in this case. That's assuming a tachycardic ventricular rate and a symptomatic patient, which I would not have qualified this man as either at the original point of contact. He remained in the 40s throughout the transport, occasionally dipping lower than that.