67yo M, A&0X4 GCS15 presents with Syncopal episode and Pinkish blood stain On pillow with 911 called by family.
Initial BP is 80 over 40 systolic and 12 lead comes back with ST elevations in V1 & V2 with recripocral changes and Septal infarct confirmed by ER physician over phone consult. Pt initially Satting about 94% RA, Chest pain 4/10, constant, non-radiating, substernal. Skins Extremely pale, Limbs cold to touch and developing diaphoresis. Pt symptomatic with Dizziness, weakness and shortness of breath.
Denies nausea, vomiting abdominal, back pain. Denies any medical history, Meds or allergies, Drug or etoh use / abuse.
pt unable to be flown out and stemi Facility 80 Mins by ground.
Enroute Dual large bore IV's started with liter of NS hung Bolus with lungs re-assesed every 250ml and remain clear.324 ASA given PO , Nitro Withheld due to Hypotension. No pain meds given as contraindicated by Hypotension. Pt Develops near syncopal episode with Drop in BP to 50/20, Brady to 50's and Drop in SP02 to 80's.....
placed flat with legs elevated, NRB @ 15LPM.... Symptoms clear and BP begins to rise...
- Serial 12 leads show Evolving Stemi tombstoning and Deep ST depression almost globally.....Also begins to show Widespread interventricular Conduction Defects / delays and a widening QRS.
After approx 900ML Pt develops increasing shortness of breath on NRB and Becomes tachy, BP now 111/ 78, States cannot catch breath......Extremely anxious. SP02 Worsing to 80's and Resp Rate 30's with Now bilateral Rhonci / Rales. Pt is placed on CPAP With little to No improvement in symptoms. Pt is foaming at mouth and nose after being on CPAP and Suctioned as necessary. Nitro is still withheld due to Pt anxiety / non-compliance..... Pt States Breathing is WORSE on Cpap and Cannot tolerate and removes mask and placed back on NRB....
approx 10 mins out Pt codes, ACLS Protocols followed to best of my abilities with 2 rounds epi given. OPA in place and CPR started immediately. 12 lead captured during pulse check shows a PEA rthym. Hospital Immediately intubates, Bloody foamy sputum in tube immediately. Dr confirms Major Septal infarct........
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Sooooooo........This guy seemed to be in left heart failure from the start As well as A Septal infarct that was clearly affecting his conduction system....
Our protocls Go against dopamine Unless IV fluids are refractory (which they were not)
Fluid was NECESSARY due to extreme hypotension and symptomatic.....and was trying to do permissive hypotension as well.....But it seems clear i sorta fluid overloaded this guy.....
on the other hand, if i DIDNT give him fluid i had no chance of starting CPAP or hopes of ever giving him nitro which is what he badly needed...
So did he crash cause Flash pulmonary edema? or A major septal infarct that Stopped his heart? A bit of both? We'll never know?
What could i have done better? differently?
Initial BP is 80 over 40 systolic and 12 lead comes back with ST elevations in V1 & V2 with recripocral changes and Septal infarct confirmed by ER physician over phone consult. Pt initially Satting about 94% RA, Chest pain 4/10, constant, non-radiating, substernal. Skins Extremely pale, Limbs cold to touch and developing diaphoresis. Pt symptomatic with Dizziness, weakness and shortness of breath.
Denies nausea, vomiting abdominal, back pain. Denies any medical history, Meds or allergies, Drug or etoh use / abuse.
pt unable to be flown out and stemi Facility 80 Mins by ground.
Enroute Dual large bore IV's started with liter of NS hung Bolus with lungs re-assesed every 250ml and remain clear.324 ASA given PO , Nitro Withheld due to Hypotension. No pain meds given as contraindicated by Hypotension. Pt Develops near syncopal episode with Drop in BP to 50/20, Brady to 50's and Drop in SP02 to 80's.....
placed flat with legs elevated, NRB @ 15LPM.... Symptoms clear and BP begins to rise...
- Serial 12 leads show Evolving Stemi tombstoning and Deep ST depression almost globally.....Also begins to show Widespread interventricular Conduction Defects / delays and a widening QRS.
After approx 900ML Pt develops increasing shortness of breath on NRB and Becomes tachy, BP now 111/ 78, States cannot catch breath......Extremely anxious. SP02 Worsing to 80's and Resp Rate 30's with Now bilateral Rhonci / Rales. Pt is placed on CPAP With little to No improvement in symptoms. Pt is foaming at mouth and nose after being on CPAP and Suctioned as necessary. Nitro is still withheld due to Pt anxiety / non-compliance..... Pt States Breathing is WORSE on Cpap and Cannot tolerate and removes mask and placed back on NRB....
approx 10 mins out Pt codes, ACLS Protocols followed to best of my abilities with 2 rounds epi given. OPA in place and CPR started immediately. 12 lead captured during pulse check shows a PEA rthym. Hospital Immediately intubates, Bloody foamy sputum in tube immediately. Dr confirms Major Septal infarct........
----------------------------
Sooooooo........This guy seemed to be in left heart failure from the start As well as A Septal infarct that was clearly affecting his conduction system....
Our protocls Go against dopamine Unless IV fluids are refractory (which they were not)
Fluid was NECESSARY due to extreme hypotension and symptomatic.....and was trying to do permissive hypotension as well.....But it seems clear i sorta fluid overloaded this guy.....
on the other hand, if i DIDNT give him fluid i had no chance of starting CPAP or hopes of ever giving him nitro which is what he badly needed...
So did he crash cause Flash pulmonary edema? or A major septal infarct that Stopped his heart? A bit of both? We'll never know?
What could i have done better? differently?