Rural Emed case to discuss

[EMEDPA]

All are welcome to participate. A few things: this case happened in the middle of the night at a rural, critical access hospital dept with solo coverage, a single nurse, a single xr tech, a lab tech, and NO resp therapy, advanced imaging beyond CT, or available in-house consultants. Additionally, every larger hospital within 200 miles is on divert due to covid.

I will present it as it played out and let folks ask all the questions they like. 

Here goes: elderly woman dropped off at ambulance bay by her son. Pale, Very short of breath with audible wheezing.

Initial VS: sao2 80%, Resp around 32, hr 135(ST on monitor), bp 180/110, temp nl

sao2 90% on 6 L by NC

Go!

[ohiovolffemtp]

OK, though I have 2 nurses....

1. Physical exam: 
   1. Lung sounds: just wheezing or rales or other sounds?
   2. Chest: retractions and/or accessory muscle use?
   3. Abdomen: distended?
   4. Legs: cankles?
2. History: if patient can speak, cardiac, CHF, COPD, emphysema, hx of DVT or PE, home O2 use, how long have s/s being going on and how have they progressed - or get info from son.  Is pt having chest pain, nausea, or other s/s?
3. Immediate tx: if pt working hard, start BiPap, 10/5 FiO2 100%, increase pressures until pt doing better, then titrate O2 down.  In-line Duoneb, othewise neb mask for the Duoneb if BiPap not needed
4. Diagnostics: stat bedside CXR, EKG
   1. labs: CBC, BMP, BNP, trop, d dimer, mag, COVID & flu swabs, mostly because they'll be required for admission which this pt will need, blood gas: probably venous because I can get that faster
5. Check EMR for any hx on pt.

Q15 min, check on patient.  Hopefully she is improving.  If pt needs BiPap & not tolerating, try ativan 1st then ketamine.

Decisions based on changes in patient condition and results:

1. Intubate?
2. Diurese?
3. CTA chest - if dimer > age adjusted or CXR very concerning and kidney fn permits
4. Steroids?

[EMEDPA]

29 minutes ago, ohiovolffemtp said:

OK, though I have 2 nurses....

1. Physical exam: 
   1. Lung sounds: just wheezing or rales or other sounds? GENERALIZED WHEEZING WITH RALES B/L BASES
   2. Chest: retractions and/or accessory muscle use? YES, BOTH
   3. Abdomen: distended? NO
   4. Legs: cankles? NO
2. History: if patient can speak, cardiac, CHF, COPD, emphysema, hx of DVT or PE, home O2 use, how long have s/s being going on and how have they progressed - or get info from son.  Is pt having chest pain, nausea, or other s/s? HX OF SINGLE STENT FOR MI 5 YEARS AGO, HX EMPHYSEMA, STILL SMOKES, NO HOME 02. PLEURITIC CP/SOB WORSENING FOR 12 HRS. NO DVT OR PE HX OR FH.
3. Immediate tx: if pt working hard, start BiPap, 10/5 FiO2 100%, increase pressures until pt doing better, then titrate O2 down.  In-line Duoneb, othewise neb mask for the Duoneb if BiPap not needed. SATS OK ON NC, GIVEN DUONEB X 2. BIPAP STANDING BY, NOT USED. DID USE ANOTHER BRONCHODILATOR IV AS WELL
4. Diagnostics: stat bedside CXR, EKG: CXR VIRAL PNEUMONIA VS PULMONARY EDEMA. EKG UNCHANGED FROM LAST YEAR OTHER THAN RATE. OLD ANTEROLATERAL Qs AND ST DEPRESSION
   1. labs: CBC, BMP, BNP, trop, d dimer, mag, COVID & flu swabs, mostly because they'll be required for admission which this pt will need, blood gas: probably venous because I can get that faster. RELEVANT LABS: WBC 23,000, BNP 2000, TROP NL, DIMER 1.5, COVID AND FLU NEG. MAG 1.8, K 3.3. VBG LOOKS OK. PCO2 50. PH 7.34. LACTIC ACID 2.2
5. Check EMR for any hx on pt. DM, HTN, MI X 1

Q15 min, check on patient.  Hopefully she is improving.  If pt needs BiPap & not tolerating, try ativan 1st then ketamine.

Decisions based on changes in patient condition and results:

1. Intubate? NO
2. Diurese? YES (ALSO ANOTHER MED TO VASODILATE AND MOVE SOME FLUID)
3. CTA chest - if dimer > age adjusted or CXR very concerning and kidney fn permits DONE AND NO PE. FINDINGS C/W CHF OR PNEUMONIA. NO PTX OR MASS. SMALL PLEURAL EFFUSIONS
4. Steroids? YES

OK, you hit most of the high points and your thinking was similar to mine. so far we have apparent chf +/- copd exacerbation and a few lyte abnormalities. I did give mag before getting the level back as a bronchodilator and also applied an inch of ntg paste. started with only 20 mg of lasix because pt is diuretic naive and <100 lbs. contacted hospitalist and I wrote overnight orders. also addressed htn with metoprolol and leukocytosis/possible pna with rocephin/zithromax. lovenox given as dvt  prophylaxis. was on propranolol at baseline(not ideal as nonspecific beta effects)  and daily asa.

much improved at time of admit with sao2 92% on 5l, hr 92, R 18. feels better and no wheeze. fixed her, right? 

care to guess the transfer dx the next day when the hospitalist called me back? He missed it too. 

[MediMike]

Well dangit.  Thought I had it all figured out until you threw in a curveball surprise dx at the end huh?

My thoughts (armchair quarterbacking):

I try to be particularly careful with ketamine in hypertensive patients, can have a tendency to increase tachycardia as well as BP which this gal with what sounds like a AHFE probably doesn't need, of course I don't use it nearly as much as you gentlemen.

Not sure what toys you've got to play with, but were you able to throw a probe onto her chest? I hate giving beta blockers to these folks presenting with edema until I know what their squeeze is doing.  Given the option I'll hit them with NTG and hydralazine for afterload reduction until I know what I'm dealing with.

Did your reply say something about intravenous bronchodilators?! And who in the world puts little old ladies on propranolol? Kills my soul a bit.

 

[EMEDPA]

The IV mag was the IV bronchodilator. My bedside u/s skills are basically fast exam at this point. I have a few workshops coming up to try to improve in that arena. 

So the next morning she felt great, had diuresed a bunch, was off o2 and wanted to go home and the hospitalist decided to check one more set of labs before sending her out the door. 

Her morning trop was 15. Really no chest pain to speak of other than a pleuritic complaint initially when her sats were in the toilet and her resp rate was fast. we ruled her out for PE. her trop was normal initially. She probably had her NSTEMI while in severe resp distress before we got her fully stabilized but fewer than 3 hrs after arrival. 

Transferred by ground to the nearest cath lab with availability....4 hours away.....don't know if she got a stent or not. 

elderly, female, dm, prior acs I should have held her in the ED for a second trop. She just really looked like copd + chf and improved rapidly when treated that way. was worried about PE, but CTA neg. . Her outcome will be fine, I just feel stupid. 

[MediMike]

@EMEDPA noooooo hahaha...you are the only ED provider I've ever met who doesn't order a trop that is trended q3h x 1,000,000hrs.

Although I've got to admit I'm pretty shocked that by 12h of symptoms she hadn't bumped her trop. 

For any students out there one of the can't miss causes of pulmonary edema is ischemia (it even rhymes...kinda). A troponin is almost always positive by 6hrs of symptom onset and by 12 hours everyone should have lab evidence of it.

Absolutely crazy that she got up to 15.

 

[ohiovolffemtp]

NSTEMI was on my list, but below post-COVID syndrome.  I had a patient with a similar presentation at my PRN job at a community hospital.  He wound up admitted on Vapotherm.  Will try to see how he's doing next week when I go back.

@Mikey - I've not had a problem with ketamine increasing tachycardia or BP, especially at what I consider low doses, e.g. 0.1-0.5 mg/kg range.  Probably would have given this tiny lady 10-15 mg and watched how she did.  It's become my go to when benzos aren't working at the max dose I'm comfortable with.  My trop sequence is now, 3 hours, and then 9 hour - though try to get the patient to the floor after the 3 hour trop, unless no beds available (like tonight).

[MediMike]

Probably just a combination of the upstairs mentalities that "benzos are the devil" and "precedex should be in the water supply"

Small aliquots of ketamine are definitely the way to go. Seen multiple people just slam big 'ol doses rather than giving what you need to get the job done!

[EMEDPA]

I use 0.1 mg/kg to start with bipap, so around 10 mg for most folks. brochodilates and they chill right out. I use it before benzos. 

[ohiovolffemtp]

12 hours ago, MediMike said:

"precedex should be in the water supply"

Where I am precedex is pretty much a legendary lost gold mine.  You know it's out there somewhere, but you'll never see it in your lifetime.

[EMEDPA]

11 hours ago, ohiovolffemtp said:

Where I am precedex is pretty much a legendary lost gold mine.  You know it's out there somewhere, but you'll never see it in your lifetime.

ditto. 

[MediMike]

So funny. I can get ketamine but normally have to wait forever for pharmacy to send it. Had a period of time where it was trialed for analgosedation on our folks... didn't work out too well. 

[EMEDPA]

1 hour ago, MediMike said:

So funny. I can get ketamine but normally have to wait forever for pharmacy to send it. Had a period of time where it was trialed for analgosedation on our folks... didn't work out too well. 

I was in Iraq summer 2017 at a battalion aid station. We were not allowed narcotics in country so everyone got 50 mg of IV ketamine for their GSWs, severe fxs, etc. Worked pretty well. Hundreds of doses given with only 1 episode of emergence reaction. 

[MediMike]

17 hours ago, EMEDPA said:

I was in Iraq summer 2017 at a battalion aid station. We were not allowed narcotics in country so everyone got 50 mg of IV ketamine for their GSWs, severe fxs, etc. Worked pretty well. Hundreds of doses given with only 1 episode of emergence reaction. 

I think we can agree there's a big difference between treating acute pain in an otherwise healthy 18-35yo and managing a 75yo intubated patient on the vent for a week or two. 

For acute issues I think it works great. I haven't seen much evidence of efficacy for longer term use. It's use in the critically ill, especially those with hemodynamic perturbations is chancy. 

[ohiovolffemtp]

11 hours ago, MediMike said:

I think we can agree there's a big difference between treating acute pain in an otherwise healthy 18-35yo and managing a 75yo intubated patient on the vent for a week or two. 

For acute issues I think it works great. I haven't seen much evidence of efficacy for longer term use. It's use in the critically ill, especially those with hemodynamic perturbations is chancy. 

Very much so.  I think the biggest difference is the duration, not the patient's age, comorbidities, etc.  I hope that I'm not having to manage sedated patients for more than about 4 hours,  ideally not more than 1-2 before I ship them out.  My toolbox is: paralytics: sux & roc, inducing agents: etomidate and ketamine, pain control: opiates, sedation: benzos & propafol.  Sometimes it's a challenge keeping someone down.

[davidr14]

On 12/3/2021 at 12:37 AM, EMEDPA said:

The IV mag was the IV bronchodilator. My bedside u/s skills are basically fast exam at this point. I have a few workshops coming up to try to improve in that arena. 

So the next morning she felt great, had diuresed a bunch, was off o2 and wanted to go home and the hospitalist decided to check one more set of labs before sending her out the door. 

Her morning trop was 15. Really no chest pain to speak of other than a pleuritic complaint initially when her sats were in the toilet and her resp rate was fast. we ruled her out for PE. her trop was normal initially. She probably had her NSTEMI while in severe resp distress before we got her fully stabilized but fewer than 3 hrs after arrival. 

Transferred by ground to the nearest cath lab with availability....4 hours away.....don't know if she got a stent or not. 

elderly, female, dm, prior acs I should have held her in the ED for a second trop. She just really looked like copd + chf and improved rapidly when treated that way. was worried about PE, but CTA neg. . Her outcome will be fine, I just feel stupid. 

I recently had a similar case, I think you did a great job hitting all of the critical actions. You stabilized the patient and successfully transferred the patient. I know most mnemonics suck, but with CHF exacerbations I always sit down after placing orders and ask why. the FAILURE mnemonic is a good thing to keep in your back pocket. As Mike said a bedside echo and possibly repeat EKG could have been beneficial. 

Forgot meds 

Arrythmia/anemia

Ischemia/Infarct/Infection 

Lifestyle 

Upregulation of CO

Renal failure 

Embolism