WWJD - 1

[8654Maine]

WWJD - What Would Joseph(ina) Do, Case 1.

You are Joseph(ina).

You are a Corpsman/medic doing sick call at the local Base hospital. You pissed off someone, so you are stuck with the overnight shift.

A 46 y.o. male comes in with CP x 1 hour. He had an MI 7 years ago requiring 2 stents.

His EKG looks funny but not diagnostic. By this I mean, it looks like it showed a previous inferior MI but you don't have an old one to compare it to.

As you are talking to him, his eyes roll back, he becomes unresponsive.

You establish that he is unresponsive, you check pulses (not there) and you look at the rhythm strip:

(copied from Medblog)

What would YOU do?

Hint #1:
Step 1: _______
Step 2:_______
Step 2a:______
Step 2b:______
Step 3:_______

Hint #2: There are only 3 things you really need to do to revive this dead man. Yes, he is dead. You have a very limited time to undead him.

Hint #3: KISS rule. Permissive hypothermia, surgery, anti-arrhthmics, ECMO, etc will not save this guy right now.

 

[Muppet]

Defib, CPR and classic ACLS. Looks like coarse vfib but faintly looks like torsades... Either way, needs shocking nonetheless....

M.

 

[TLDR20]

Step 1: Activate the Emergency Response system

Step2: Begin CPR

Step 2B: I would assume he is hooked to a monitor that can shock...? If not get an AED.

Step 3: get an IV and an airway adjunct.

Step 4: Epi

 

[Muppet]

Ok. First shock in followed by 2 mins of God damned awesome CPR. Any ROSC? If not, continue with shocks if VF or CPR if a systole. If ROSC, do post resuscitation care to include no hyperventilation, pressors for a MAP of 110, fluids to support that first, intubate if not done or if fighting tube, sedation. Only treat fast or slow heart rates if life threats, make him cold if able and safely able to do so, sedate/ paralyze him, drop a esphageol temp for continuing temp, get serial 12 leads to rule out STEMI and attempt to find cause of arrest.

If he is still dying, CPR is the only damned thing that will save him with counter shocks...

M.

 

[8654Maine]

I've had a long weekend with many drunk idiots.

I hate propane explosions.

To sum up this case:

Step 1: I yelled for help in a loud, no BS voice. I needed help, no ifs, ands or buts.

Step 2: Try to restore perfusion: basically keep critical organs alive, i.e. brain, heart and kidney.
Step 2a: CPR: after establishing pulseless dysrhythmia, I took 2 steps back and launched onto his chest and did a precordial thump that would have made the Rock proud, and then started compressions. Proper compression is like sexual intercourse: all about the proper use of hips and core muscles. Should have seen the wife's jaw drop. I thought she was calling the cops on me. Just as I was telling her that her husband was in cardiac arrest, the guy did several things. His eyes opened, he took some breaths and his arms moved up. I think he was being attacked by some strange dude and he was about to grab my family jewels. Good thing he went back into cardiac arrest.

Step 2b: Defibrillate. Modern AEDS are made so that a retard on medical marijuana could easily do it. In this case, my yell for help brought in the crash cart. After coaxing my gonads back into my ball sack, the pads were placed on his chest, shocked at 150J. Still in arrest. Increased to 200J. Return of spontaneous circulation. For those who are providers, if your initial shock doesn't work, either increase the juice, change the pad placement or get new pads. During a resuscitation, the pads are usually placed on the anterior/apical orientation to the chest. The anterior/inferior orientation has been my go to pad placement.

This guy immediately opened his eyes. He was looking around and was asking what was going on. He had no idea what happened. "I think I might have passed out" were his words. His wife told him what happened. He looked at me and thanked me for saving his life. I told him I'm glad he didn't grab my junk.

Step 3: Get that person to a higher level of care. Call 911, call cardiologist for further diagnostic testing. ROSC (Return of Spontaneous Circulation) is useless without further evaluation. Get that person to a facility or person who can do interventional cardiology.

In this case, Interventional cardiology came down, he got a cardiac catheterization and 3 brand new stents and a new lease on life.

Anyone can do this. Notice that none of these steps require any advanced degree. Get trained in BLS, ACLS, PALS, ATLS. It will save someone's life, maybe someone close to you.

Hope this was informative and entertaining.

 

[Muppet]

I have thumped a few. All STEMI's I place the combi pads on so if they code, shazaam, they get hit with 150 biphasic. Word on the case study doc... Doc. Have you used or heard of multi seq. defib. 2 monitors, 2 pads with A/A and 2 pads with P/P? Twice the amount of electricity. I hear Wake County in N.C. are getting ROSC WITH neuro intact, walking out of hospital...

M.

 

[policemedic]

I have thumped a few. All STEMI's I place the combi pads on so if they code, shazaam, they get hit with 150 biphasic. Word on the case study doc... Doc. Have you used or heard of multi seq. defib. 2 monitors, 2 pads with A/A and 2 pads with P/P? Twice the amount of electricity. I hear Wake County in N.C. are getting ROSC WITH neuro intact, walking out of hospital...

M.

Funny, but those are the first two thoughts I had. Precordial thump (I'm old school, I guess) if the pads weren't attached; biphasic jolt if they were. Truth is, I'd argue recklessness if one of my junior medics was presented with a pt with that complaint and Hx and did not prophylactically place the pads.

Obtaining the 12-lead early is very important, but the lack of diagnostic features on EKG does not r/o AMI. I've often done serial 12s, right-sided and posterior EKGs to look for problems. I'm also a big advocate of 2 access sites in these cases precisely because they may crash out of nowhere.

@8654Maine I don't know that your notional medic would have had time in this scenario but I like POC testing for cardiac enzymes and other labs. Data, data, data...even if I can't affect the particular number it gives me a baseline and a better idea of the patient's current condition, plus it helps with ddx.

The emphasis on basics was spot on. I thinks sometimes we get wrapped up in the minutiae of medicine--I'm particularly guilty of this with cardiology--but the truth is unless we can do the basics we aren't any good to anyone.

 

[8654Maine]

Very important points:
(1) SERIAL EKG's. One negative doesn't rule out an MI. MI's evolve.
(2) First cardiac enzyme was negative. The symptoms were too early for release of enzyme to be captured. This was truly a widowmaker.
(3) With really obese people, then 2 pads A/P.
(4) Prophylatic pads are a good idea, but this guy just walked in and was getting undressed as I was talking to him.
(5) If they don't need intubation, try to avoid it. Biggest reason is that when cardiology caths them and look for culprit lesions in the coronaries, besides looking at TIMI flow, they ask the patient how his symptoms are. If he feels totally better, then they know they have the culprit lesion. Many folks have diffuse disease and it is tough to tell which lesion is causing the current symptoms.
(6) Again, anyone with basic knowledge could have identified the problem and saved this guy's life. Life is already complicated enough, KISS it down.

So, just for shits and giggles, what would be some advanced things you guys could have done? Forget airway, drugs, hypothermia.

What I mean is: We always think Coronary Artery Dz, when someone has an MI and has Vfib. What things can mimic this?

Format for this: As you're talking to the cardiologist/ER/ICU to give report, this is what you're saying and fill in the blanks:

"Doc, this 46 y.o. guy came in w/ 1 hour of anginal CP. His initial EKG wasn't diagnostic. He had witnessed cardiac arrest with Vfib. He got shocked twice and we got him back. His vitals looks fine now and his 2nd EKG looks like a big anterior STEMI. I need the cath team activated. I think it's a proximal LAD lesion or maybe a left Main. However, I think it might not be CAD but _____a______ because he has this other risk factor(s)____b____."

If I hear this on the radio, this tells me a few thing: you know your shit and you are thinking. I and my team will think you a star. I'll want you as my EMS truck when I or my family has a near fatal one.

I'll give an example:

(1) a = severe Aortic stenosis, b = he has a harsh systolic murmur, narrow pulse pressure and for someone with prior CAD/MI, he's not on ACEI or nitrates (hmmm).
(2) a = Cocaine OD, b = he's got IV track marks, drug paraphenalia, and a huge hole in his nasal septum.

Basically, I'm looking for the few diseases that if this guy got started on a whole bunch of cardiac meds, would probably kill him, i.e. can't miss this diagnosis.

This isn't a right/wrong scenario.

Besides neglecting the basics, another thing that happens to folks in this biz is that things become rote. Habits start: CP = nitro, ASA, EKG and get them to a hospital. I always like to know that there is some thought process going on.

 

[Muppet]

Saved for later but there are dozens of mimics for AMI but right off the bat, as stated, coke OD will cause an MI with STEMI, Takasubos will cause chest pains and STEMI pattern if I am not mistaken. Hard if not impossible to tell in the field. Beta blockers with coke OD will off the pt. faster because of the now un blocked alpha effects of coke. Right doc? I'll get back later. Got to see pop in hospital...

M.

 

[wallium]

Surgical aortic valve replacement (SAVR) is a treatment option for aortic stenosis that takes place during an open-heart procedure, where the sternum (bone in the center of your chest) is divided to visualize the heart.

 

[Teufel]

Damn I can’t believe so many of you missed the fundamentals. First drink water, then change socks. Next prescribe Motrin. If that doesn’t work it’s clearly a terminal case of whatever and go about your day.