CPR in progress

teedubbyaw

teedubbyaw

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Interesting case a cadet worked:

Dispatched to assisted living facility for cardiac arrest. 80y/o F. Arrive on scene, as you're going up elevator, fire communicates that CPR is NOT in progress.

Pt is on floor, fire fighter assisting them into an upright sitting position. You can hear wet lung sounds from the doorway. Pt appears extremely pale. Nursing staff states that they went to check on her and she was unresponsive. They began chest compressions and after a few compressions the pt starting moaning (surprise!). Pt had a pacemaker implanted 3 days ago. No other hx.

Pt minimally responsive, not self-supporting, blood is seen near her mouth but airway is clear.
HR: 110
BP: 148/86
O2 sats: 70's
12 lead shows wide complex tachycardia, presumed wide due to pacer.

What do you want to know?
 
also check for JVD, Pedal edema, meds, hx, allergies, infection? accessory muscle use, tripod, ect. confirm mechanical pulse matches monitor. shes big sick so no delay on transport.

due to her mental status Im thinking BVM instead of CPAP
 
Full cardiac medical history from nursing staff and procedure briefing/note if possible. Mainly, I want to know why an 80 year-old female was discharged 3 days post-op from a major cardiac procedure to an assisted living facility. Having worked on a med/surg floor, it is very rare for an inpatient to be discharged 3 days post-anything major.
 
Is she a DNR? That is honestly the most important thing to know about this elderly nursing home patient.
Unless we're missing someone, this doesn't seem very complicated. CPAP or assisted ventilations, and transport. If you think that this is cardiac related pulmonary edema and not pneumonia/sepsis then you could consider nitro.
 
Lung sounds reveal crackles throughout all fields. She fights a BVM, so she is put on high flow O2 and by the time you get her back to the ambulance her sats have increased marginally and she is capable of supporting CPAP. CPAP brings her sats to 82 where she remains. Nitro was considered but not administered. She can not answer any questions, but continues to mumble incomprehensible words. Nurses state she usually has a normal mental status. Very limited information on her as she is a fairly new patient and the staff didn't have their crap together.

The learning point for this cadet was what happened in the first place, and are you going to treat a wide complex tachycardia as the cause of the problem?
 
What else is there to do? Is there a zebra here? Was she febrile? You have to guess if this is an MI causing pulmonary edema, or another cardiac issue, or pneumonia. You cant interpret the 12 lead if its a paced rhythm as you say, so you cant make an easy diagnosis. Why not just transport and let the ER figure this out with a cxr and bnp, etc.?
 
Agreed. Manage what you can manage and wait for better dx tools in the ED.
 
Not sure a paced rhythm would be at 110...
What's her respiratory rate and effort? Skin signs? Is she febrile?

3 days post op would be textbook PE.
 
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