polarbebe Posted June 10, 2022 Share Posted June 10, 2022 (edited) I am sharing an interesting case (my first on this forum so bear with me). A small hint… the first confirmed case I have seen in my career working in a mixed ICU. Patient specifics have been slightly altered to protect patient identity. Cc: syncope 73 y/o male PMH HTN, metastatic laryngeal CA (recent chemo) CAD s/p PCI on antiplatelet, GIB, cirrhosis, former smoker (40 pack years), hypothyroid, osteoarthritis, s/p remote appendectomy recently admitted for PNA and hemoptysis thought secondary to CA. Syncope this AM on toilet with trauma to head. Vitals: 135/107. HR: 63, RR: 18 SpO2: 96 on RA Glucose: 82 ROS: +cough +generalized weakness, syncope +edema Exam: ill appearing Lethargic requiring verbal stimulus to arouse Dysphonia, no stridor no M/R/G Decreased breath sounds benign abdomen b/l LE mild edema old appearing hematoma and ecchymosis to forehead (another prior head trauma) While awaiting initial set of labs/data to return: HR dips down to 26 while “asleep” with resulting mild hypotension Edited June 10, 2022 by polarbebe Added something 1 Quote Link to comment Share on other sites More sharing options...
ChrisPAinED Posted June 10, 2022 Share Posted June 10, 2022 Was a head CT ordered? Athletes have low heart rates already so if they are a athlete a heart rate of 26 wouldn't be concerning but if not a athlete I recommend a ECG to look for heart blocks or other pathology or other acute findings. How bad was the head trauma? Did the patient pass out? Was there any vomiting or nausea? Was the head bleeding if so how large was the laceration and how deep? I would recommend a CBC BMP and UA. Also decreased breath sounds so CXR? Or CT chest? If this patient has a A line I would get a ABG if not a VBG would be fine. 1 Quote Link to comment Share on other sites More sharing options...
polarbebe Posted June 10, 2022 Author Share Posted June 10, 2022 (edited) 33 minutes ago, ChrisPAinED said: Was a head CT ordered? Athletes have low heart rates already so if they are a athlete a heart rate of 26 wouldn't be concerning but if not a athlete I recommend a ECG to look for heart blocks or other pathology or other acute findings. How bad was the head trauma? Did the patient pass out? Was there any vomiting or nausea? Was the head bleeding if so how large was the laceration and how deep? I would recommend a CBC BMP and UA. Also decreased breath sounds so CXR? Or CT chest? If this patient has a A line I would get a ABG if not a VBG would be fine. To allow more readers to participate will follow up with more data later today or early tomorrow. Thank you for posting. However to address some of your points. It’s important to look at the patient as a whole and their risk group. Correct an athlete could have sinus bradycardia. In my experience HR 26 would be markedly low even while sleeping (unless having excessive vagal tone). Given the history of 70s year old with PMH of CAD and 40 pack years, it is likely this gentleman has not been athletic for a long time. Any elderly patient with marked bradycardia near the top of your differential should be BB toxicity (or ACS as you mentioned ECG) especially in the case where you have hypotension. Absolutely agree with an ECG, at least the labs you mentioned and consideration of imaging. Generally an indication for an a-line in a mixed ICU or MICU (indications for SICU are different): unreliable pulse ox for moderate/severe hypoxic patients, frequent ABGs, ARDs, labile BP, possibly multiple vasopressors. Still management and culture vary by ICU and institution. An a-line was not placed, patient is on RA and so far in the course only mild hypotension in the setting of severe bradycardia. Agree that a VBG would be sufficient and an ABG is not necessary if the pulse ox is reliable, especially the patient has a good SpO2 on RA patient would not have any significant retention. Edited June 10, 2022 by polarbebe 1 Quote Link to comment Share on other sites More sharing options...
ohiovolffemtp Posted June 10, 2022 Share Posted June 10, 2022 Coming from an EM perspective, I'm expecting that this patient got to your ICU via the ED, so most likely his ED workup included: CT's: head d/t the head trauma and anti-coagulation, neck and/or cervical spine d/t same plus CA hx - what did those show, in particular any anatomical abnormalities near the base of the tongue, epiglottis, and larynx? (potential mechanical obstruction when sleeping); CT or more likely CTA of chest given hemoptysis Plain films: CXR EKG: 12 lead read? Also, what does the monitor show when he brady's down? Labs: CBC Coag's CMP Mag Trop's - likely serial BNP UA TSH - given hypothyroidism, otherwise not part of most ED workups, possibly T4 VBG lactic Swabs: COVID, influenza for most of these - how do his current results compare with his baseline? Other: Temp: fever, hypothermia? Does he wear CPAP @ home while sleeping? Home meds: opiates? benzo's? beta blocker?, anti-emetics? how long was he in the ED - would these have metabolized? This is the detailed version of the key question: what information did the ED give you vs what you have to dig for in the unit? 2 Quote Link to comment Share on other sites More sharing options...
ChrisPAinED Posted June 10, 2022 Share Posted June 10, 2022 5 minutes ago, ohiovolffemtp said: Coming from an EM perspective, I'm expecting that this patient got to your ICU via the ED, so most likely his ED workup included: CT's: head d/t the head trauma and anti-coagulation, neck and/or cervical spine d/t same plus CA hx - what did those show, in particular any anatomical abnormalities near the base of the tongue, epiglottis, and larynx? (potential mechanical obstruction when sleeping); CT or more likely CTA of chest given hemoptysis Plain films: CXR EKG: 12 lead read? Also, what does the monitor show when he brady's down? Labs: CBC Coag's CMP Mag Trop's - likely serial BNP UA TSH - given hypothyroidism, otherwise not part of most ED workups, possibly T4 VBG lactic Swabs: COVID, influenza for most of these - how do his current results compare with his baseline? Other: Temp: fever, hypothermia? Does he wear CPAP @ home while sleeping? Home meds: opiates? benzo's? beta blocker?, anti-emetics? how long was he in the ED - would these have metabolized? This is the detailed version of the key question: what information did the ED give you vs what you have to dig for in the unit? You typed all of that... Impressive lol I would have ordered the same but I like how the computers make it easier to order labs and radiology. Quote Link to comment Share on other sites More sharing options...
polarbebe Posted June 11, 2022 Author Share Posted June 11, 2022 (edited) 17 hours ago, ohiovolffemtp said: Coming from an EM perspective, I'm expecting that this patient got to your ICU via the ED, so most likely his ED workup included: CT's: head d/t the head trauma and anti-coagulation, neck and/or cervical spine d/t same plus CA hx - what did those show, in particular any anatomical abnormalities near the base of the tongue, epiglottis, and larynx? (potential mechanical obstruction when sleeping); CT or more likely CTA of chest given hemoptysis Plain films: CXR EKG: 12 lead read? Also, what does the monitor show when he brady's down? Labs: CBC Coag's CMP Mag Trop's - likely serial BNP UA TSH - given hypothyroidism, otherwise not part of most ED workups, possibly T4 VBG lactic Swabs: COVID, influenza for most of these - how do his current results compare with his baseline? Other: Temp: fever, hypothermia? Does he wear CPAP @ home while sleeping? Home meds: opiates? benzo's? beta blocker?, anti-emetics? how long was he in the ED - would these have metabolized? This is the detailed version of the key question: what information did the ED give you vs what you have to dig for in the unit? Very thorough workup... Before the labs return. The ED gives atropine with improvement in HR to 60s. WBC 5.3, Hgb 9.3, Plt 214 Na 134 K 3.6 Bicarb 24 Cr 0.9 Glu 86 Ca 7.9 (prior CR 0.7) PT 13.1 INR 1.0 PTT 41.7 AST 27 ALT 13 ALP 257 Total 0.7 Protein 6.6 Alb 3.2 BNP 157 Lactate neg Trop neg Magnesium not ordered in the ED. UA in progress TSH in progress COVID in progress ECG 1st degree block HR 44 PR 224ms QTc 523 low voltage noted CXR patchy b/l airspace opacities with L > R with milder nodular opacities in the right upper. Similar to prior CXR in 2021 compatible with multifocal broncholitis or broncho PNA possibly from recurrent aspiration CT head negative CT c-spine no acute cervical fracture No fever. Temp 34.7C No known OSA/OHS. Body habitus is thin Meds include opiates, no BB. Unknown antiemetics ICU and cardiology consult is called. Edited June 11, 2022 by polarbebe 1 Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted June 11, 2022 Moderator Share Posted June 11, 2022 11 hours ago, ChrisPAinED said: Athletes have low heart rates already so if they are a athlete a heart rate of 26 wouldn't be concerning a HR of 26 is concerning in anyone. When Lance Armstrong, 7 time winner of the tour de france, was in the best shape of his life his resting HR was 34. I am a skinny marathon and ultramarathon runner and at my best, running a marathon every weekend for six months in training for a 100 mile ultra, my resting HR was 47. These days it is in the 50s. High 40s in an elderly male on a beta blocker who is not hypotensive is ok. anything lower than that is worrisome. 2 Quote Link to comment Share on other sites More sharing options...
ChrisPAinED Posted June 11, 2022 Share Posted June 11, 2022 3 minutes ago, EMEDPA said: a HR of 26 is concerning in anyone. When Lance Armstrong, 7 time winner of the tour de france, was in the best shape of his life his resting HR was 34. I am a skinny marathon and ultramarathon runner and at my best, running a marathon every weekend for six months in training for a 100 mile ultra, my resting HR was 47. These days it is in the 50s. High 40s in an elderly male on a beta blocker who is not hypotensive is ok. anything lower than that is worrisome. Yeah its concerning for anyone unless patient was really athletic with a heart rate of 40 then sleeping would drop it more. Right? Quote Link to comment Share on other sites More sharing options...
polarbebe Posted June 11, 2022 Author Share Posted June 11, 2022 (edited) TSH 67 (0.32 to 5 normal range) Arrives in ICU somnolent with HR mid 20s. Given physical stimulus to arouse patient with increase in HR 40s. Endo consulted, endocrinologist says will be by after clinic in the early evening. Additional history obtained no recent chemo/radiation, reportedly compliant with meds. With hypothermia (sepsis until proven otherwise unless clear exposure history) and questionable CXR, started on broad spectrum antimicrobials covering MRSA, pseudomonas and atypical organisms. Infection potentially being a precipitant for myxedema (patients do not need to be comatose, only have altered mental status as manifested by lethargy). Pacer pads placed. Peripheral dopamine gtt started, titration to HR. Mental status improving. Strongly opinionated patient refusing intro placement for transvenous pacing while threatening to self d/c access if placed. Bedside POCUS showed adequate LV function to administer thyroxine. Synthroid IV 250mcg with stress dose steroids (hydrocortisone 100mg IVP followed by 50mg Q6) to reduce risk of adrenal crisis. Cardiology does not recommend PPM as likely due to severe hypothyroidism. Troponin negative x3. Endo agrees with current management with plan to taper to IV synthroid 100mcg for couple days then to PO with daily TFTs. Official echo normal. Dopamine gtt being titrated down with improvement in HR. Edited June 11, 2022 by polarbebe Quote Link to comment Share on other sites More sharing options...
polarbebe Posted June 11, 2022 Author Share Posted June 11, 2022 8 hours ago, ChrisPAinED said: Yeah its concerning for anyone unless patient was really athletic with a heart rate of 40 then sleeping would drop it more. Right? Yes. He likely had a low baseline HR and on toilet increased vagal tone then has syncope. Patients with severe pulmonary HTN this is quite common, to have syncope. Also commode cardia, high mortality - death by valsalva. 1 Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted June 11, 2022 Moderator Share Posted June 11, 2022 12 hours ago, ChrisPAinED said: Yeah its concerning for anyone unless patient was really athletic with a heart rate of 40 then sleeping would drop it more. Right? In 35 years in the ED I have never seen someone with a HR below 30 who did not require atropine or pacing. Of course, an athlete of that caliber probably is not in the ED unless they are a trauma. 1 Quote Link to comment Share on other sites More sharing options...
ChrisPAinED Posted June 12, 2022 Share Posted June 12, 2022 11 hours ago, EMEDPA said: In 35 years in the ED I have never seen someone with a HR below 30 who did not require atropine or pacing. Of course, an athlete of that caliber probably is not in the ED unless they are a trauma. I haven't seen a HR below 35 that didn't require pacing or atropine but I have only been practicing for a few years. I have seen athletes for traumas, electrolyte abnormalities, and hypoglycemia. I was just coming up with a hypothetical. Quote Link to comment Share on other sites More sharing options...
ohiovolffemtp Posted June 12, 2022 Share Posted June 12, 2022 On 6/10/2022 at 10:12 PM, EMEDPA said: I am a skinny marathon and ultramarathon runner and at my best, running a marathon every weekend for six months in training for a 100 mile ultra, my resting HR was 47. I was an average condition early 50's firefighter/medic and during the 6:00 AM truck checks the monitor would show me in the high 50's - low 60's before caffeination. Quote Link to comment Share on other sites More sharing options...
UGoLong Posted June 12, 2022 Share Posted June 12, 2022 I've not seen anyone with a HR<35 (day or night) that was constitutional bradycardia (i.e, from exercise, etc). Even if it was transient, there was generally a pathological cause. Quote Link to comment Share on other sites More sharing options...
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