CVT student's nightmare

[Protoman2050]

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

 

[Jersey]

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

 

[Protoman2050]

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.

 

[Shishkabob]

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?

 

[Protoman2050]

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?

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?

 

[Dominion]

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.

 

[usalsfyre]

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.

 

[Protoman2050]

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.

 

[daedalus]

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).

 

[Protoman2050]

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?

 

[daedalus]

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.

 

[usalsfyre]

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...

 

[Protoman2050]

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?

 

[Protoman2050]

...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...

 

[VentMedic]

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.

 

[Protoman2050]

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.

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?

 

[Summit]

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

I blame you for his condition.

 

[VentMedic]

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.

 

[Shishkabob]

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...)

 

[usalsfyre]

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...

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?