Chest Pain/Dyspnea Case 1

Página 1

Obese 39yof, presenting with chest pain and shortness of breath for 6 hours.

HR/Rhythm: sinus tach 122

BP: 100/62

RR: 32

SpO2: 85% --> 94% on NRB 15Lpm

T: 37

Glucose: 100

Weight: 100kg

Critical actions:

Obtain full set of VS including temp, glucose and WEIGHT (patient may need weight based medications e.g. heparin drip)

place patient on monitor

set BP cuff to cycle q3 mins

establish 2 large bore IVs

move to resus bay if available

Página 2

HPI: pain is constant, severe, sharp, R sided, nonradiating, worsens with inspiration. Feels very short of breath. Recently returned from flight to Japan. No recent surgeries, no h/o clots, no h/o cancer. No family hx of clots. No hemoptysis

PMH: HTN, DM, smoker 1ppd, takes OCPs

Physical Exam:

Gen: appears tachypneic and in pain

Lungs: clear

CV: tachy but otherwise unremarkable

Abd: unremarkable

Ext: pulses equal. BLE 1+ edema, RLE tenderness in the popliteal fossa.

(WYD)

[Ultrasound images]

Critical Actions:

obtain pertinent history, perform physical exam with attention paid to lungs

for MS4s/Interns: discuss Wells criteria and when to use wells and PERC

Perform BSUS of heart, lungs and RLE (DVT)

obtain EKG

order CXR but verbalize to not wait for CXR before proceeding to CT

order CT PE study

start heparin drip based on U/S, if not already started empirically

order labs: CBC, BMP, Troponin, BNP, VBG

notify pharmacy of potential need for tPA

Discuss reasoning for ordering the BNP (assess for R heart strain) and troponin (assess for heart strain and severity of PE)

Discuss PESI score and the anticoagulation regimens - heparin drip vs enoxaparin vs tPA

Discuss accuracy of POC US for PE

Página 3

CT says there's two traumas that are already in line for the scanner

While awaiting CT, patient goes into AF RVR rate 170s, BP drops to 86/40

[sedate and cardiovert, ineffective until cardioverting at 200J ]

BP improves to 98/60

[echo ultrasound images]

[LE compression ultrasound images]

Critical actions:

recognize need for electrical cardioversion

recognize the potential need to infuse tPA if BP does not improve after cardioversion

should have pharmacist prepare the tPA and have it ready to go if need be

discuss sedation regimens for cardioversion (see below, reference: mostly uptodate)

methohexital IV:

dose: 0.75-1.5mg/kg (according to retrospective review of sedation in ED, avg dose 1.4mg/kg)

onset: immediate

duration: 5-15 mins

etomidate IV:

dose: 0.15-0.3 mg/kg

onset: 30-60s

duration: 2-15 mins

metabolism: 76% protein bound, primarily hepatic metabolism

ketamine IV:

dose: 1-2 mg/kg

onset: 30-60s

duration: anesthetic effect 5-10mins, full recovery 1-2 hours

midazolam IV:

dose: 0.5mg-2mg initial dose then additional doses q2-3min. Usual required dose 2.5-5mg

onset: 3-5 min

duration: 1-2 hours (dose dependent)

Discuss PESI score and the anticoagulation regimens - heparin drip vs enoxaparin vs tPA

Discuss accuracy of POC US for PE

Página 4

If intern: patient codes in the ED prior to going to CT scanner

If senior resident: You go with the patient to CT scan, as the patient is on the table in the scanner, you see the monitor go into VT.

Critical actions in the following order:

start CPR and direct someone to place CPR board on stretcher

connect pads to defibrillator and charge defibrillator

place pads on patient

pulse and rhythm check [pulseless VT]

deliver shock

pull patient onto stretcher with CPR board

??turn heparin drip off so tPA can be given??

resume compressions

return to ED with patient and compressions ongoing

delegate someone to charge the defibrillator at 1:50

Once returned to ED it has been approx 2 minutes.

Critical actions in the following order:

charge defibrillator at 1:50

pulse and rhythm check [pulseless 3rd degree heart block]

resume CPR and disarm defibrillator

push 1mg epinephrine

hang tPA [discuss tPA dosing and continuing compressions for several minutes even if ROSC achieved]

_____ does tPA need to be delivered through CVC?

intubate patient

place femoral arterial line [link to art line video]

approaching the next 2 minute mark.

charge defibrillator at 1:50

pulse and rhythm check [sinus tach 128 with a pulse]

evaluate BP [60/38]

start norepinephrine drip @10mcg/min (can titrate up or down as needed)

evaluate mental status [localizes to pain but does not follow commands]

put on ventilator and start fentanyl drip for analgesia

start post-arrest care (does not have to be in order):

elevate head of bed to prevent vent associated pneumonia

obtain CXR to confirm tube placement

obtain repeat EKG

place NGT

initiate hospital's hypothermia protocol

admit to ICU

For bonus points:

if patient were to be refractory to the norepinephrine, what would you do?

max norepi, start vaso, start epi drip

how do you make a dirty epinephrine drip?

inject 1mg of the 0.1mg/mL (code) epinephrine into 1L bag of NS to give 1mcg/mL concentration of epinephrine

If patient remained profoundly hypotensive despite multiple pressors and there was still evidence of R heart strain on POCUS, what would you do?

start VA ECMO and have patient go for either catheter directed lysis or thrombectomy depending on the preference of the surgeon/IR team

Página 5

Pulmonary Embolism Management References/Resources: