Sunday, July 8, 2007

Tachy

Dispatch asked us to intercept with a BLS unit south of our location. They were headed towards us out of a quiet nearby town, and asked for paramedic help as soon as they saw their patient.

He was 45 years old, racked with disease for years that seemed to count double their time. The man looked 80, easialy. He was unresponsive with a glascow coma scale of 4, gaining only one point for his occasional incomprehensible moans. His body remained slack, absolutely still despite whatever stimuli we could deliver. I rubbed his sternum hard with my knuckles. Nothing.

Despite his calm demeanor, though, his body was a cataclysm of active turmoil. His respiratory rate was just shy of 50 breaths per minute, his heart counting 190 beats in the same time. None of us could get a blood pressure manually, and the automated machine spit "NIBP Timeout" back at me over and over again. I thought I could find a radial pulse, but maybe it was nothing. The pulse oximeter refused to read, and end-tidal CO2 returned a measly 10 mmHg.

I ask as many questions as I can think of, rapid fire as I try to get a sense of the story. The patient has a history of brain abscesses and has been declining over the past few weeks. The family told the EMTs that this has been his baseline mental status for the past week, and that they called 911 only because it seemed he was having trouble breathing. I am struck by the story. Unresponsive like this for a week? Really?

I get the EMTs to insert an oral airway and start assisting the man's breathing with a bag-valve mask while I do the rest of my assessment. The eyes have a dysconjugate gaze to the upper left, and pupils are sluggish to react at about 3 millimeters. Lung sounds are with bilateral rhonchi, but filling up adequately with each squeeze of the BVM's bag. The skin is warm and pink at the core but mottled and slightly cyanotic towards the extremities. Blood sugar is 146. A rapid trauma assessment is without significant finding. On goes the checklist while I start an IV. I plug together the monitor cables and get these in reply:





The man is in shock, crashing in front of my eyes but I cant pinpoint an exact cause. The eyes and mental status suggest a neuro event, although the vital signs defy the textbook Cushing's triad. ...And the family says the mental status is baseline. The 12 lead shows a significant tachycardia, and generalized ischemia across the man's heart. The blood pressure is too low to read. Sepsis? PE? I dont know.

I get the patent in trendelenburg and open up the IV, reviewing my options. I think about intubation, but we are 5 minutes from the hospital and the man is biting on the OPA. I dont think I have time, and the BVM has been pretty effective. Full, equal lung sounds and the end tidal CO2 is slowly coming back up as the EMT controls the man's runaway tachypenia.

Looking at the patient, and the monitor, I feel that I need to do something about the heart rate. The hypotension could very well be related to the tachycardia, and while it is possible that the heart rate could be compensatory for some unseen hypovolemia or otherwise, I doubt it. I remember from ACLS that heart rates over 150 are very rarely compensatory, and still, at this rate cardiac refilling time must be seriously hindering effective output.

We are 3 minutes from the hospital and I draw up adenosine. 6 milligrams, and a 10 cc normal saline flush behind it. I push print on the monitor and flush both syringes through the line. As we come to a stop in the ambulance bay I stare intently at the monitor.

No change whatsoever.

In the hospital they listen to my story with raised eyebrows. They are skeptical about the family's story too, but accept what I have to give them. The man is paralyzed and intubated, bloods drawn and x-rays taken. The team converges around the man, working intently as they pass lines and instructions to eachother. The man codes. Four times, resuscitated each time with jolts of electricity as I write my run form. When I return with paperwork the team is sweaty and tired. Empty boxes of epinephrine litter the floor. They are mixing up an epinephrine drip to maintain the blood pressure, and the doctors are calling more doctors to discuss what could possibly be wrong. Nobody knows yet.

**

It was a good call in many ways. There was a lot to do in a short amount of time, a complicated story to assimilate and an important treatment decision to make. It was a job to remain calm and focused, to get things right and make sure I didnt miss anything important.

I ran through the call with some of my coworkers, and there are always raised eyebrows around the time that I mention the adenosine. I know. I knew it then, too, but I felt that I had to do something about that heart rate in the face of the rest of the patient's presentation: and I stand firm that there was value in the choice both as a treatment and as a diagnostic tool. If it worked, great. If it didnt, a pathology eliminated.

I may or may not have been right. Maybe the heart rate was actually a compensating effort. Perhaps the rate was completely unrelated to the rest of the presentation. Maybe I should have focused instead on doing something else. I dont know, and as far as I've heard thus far- neither do the doctors. It is a little frustrating to not know, to remain in the dark after such a fervent effort.

I did my best though, and I stand by my decisions. In work where often nothing is certain, and choices must be made quickly and accurately based on experience and talent: I think that counts for something.

7 comments:

David said...

Quite an event, dude!

Decisions in EMS are made not only on previous experiences & talent, but also on skills & knowledge. You put all of those to use during that call, and it's laudable that you're self evaluating.

I'm an EMT-IV in Tenn., and I plan to go to Paramedic school in the fall. I really enjoy reading your blog. It helps keep me sane!

l8r
David

Anonymous said...

Check out last months JEMS. There is a somewhat useful CE article ("Rhythm & Clues: The evaluation & management of atrial rhythms") that you might find interesting.

If you have JEMS online access, go to this link:

http://www2.us.elsevierhealth.com/inst/serve?article=as019725100772199x&arttype=full

Anonymous said...

without looking it up isn't it something like 120 plus the age equals the max rate of the SA node?

Brett said...

Here is my thought... 190 isnt compensating for anything (and anyone who tells you that it wasnt a problem should be smacked in the the head)... maybe something else caused it... but thats too fast to be doing ANY good. You were right on the money in my book that the heart rate was a problem... I may have done things slightly different, but I would have had the same priorities, Fix the Resp rate, get the pts BP up... If a team of doctors with lab tests and X-rays cant figure it out... Then there is no way you could have figured it out in the 10 mins you had the patient

Anonymous said...

It sounds like this would have been a difficult run for any of us. Please do post an update if you're able to learn more.

Me, I probably would have led with a generous fluid bolus and possibly some pressors. It isn't clear whether the rhythm was a junctional reentry SVT, but if it was I might have skipped adenosine and moved directly to synchronized cardioversion. It sounds like the patient was sufficiently unstable to justify electricity.

Still, it was a good run and a good job writing it up. Hang in there!

-Just a medic

Brendan said...

Good job all around! Great job to your BLS crew, to you, and the ER staff for getting him back 4 times.

Only thing I may have done differently is get another IV going. As for the rhythm, you would probably have been more than justified in lighting him up, but I have a feeling you would've been working your first code as a cut-loose medic if you had.

You left him better than you found him, which in this situation is better than a LOT of people could have done. You da man!

Anonymous said...

First off, excellent job managing the airway. Good decision not to intubate (Do you have RSI?) as long as the bagging seems to be improving the patient's ventilation and he has a gag.

Not having been there to see the whole picture, as I read your account I am thinking runaway sepsis (apparently bed-ridden, decreased MS for a week, rhonchi, no BP, tachypnic, mottled extremities). The ECG, like the computer, I read as a sinus tack, which fits with the history. I'm thinking fluid, fluid, fluid. (Both your ECGs show a rate of 170 by the way, not 190 adding more credence to being a sinus tack. Plus 170 is not out of line for a 40 year old, even a sick one.)

Some physicians say adenosine is harmless as a diagnostic, other say it can be a dangerous drug. Cardizem on the oft chance it is an atrial tachycardia(I admit the p-wave is a little funny looking like it can be with some atrial tachycardias), maybe, but with no pressure, cardizem could do some serious harm. 5 Minutes out, I'd let the hospital decide to go down that road, not me. Plus with his history, his problem doesn't seem nearly as likely to be electrical as infectious.

I'd dump some fluid in first, then revaluate.

But like I said, I wasn't there and may have missed some clues and some of the call texture you didn't mention.

Reading your blog, you will be an excellent medic.