Moderator EMEDPA Posted February 26, 2023 Moderator Share Posted February 26, 2023 90 yr old guy brought in from home by EMS with a pretty good story for an MI. Burning Epigastric and substernal CP, nausea, diaphoresis, etc Lives independently at home with his wife, walks unassisted, still drives, etc Field tx: ASA, 12 lead showing acute appearing Inf MI (later ekg in ED looks similar, but old EKG was the same from 3 years prior) PMH Htn, known stable thoracic aneurysm last measured at 4.8 cm, afib on coumadin. echo 2 years ago nl, recent inr nl, GERD Meds Dilt, coumadin SH: nonsmoker ever, no etoh ever VS Bp 120/76, P 68, R 16, sao2 94%, T 37 exam + only for epigastric and RUQ TTP. still has GB, looks ok on bedside u/s. IVC looks ok. Not able to get great cardiac windows. aorta looks big pertinent labs: H/H nl. initial trop nl, 3 hr trop a bit of a bump, but still nl, INR 2.5 pain gone after 2 mg of morphine. Given GI cocktail for gerd hx and c/o burning stomach with improvement. wants to go home. Um, what about that aneurysm? Might as well image it. Slow day in the ER. CTA chest/abd/pelvis shows actively dissecting 6 cm type A ascending dissection with flap and hemopericardium. ok, Vit K (later KCentra as well) to reverse warfarin, life flight on standby, no beds anywhere. I talk to 3 CT surgeons who refuse the pt, all stating < 10% chance of surviving surgery or being alive regardless in 24 hrs without surgery and less than that for meaningful recovery without deficits or need for dialysis, etc. Last surgeon was kind enough to do a phone conference with the patient and family with her concerns and answered all questions. Plan to admit to my facility for expectant management, assuming only a few hrs to live. POLST completed by me. Now DNR. Hospitalist ok with admit. Sitting up in bed talking this am with stable VS. Never required labetalol for BP. Total analgesics given in 24 hrs: 8 mg morphine and 2000 mg IV tylenol. Pt wants to go home. Will obs another day then home on a beta blocker. No more coumadin, so CVA risk higher now. This is the most stable actively dissecting pt I have ever seen. Makes me wonder how many we all miss and how many don't come in for their "tummy ache" and do fine. . 2 Quote Link to comment Share on other sites More sharing options...
ohiovolffemtp Posted February 27, 2023 Share Posted February 27, 2023 Yes. I had a tiny elderly lady with a 13 cm aortic aneurysm. CT surgery told me to try to talk her out of transfer as this was too big for surgery. Had an "interesting" conversation with the patient prior to her d/c home with tight BP control. "What will happen when this bursts?" "You'll have a terrible pain in your belly for a few seconds, then you'll pass out and never wake up." Quote Link to comment Share on other sites More sharing options...
SedRate Posted February 27, 2023 Share Posted February 27, 2023 Wow. Just, wow. Quote Link to comment Share on other sites More sharing options...
CAAdmission Posted February 28, 2023 Share Posted February 28, 2023 Tough old geezer. You don't get to be 90 unless you have good protoplasm (and probably a good guardian angel). Was he a veteran? Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted February 28, 2023 Author Moderator Share Posted February 28, 2023 Not a vet. Just found out he died last night here at the hospital. Went out fast without any pain. Not a terrible way to go. 1 Quote Link to comment Share on other sites More sharing options...
Recommended Posts
Join the conversation
You can post now and register later. If you have an account, sign in now to post with your account.