Clinical ride cardiac arrest

[crispy91]

Ok. So I was recently on a clinical ride and we ran a rather interesting call. Unfortunately, the pt died. But I have an idea as to why.

So we were dispatched for a pt not breathing, cpr not started. We get on scene and fd was already there. They had canceled rescue, so we thought it wasn't too particularly bad . Scene was safe. The pt was found with her daughter. She was lying recumbent in the living room next to a large basin, almost completely full of a yellow, clear, bile-like vomit. The pt spoke only swahili. Her daughter said she had been vomitting for approx 30 min. Pt had hx of controlled hypertension, and type 2 diabetes. D-stick was 223.

LOC- V, lethargic
A- patent
B- tachypneic, adequate
C- rapid, weak, regular, and equal in all extremities. Skin was pale, cool, and clammy.

We got her in the truck, started an Iv of 1000 mL NS, and took her vitals.

Pulse- 112
BP- 100/60 (est)
Resp- 24
SaO2- 97% (2 lpm o2 via nc)
Ekg- Sinus tachy

So we started for the hospital non emergent. We gave the pt zophran for the nausea, and I started an assessment. Pupils were PERRL, and that's as far as I got. The sat straight up, made a grunting noise, and frantically pointed at her chest. She then went unresponsive.

A- occluded
B- apneic, being bagged
C- slow, weak pulse
Pulse- 34
Bp- 70/40
SaO2- 80% (15 lpm, bvm)
EKG- Mobitz II

So I started bagging her, while my partner began pacing. We got capture at 30 Ma, and paced at 80. I asked for an OPA, but my partner said he was going to intubate. We couldn't get her tubed because of an equipment malfunction. So, we bagged until we arrived at the hospital. We hit a bump on the way in and lost capture. A supervisor met us there and helped us get her in. She coded the first time right outside the room. We started cpr and transferred her to a bed. Nurses took over compressions while I managed her airway. Atropine was given. After about five minutes, we got rosc. The doc got her tubed, and a nurse confirmed placement. She coded once more abd we again got rosc. We later found out the pt died in ICU.

Here's my theory: I think this went on for days. I think she had either been vomitting for days , or had a cardiac problem. She probably went into shock , decompensated that day, and went irreversible in the truck. Here's my logic: the daughter, who had called, really didn't think of this as a massive issue until we got her in the truck . I think she really didn't realize how sick her mother was until it was too late.

Lemme know what you think!

 

[NYMedic828]

Were serial 12 leads taken?

Diabetic, heavy vomiting, classic skin presentation, progressed to a mobitz II and my guess is it went on to a complete blockage when she coded. High suspicion for inferior wall MI.

Long time diabetics sometimes do not experience the same symptoms a normal person would in the presence of an MI. Whenever I have a diabetic with abdominal pain/vomiting/nausea I record a 12 lead. The inferior wall rests on the diaphragm and during infarction irritate the diaphragm or phrenic nerve and can result in profound vomiting in some cases.

 

[Martyn]

Ok. So I was recently on a clinical ride and we ran a rather interesting call. Unfortunately, the pt died. But I have an idea as to why.

It was her time, nothing will change that, just delay it

 

[Veneficus]

Here's my theory: I think this went on for days. I think she had either been vomitting for days

Don't think this is the issue.

or had a cardiac problem.

I wasn't there, you did not give enough info, but I would bet on this.

She probably went into shock , decompensated that day, and went irreversible in the truck.

This does not sound reasonable the way I understand it.

She was in shock for days, suddenly decompensated despite your intervention, and then went into irreversible shock post volume restoration?

It sounds to me like you don't understand shock.

Here's my logic: the daughter, who had called, really didn't think of this as a massive issue until we got her in the truck . I think she really didn't realize how sick her mother was until it was too late.

That describes most patients who die suddenly.

If I had to guess, which is all it is, based on the limited info, she had an MI and she was paced and atropined to death.

 

[Veneficus]

or phrenic nerve.

Step up your game

Which branch?

 

[NYMedic828]

Step up your game

Which branch?

:wacko:


Tried to find it myself and failed.

So is it left, right, anterior, posterior or lateral?

I assume it isn't posterior or lateral so my vote is for anterior.



To the OP

As far as blockages in the heart

1st degree, which is benign sometimes presents with bradycardia in general and isn't a true block. It is also baseline for some people like runners.

Mobitz I, often vagal in nature. Usually occurs higher up in the AV node.

Mobitz II, start suspecting insult to the heart. This is where things start to go south. Often occurs infranodal as a result of cardiac damage.

3rd degree, total disassociation between ventricles and atria. Usually presents with a wide QRS and goes south pretty fast.


1st and mobitz I are the only two really affected by atropine because they are presumed to be vagal induced. It may have some benefit in mobitz II depending on how many atrial impulses are really getting through but usually it's not indicated. (I've seen it once, atropine did nothing)

Blockages don't often occur as a result of hypopoxia. That's when arrthyhmias happen because hypoxia cells get irritable and unstable. Blockages are usually due to physical damage or insult to the heart and it's conduction network.


Also, always obtain a 12 lead before you begin pacing. Obviously once pacing begins, you cannot acquire a 12 without stopping. A 3 lead is not meant to be diagnostic, atleast not a substantial degree anyway. That's what a 12 is for.

I have seen people on rotations before I knew better that used Lead II as a diagnostic and looked like real morons when the ER did a 12 to discover a major inferior MI.

 

[Veneficus]

:wacko:


Tried to find it myself and failed.

So is it left, right, anterior, posterior or lateral?

I assume it isn't posterior or lateral so my vote is for anterior.

Not an easy answer to find online I see.

I learned that the phrenic nerve branches from both the left and the right on the thoracic diaphragm followed the same path as the arteries, so were refered to as the "superior" branches of the phrenic nerve. (supplying the diaphragm and the pericardium)

This allowed them to be functionally seperated from the abdomino-phrenic branches.

Most of the sites i found just say "no named branches."

 

[NYMedic828]

Never mind knowing some extra fun facts

 

[TomB]

There's no way you had capture at 30 mA. Post the strips and if I'm wrong I'll pay you $100.00.

 

[Anjel]

There's no way you had capture at 30 mA. Post the strips and if I'm wrong I'll pay you $100.00.

I Paced my arm with 60mA lol that hurt. But 30 doesn't seem like enough.

 

[the_negro_puppy]

Sounds like a cardiac event to me. A view of the ECG before she arrested or went unconscious would have been good

 

[VFlutter]

Long time diabetics sometimes do not experience the same symptoms a normal person would in the presence of an MI. Whenever I have a diabetic with abdominal pain/vomiting/nausea I record a 12 lead. The inferior wall rests on the diaphragm and during infarction irritate the diaphragm or phrenic nerve and can result in profound vomiting in some cases.

Or the heart block was vagally induced by emesis. However I would expect to this occur right after an episode of vomiting.

If she truly was vomiting bile then gastroenteritis or intestinal obstruction should be on the DDX along with Lyte imbalance, sepsis, met alkolosis, etc

 

[NYMedic828]

I Paced my arm with 60mA lol that hurt. But 30 doesn't seem like enough.

Drunk? Lost a bet? Dare?



Maybe the patient was anorexic.

 

[Anjel]

Drunk? Lost a bet? Dare?



Maybe the patient was anorexic.

Medic class lol

We all took turns. So we could sympathize with our patients.

 

[NomadicMedic]

Anyone guess PE?

 

[NYMedic828]

Anyone guess PE?

With a mobitz II? I'd say cardiac?

 

[NomadicMedic]

With a mobitz II? I'd say cardiac?

Sure, the electrolyte imbalance or a big old MI might have been the cause...

But I'm still not convinced of the validity of the details. The capture at 30mA is telling. The OP is a basic. How much of this is valid info? Was it really a Type II?
Eval consists of PERL and that's it?

Really?

Too much guess work. Sepsis, electrolyte imbalance, PE, an MI... Demonic possession? Could be anything.

No way to hazard a guess without being there.

 

[Anjel]

And zophran! Don't forget the zophran!

 

[NYMedic828]

Or the heart block was vagally induced by emesis. However I would expect to this occur right after an episode of vomiting.

If she truly was vomiting bile then gastroenteritis or intestinal obstruction should be on the DDX along with Lyte imbalance, sepsis, met alkolosis, etc

Mobitz I is usually presumed to be vagal induced.

Mobitz II is usually infranodal and not affected by vagal tone.




Also I think OP is a medic student, but just a guess.

 

[Veneficus]

Sure, the electrolyte imbalance or a big old MI might have been the cause...

But I'm still not convinced of the validity of the details. The capture at 30mA is telling. The OP is a basic. How much of this is valid info? Was it really a Type II?
Eval consists of PERL and that's it?

Really?

Too much guess work. Sepsis, electrolyte imbalance, PE, an MI... Demonic possession? Could be anything.

No way to hazard a guess without being there.

That is perfect!

I wonder if anyone would notice if I wrote that on my next chart?

I considered PE briefly, but even with the poor details, I decided cardiac.