Discussants: Christina Lu, Ryan Barnicle, Thomas Kearns
Presentation:
73 y/o F with PMH CAD s/p PCI to LCx, AF (on eliquis), severe MR s/p mitral valve replacement (porcine, 31 mosaic) + CABGx1 (SVG-OM2) + LAA clip on 10/11/2017, ICM (last EF 29%), LBBB s/p BiV-ICD, COPD (DLCO 24%) presents from WR to resuscitation room with tachycardia and dyspnea.
Chief Complaint:
Shortness of breath, nausea, vomiting, malaise
Triage Vitals:
BP: 94/43
Pulse: 158
RR: 22
Temp: 97.5F
SpO2: 96%
History of Present Illness:
Patient presenting for evaluation of shortness of breath, nausea, vomiting, and malaise.
Patient states that the symptoms started 48 hours PTA and she was unable to tolerate her medications over the span of 24 hours. She started feeling short of breath yesterday which prompted her to go to the emergency department today for further evaluation. On arrival to the emergency department, the triage team noted that the patient was significantly tachycardic and the patient was moved to a resuscitation bay.
Physical Exam Findings:
Obese, elderly, obvious respiratory distress, tachycardic, cool to the touch, pale
ED Course:
T 5min: Arrives from waiting room, found to be hypotensive in triage and significantly tachycardic which prompted the patient to present to the resuscitation bay. She is placed on cardiac monitor and HR appears to be anywhere from 110s to 170s.
CLu – Question / Pause: You have an elderly female in obvious extremis. Her blood pressure from triage is borderline and her HR seems to be extremely tachycardic, though variable. Her exam is concerning for poor perfusion. What are your immediate priorities in the first minutes after arrival?
Scott – Answer.
Tom/Ryan commentary: We were immediately concerned for cardiogenic shock just by examining her. As the RNs obtained access and attempted to get reliable monitoring, Tom performed a FOCUS exam.
T 8min: Bedside echo reveals poor LV systolic function, dilated LV, and diffuse B-lines. Respiratory therapy called for BPAP given increased work of breathing and apparent hypoxemia. The pleth was poor but read as SpO2 70s-80s-90s intermittently. B lines concerning for pulmonary edema. Labs drawn: CBC, CMP, magnesium, thyroid studies, NT-proBNP, high sensitivity troponin. CXR ordered.
T 16 min: First EKG obtained.
EKG from ~ 4 months PTA for comparison:
T 17 min: Concern for wide complex tachycardia, specifically ventricular tachycardia versus SVT/AF with aberrancy.
CLu Question / Pause: You have a patient who has a borderline soft blood pressure. She is in respiratory distress. Obtaining a peripheral SpO2 is difficult, which coincides with her cool extremities. The EKG shows WCT in the 170s. What would you do next?
Scott Answer
Ryan/Tom Commentary: Obviously we were worried about VT. However, the monitor kept showing a significantly changing HR that distracted me and made me wonder if this was AF w/ abberancy. I was concerned for secondary cause at this point. We placed defib pads on and we got meds in the room to sedate but since her mentation was normal and her BP was not awful, I held off on cardioversion. I did not think she peri-code but I also did not love the idea of sedating someone in extremis.
CLu Followup Question: According to ACLS protocol, the cardioversion issue is black and white. We know however there is a gray zone. What is your threshold to cardiovert? Do you motify your sedation plan?
Scott Answer.
Cardiology immediately consulted, though they were delayed.
After discussion with pharmacy, decision made for bolus of 150 mg of Amiodarone and Calcium gluconate 1 g IV / insulin / destrose / abluterol / Lasix. (based off I-STAT K of 6.2).
WOB improved after BPAP.
CLu question: This patient on bedside echo appears fluid over loaded and outwardly has some respiratory distress. She remains hypotensive however. Neverminding the hyperkalemia, do you diurese the hypotensive patient? Are there considerations?
Group answer.
T 27 min: Concern for emesis, BPAP removed and Zofran 4 mg IV administered
T 37 min: Additional bolus of Amiodarone administered without significant change in tachycardia
Labs: Na 131, K 6.2, Cl 93, Bicarb 19, Gap 19, BUN 39, Cr1.73 (baseline 0.8 – 1.0), BG 250, Mg 3.0, AST 63. ProBNP 31,500 (3900 in 09/2021), hsTrop 294-263-364. WBC 15.5, Hgb 15.8, Plts 835. Lactate 5.0. UA 4+ glucose otherwise wnl.
T 46 min: Patient noted to be hypotensive to 60s systolic with fairly unreliable blood pressure readings. Decision made to place an arterial line and start norepinephrine gtt.
Ryan/Tom: At this point, she was relatively stable on NE. Our arterial line was working. We now had a good SpO2 pleth that was reliable showing normal oxygenation.
T 66 min: Cardiology at bedside and after discussion with them and the patient’s consent, decision made to pursue electrical cardioversion. Patient given 6 mg of etomidate and cardioverted with 200J. EKG after cardioversion noted below. Decision was made to admit patient to cardiac intensive care unit.
Hospital Course:
HD1: Seen by electrophysiology team who noted that the patient likely had slow ventricular tachycardia based off their examination of the EKG as well as device interrogation. Of note, patient’s VT recognition zone was changed to >160 BPM whereas it had been higher (190) previously and thus she was not treated by her ICD prior to ED presentation. It was determined that she had a 41 hour episode of VT which started on 6/8/22 and did not resolve until cardioversion in the Emergency Department.
HD2: Continued episodes of arrhythmia though not meeting treatment threshold. EP discussed the idea of an ablation with the patient and she agreed with plan for LHC on 6/13/22 and ablation on 6/14/22.
HD3: LHC not significantly changed from prior. Deemed okay for EP study.
HD4: Patient underwent ablation of AVN and VT focus and plan was made to continue amiodarone.
HD6: Transferred from CCU to floor
HD10: Patient discharged home with plan for EP follow-up.
ED attending Attestation:
I saw and examined the patient. I agree with the findings and plan of care as documented in the resident's note. Of note – I met the patient on arrival. She appeared critically ill. She was initially hypotensive, hypoxemic, and tachycardic. She appeared pale/gray. Her lower extremities were cool. I was concerned for cardiogenic shock. Her EKG showed a WCT that appeared regular on the 12 lead but on the monitor it was very irregular ranging form 110s to 170s. Her noninvasive BP was also sporadic ranging from SBP 40s-180s and I deemed in completely unreliable, but probably low. We never had a great SpO2 pleth and I suspect this was due to a perfusion issue as opposed to true hyoxemia but given her B lines on POCUS, I treated it as real with NIPPV and her tachypnea and respiratory distress resolved and we eventually got a good pleth of 100%. Concurrently, we started norepinephrine for support of presumed cardiogenic shock and we becan loading her with amiodarone for both empiric tx of VT and rate control if this was AF w/ aberrancy. Cardiology consult was initiated. A line was placed. She began to improve. I also suspected a component of hypovolemia due to history of n/v/d over the past 2 days and cautiously bolused IVFs. Her elevated K may have been contributing to her EKG and was aggressively treated with calcium with some narrowing of her complex but ultimately her rhythm began to be more regular and I agreed with cardiology fellow that we should treat this as VT with electrical cardioversion, which was successful. See procedure not. Her overall appears significantly improved s/p sedation and BPs were more stable, but still on 0.5 of NE. Device interrogation revealed multiple different dysrhythmias. We gave additional IVFs for ECV depletion. She remains on NE and is admitted to CCU. I do not suspect sepsis despite elevated lactate, so will defer antibiotics for now. Given her poor EF, she is not a candidate for a full 30cc/kg bolus in the ED though she may need it over time in the ICU.
Main Discussion Points:
- Identifying the type of shock
- Determining fluid status of the patient. Give fluids or diurese?
- When do you decide electric cardioversion vs. medical management of tachyarrythmias
Now on to the Podcast
- EMCrit 373 – Mike Weinstock with another Critical Care Bounceback: “Asymptomatic Hypertension” - April 18, 2024
- EMCrit Wee – Ross Prager on 10 Heuristics for the New ICU Attending - April 13, 2024
- EMCrit 372 – FoundStab Intubation SOP - April 5, 2024
What a great episode !!! I had the exact same take-home than Scott, i thought you did a great job and were a bit harsh on yourself 😉 What a luxury to come calmly to the ED with your compass to look on the Ekg and complain about the lack of previous cardioversion haha Ok couple of thoughts, I do not agree with your critique of the timing of the ekg vs ultrasound. My call to cardioverse/defibrillate is made initially on the monitor + look of the patient, here i thought it was totally reasonable to go for ultrasound to… Read more »
Hey brother,
Yes-absolutely they look super crappy=shock
it is the opposite situation where the ecg is essential (like in this case) they look borderline, if they are Vtach, or probably vtach, I will usually just err on the side of shocking early, while I may play around with meds more if I think it is Afib b/c the shock usually leaves you right back where you were without the augmentation of medication if it is long-standing afib.
and the rest is great stuff!
A super interesting case, couple thoughts from a paramedic perspective. Manual blood pressures seem to be a dying skill, but can reinforce treatment decisions when the NIBP seems inaccurate. I know some people can slam in art lines in 60 seconds but have yet to see this done outside of one very capable academic ED. I think end tidal CO2 monitoring may have been helpful assessing shock early on in this case. What if any value would you place on a single ABG with an ok Pa02 in the setting of poor spo2 trace? Lacking ultrasound would in be reasonable… Read more »
Mitch,
great comments!
agree with all of them. I would usually say, just start norepi and then decide +/- on fluids