CCAT patient

[ChrisPAinED]

So our hospital has a team called the CCAT which stands for critical care admission team and the purpose is to consult on patients on the floor and ED to get people to ICU sooner and start the critical care treatments sooner. The team consist of 1 supervising physician per shift 2 Physician assistants 2 nursing practitioners and a team of critical care RNs. 

We were called to see a patient who has came from the Neuro ICU but was currently in the step down post op neurosurgery. Patient has a head injury 3 days prior requiring a emergency craniotomy 2 days Neuro ICU then stepdown reports doing extremely better then expected. Well patient had a Ventricular Arrhythmia noted and post cardioversion low BP and irregular heartbeat. Patient was a bit hypoxic at 89% and the blood pressure was 77/46. Bedside cardiology ordered labs and none were back at the time of my arrival. I decided on a POCUS and that appeared normal CXR was also clean. I put in the admission to the cardiac care unit and the cardiologist was sent the ecgs obtained and telemetry was set up. Ended up having a troponin of 11.9 again normal range 0.00-0.04 so this is not very good at all. Beside cardiology echocardiogram showed right sided Ventriclular dilation and since the O2 was low I did in fact order a CTPA which was negative. Patient was taken to Cath lab in which they had a cardiac arrest and pronounced dead. Autopsy was preformed and I don't got the results this case was a little while ago but I want your thoughts on this ask any question you want I will try to remember and get you a answer as long as it ain't too specific. Patient was a male in his 30s with no other relevant history 

[CritCareICU]

Acute RV failure has only a few causes. ruled out PE which is good, however did he have any long bone fractures from trauma could be Fat embolism?  what did the cath show? if he was older i would say most likely RCA occlusion with MI but he was only 30s.  drugs? assuming it wasn't tamponade as you would have seen on echo.   I'm assuming that patient was intubated? high pCO2 from lack of ventilation can cause RV failure.  what was his mental status post defib? is it possible he rebled intracranially? acute decompensated RV failure could have been rescued with RP impella since you can just use bicarb through the purge rather than full anticoagulation with recent head trauma, VA ecmo also if hospital has the capabilities again +/- anticoagulation? interesting case 

[Mayamom]

First thing that came to my mind was substance use...... Did you say you haven't seen the autopsy report.  What do the people going the  cardiac cath think?

[ChrisPAinED]

I was able to find the autopsy report on it. It was full of really interesting information some that weren't excepted.  The main things they noticed was prior to there death they had a unreadable ICP and they noted patient had significant about of damage to the liver and kidneys they found a mass on the liver with biopsy ended up being malignant and they kidney had some small mets. They determined the likely  cause of death was a fatty embolism from the liver that went to the right coronary close to the marginal area and the coronary started to tear. As far as I was aware the catheter never even made it to the heart before the cardiac arrest started. Really interesting case bad outcome but a I guess no one could have caught it much earlier because definitely a unusual presentation.