Re: Case for consideration

[Guest guest]

Gene:

I'm very curious about the EKG, which obviously we don't have. I'm

curious how well his pacemaker is working. Also, with the infections, I'm

wondering about sepsis.

How would the patient respond to dobutamine? It seems like a reasonable

vasopressor to start with, especially with the CHF history. Dopamine would

be contraindicated, especially with the kidney issues.

-Wes Ogilvie

In a message dated 10/2/2009 2:57:25 A.M. Central Daylight Time,

wegandy1938@... writes:

This scenario is based upon a combination of cases. This is a fictional

patient and a fictional situation.

EMS brings a 75 year old patient to a small-town rural ER. The patient's

complaints are dyspnea, dizziness, and infections in both legs.

The patient is on O2 at 12 lpm/NRB, applied by the ambulance crew which

includes one basic EMT and one Paramedic.

Examination reveals a patient with a GCS of 15, very restless and afraid,

with a rapid and irregular heart rate and rapid respirations. He states

past medical history of congestive heart failure, Stage 4 chronic kidney

disease, and Type II diabetes. He states that he has had an implanted

pacemaker

for the last 4 years. BP is 84/40. BGL is 103. Lung sounds are clear

bilaterally except for mild rales in the bases. S1, S2, and S3 are heard.

Temp is 37. Pupils are PEARLA, HEENT negative, chest expands equally

bilaterally, abdomen is soft, non-tender to palpation, and non-distended,

legs

have a rash that appears to be " weeping " and infected.

ECG shows a wide complex tachycardia at a rate varying from 95 to 124. It

is interpreted by the ER physician as VT.

An IV of NS is started and dopamine drip begun, which results in his BP

spiking to 154/88. VT continues, and the dopamine is discontinued. BP

falls

into the toilet, and the dopamine is restarted. The patient is very

restless, states that he " cannot get comfortable " and is given morphine 4

mg,

which results in his going to sleep. He is transferred to the ICU.

I have the following questions:

If you had been the EMS crew, what would you have done? What should the

prehospital treatment goals for this patient be? Assume that your

ambulance

has dopamine, epinephrine, Levophed, and dobutamine as vasopressors. Also

assume that your transport time to the hospital is 45 minutes to 1 hour

and

that helicopter EMS is not available.

Without seeing an ECG, what are your thoughts about the patient's probable

dysrhythmia? What can be going on with his implanted pacemaker? What

rhythm is he most likely in? VT or something else?

Given his Hx of stage 4 kidney failure, was his treatment in the ER

appropriate? If so, why? If not, why not?

This is a scenario that my students are working on. I will appreciate

your thoughts and will pass them on to my students.

Thanks in advance.

Gene G.

[Non-text portions of this message have been removed]

[Guest guest]

Temp of 37?

 R.

Why is it that when I press " one " for english, I still can't understand the

person on the other end?

________________________________

To: texasems-l

Sent: Fri, October 2, 2009 2:56:50 AM

Subject: Case for consideration

 

This scenario is based upon a combination of cases. This is a fictional

patient and a fictional situation.

EMS brings a 75 year old patient to a small-town rural ER. The patient's

complaints are dyspnea, dizziness, and infections in both legs.

The patient is on O2 at 12 lpm/NRB, applied by the ambulance crew which

includes one basic EMT and one Paramedic.

Examination reveals a patient with a GCS of 15, very restless and afraid,

with a rapid and irregular heart rate and rapid respirations. He states

past medical history of congestive heart failure, Stage 4 chronic kidney

disease, and Type II diabetes. He states that he has had an implanted pacemaker

for the last 4 years. BP is 84/40. BGL is 103. Lung sounds are clear

bilaterally except for mild rales in the bases. S1, S2, and S3 are heard.

Temp is 37. Pupils are PEARLA, HEENT negative, chest expands equally

bilaterally, abdomen is soft, non-tender to palpation, and non-distended, legs

have a rash that appears to be " weeping " and infected.

ECG shows a wide complex tachycardia at a rate varying from 95 to 124. It

is interpreted by the ER physician as VT.

An IV of NS is started and dopamine drip begun, which results in his BP

spiking to 154/88. VT continues, and the dopamine is discontinued. BP falls

into the toilet, and the dopamine is restarted. The patient is very

restless, states that he " cannot get comfortable " and is given morphine 4 mg,

which results in his going to sleep. He is transferred to the ICU.

I have the following questions:

If you had been the EMS crew, what would you have done? What should the

prehospital treatment goals for this patient be? Assume that your ambulance

has dopamine, epinephrine, Levophed, and dobutamine as vasopressors. Also

assume that your transport time to the hospital is 45 minutes to 1 hour and

that helicopter EMS is not available.

Without seeing an ECG, what are your thoughts about the patient's probable

dysrhythmia? What can be going on with his implanted pacemaker? What

rhythm is he most likely in? VT or something else?

Given his Hx of stage 4 kidney failure, was his treatment in the ER

appropriate? If so, why? If not, why not?

This is a scenario that my students are working on. I will appreciate

your thoughts and will pass them on to my students.

Thanks in advance.

Gene G.

[Guest guest]

Temp of 37?

 R.

Why is it that when I press " one " for english, I still can't understand the

person on the other end?

________________________________

To: texasems-l

Sent: Fri, October 2, 2009 2:56:50 AM

Subject: Case for consideration

 

This scenario is based upon a combination of cases. This is a fictional

patient and a fictional situation.

EMS brings a 75 year old patient to a small-town rural ER. The patient's

complaints are dyspnea, dizziness, and infections in both legs.

The patient is on O2 at 12 lpm/NRB, applied by the ambulance crew which

includes one basic EMT and one Paramedic.

Examination reveals a patient with a GCS of 15, very restless and afraid,

with a rapid and irregular heart rate and rapid respirations. He states

past medical history of congestive heart failure, Stage 4 chronic kidney

disease, and Type II diabetes. He states that he has had an implanted pacemaker

for the last 4 years. BP is 84/40. BGL is 103. Lung sounds are clear

bilaterally except for mild rales in the bases. S1, S2, and S3 are heard.

Temp is 37. Pupils are PEARLA, HEENT negative, chest expands equally

bilaterally, abdomen is soft, non-tender to palpation, and non-distended, legs

have a rash that appears to be " weeping " and infected.

ECG shows a wide complex tachycardia at a rate varying from 95 to 124. It

is interpreted by the ER physician as VT.

An IV of NS is started and dopamine drip begun, which results in his BP

spiking to 154/88. VT continues, and the dopamine is discontinued. BP falls

into the toilet, and the dopamine is restarted. The patient is very

restless, states that he " cannot get comfortable " and is given morphine 4 mg,

which results in his going to sleep. He is transferred to the ICU.

I have the following questions:

If you had been the EMS crew, what would you have done? What should the

prehospital treatment goals for this patient be? Assume that your ambulance

has dopamine, epinephrine, Levophed, and dobutamine as vasopressors. Also

assume that your transport time to the hospital is 45 minutes to 1 hour and

that helicopter EMS is not available.

Without seeing an ECG, what are your thoughts about the patient's probable

dysrhythmia? What can be going on with his implanted pacemaker? What

rhythm is he most likely in? VT or something else?

Given his Hx of stage 4 kidney failure, was his treatment in the ER

appropriate? If so, why? If not, why not?

This is a scenario that my students are working on. I will appreciate

your thoughts and will pass them on to my students.

Thanks in advance.

Gene G.

[Guest guest]

37 Celsius, Rick. More or less a normal temperature.

Rick wrote:

>

>

> Temp of 37?

> R.

>

> Why is it that when I press " one " for english, I still can't

> understand the person on the other end?

>

> ________________________________

> From: " wegandy1938@... "

> wegandy1938@... >

> To: texasems-l

> Sent: Fri, October 2, 2009 2:56:50 AM

> Subject: Case for consideration

>

>

> This scenario is based upon a combination of cases. This is a fictional

> patient and a fictional situation.

>

> EMS brings a 75 year old patient to a small-town rural ER. The patient's

> complaints are dyspnea, dizziness, and infections in both legs.

>

> The patient is on O2 at 12 lpm/NRB, applied by the ambulance crew which

> includes one basic EMT and one Paramedic.

>

> Examination reveals a patient with a GCS of 15, very restless and afraid,

> with a rapid and irregular heart rate and rapid respirations. He states

> past medical history of congestive heart failure, Stage 4 chronic kidney

> disease, and Type II diabetes. He states that he has had an implanted

> pacemaker

> for the last 4 years. BP is 84/40. BGL is 103. Lung sounds are clear

> bilaterally except for mild rales in the bases. S1, S2, and S3 are heard.

> Temp is 37. Pupils are PEARLA, HEENT negative, chest expands equally

> bilaterally, abdomen is soft, non-tender to palpation, and

> non-distended, legs

> have a rash that appears to be " weeping " and infected.

>

> ECG shows a wide complex tachycardia at a rate varying from 95 to 124. It

> is interpreted by the ER physician as VT.

>

> An IV of NS is started and dopamine drip begun, which results in his BP

> spiking to 154/88. VT continues, and the dopamine is discontinued. BP

> falls

> into the toilet, and the dopamine is restarted. The patient is very

> restless, states that he " cannot get comfortable " and is given

> morphine 4 mg,

> which results in his going to sleep. He is transferred to the ICU.

>

> I have the following questions:

>

> If you had been the EMS crew, what would you have done? What should the

> prehospital treatment goals for this patient be? Assume that your

> ambulance

> has dopamine, epinephrine, Levophed, and dobutamine as vasopressors. Also

> assume that your transport time to the hospital is 45 minutes to 1

> hour and

> that helicopter EMS is not available.

>

> Without seeing an ECG, what are your thoughts about the patient's

> probable

> dysrhythmia? What can be going on with his implanted pacemaker? What

> rhythm is he most likely in? VT or something else?

>

> Given his Hx of stage 4 kidney failure, was his treatment in the ER

> appropriate? If so, why? If not, why not?

>

> This is a scenario that my students are working on. I will appreciate

> your thoughts and will pass them on to my students.

>

> Thanks in advance.

>

> Gene G.

>

>

[Guest guest]

37 Celsius, Rick. More or less a normal temperature.

Rick wrote:

>

>

> Temp of 37?

> R.

>

> Why is it that when I press " one " for english, I still can't

> understand the person on the other end?

>

> ________________________________

> From: " wegandy1938@... "

> wegandy1938@... >

> To: texasems-l

> Sent: Fri, October 2, 2009 2:56:50 AM

> Subject: Case for consideration

>

>

> This scenario is based upon a combination of cases. This is a fictional

> patient and a fictional situation.

>

> EMS brings a 75 year old patient to a small-town rural ER. The patient's

> complaints are dyspnea, dizziness, and infections in both legs.

>

> The patient is on O2 at 12 lpm/NRB, applied by the ambulance crew which

> includes one basic EMT and one Paramedic.

>

> Examination reveals a patient with a GCS of 15, very restless and afraid,

> with a rapid and irregular heart rate and rapid respirations. He states

> past medical history of congestive heart failure, Stage 4 chronic kidney

> disease, and Type II diabetes. He states that he has had an implanted

> pacemaker

> for the last 4 years. BP is 84/40. BGL is 103. Lung sounds are clear

> bilaterally except for mild rales in the bases. S1, S2, and S3 are heard.

> Temp is 37. Pupils are PEARLA, HEENT negative, chest expands equally

> bilaterally, abdomen is soft, non-tender to palpation, and

> non-distended, legs

> have a rash that appears to be " weeping " and infected.

>

> ECG shows a wide complex tachycardia at a rate varying from 95 to 124. It

> is interpreted by the ER physician as VT.

>

> An IV of NS is started and dopamine drip begun, which results in his BP

> spiking to 154/88. VT continues, and the dopamine is discontinued. BP

> falls

> into the toilet, and the dopamine is restarted. The patient is very

> restless, states that he " cannot get comfortable " and is given

> morphine 4 mg,

> which results in his going to sleep. He is transferred to the ICU.

>

> I have the following questions:

>

> If you had been the EMS crew, what would you have done? What should the

> prehospital treatment goals for this patient be? Assume that your

> ambulance

> has dopamine, epinephrine, Levophed, and dobutamine as vasopressors. Also

> assume that your transport time to the hospital is 45 minutes to 1

> hour and

> that helicopter EMS is not available.

>

> Without seeing an ECG, what are your thoughts about the patient's

> probable

> dysrhythmia? What can be going on with his implanted pacemaker? What

> rhythm is he most likely in? VT or something else?

>

> Given his Hx of stage 4 kidney failure, was his treatment in the ER

> appropriate? If so, why? If not, why not?

>

> This is a scenario that my students are working on. I will appreciate

> your thoughts and will pass them on to my students.

>

> Thanks in advance.

>

> Gene G.

>

>

[Guest guest]

with the rash there could be a case made for sepsis. that could help explan the

heart rate and the low blod pressure. Prehospital, care? Support the bp as

needed with a fluid bolus

20mg/kg see how that helps the bp maybe but with the rales that maynot be the

best course, dopamine to support bp and maybe even an epi drip. Of course the

abc's and the basics will be covered with constant monitoring for any changes.

If it is sepis caused by the rash, finding what the rash is and ts cause will be

important but probaly not something that could be done in the unit unles the

patient states he has an allergy to insectcides or such. If possible a good

phyisical exame may even yield some sort of bite.

Just a guess.

Subject: Case for consideration

To: texasems-l

Date: Friday, October 2, 2009, 2:56 AM

 

This scenario is based upon a combination of cases. This is a fictional

patient and a fictional situation.

EMS brings a 75 year old patient to a small-town rural ER. The patient's

complaints are dyspnea, dizziness, and infections in both legs.

The patient is on O2 at 12 lpm/NRB, applied by the ambulance crew which

includes one basic EMT and one Paramedic.

Examination reveals a patient with a GCS of 15, very restless and afraid,

with a rapid and irregular heart rate and rapid respirations. He states

past medical history of congestive heart failure, Stage 4 chronic kidney

disease, and Type II diabetes. He states that he has had an implanted pacemaker

for the last 4 years. BP is 84/40. BGL is 103. Lung sounds are clear

bilaterally except for mild rales in the bases. S1, S2, and S3 are heard.

Temp is 37. Pupils are PEARLA, HEENT negative, chest expands equally

bilaterally, abdomen is soft, non-tender to palpation, and non-distended, legs

have a rash that appears to be " weeping " and infected.

ECG shows a wide complex tachycardia at a rate varying from 95 to 124. It

is interpreted by the ER physician as VT.

An IV of NS is started and dopamine drip begun, which results in his BP

spiking to 154/88. VT continues, and the dopamine is discontinued. BP falls

into the toilet, and the dopamine is restarted. The patient is very

restless, states that he " cannot get comfortable " and is given morphine 4 mg,

which results in his going to sleep. He is transferred to the ICU.

I have the following questions:

If you had been the EMS crew, what would you have done? What should the

prehospital treatment goals for this patient be? Assume that your ambulance

has dopamine, epinephrine, Levophed, and dobutamine as vasopressors. Also

assume that your transport time to the hospital is 45 minutes to 1 hour and

that helicopter EMS is not available.

Without seeing an ECG, what are your thoughts about the patient's probable

dysrhythmia? What can be going on with his implanted pacemaker? What

rhythm is he most likely in? VT or something else?

Given his Hx of stage 4 kidney failure, was his treatment in the ER

appropriate? If so, why? If not, why not?

This is a scenario that my students are working on. I will appreciate

your thoughts and will pass them on to my students.

Thanks in advance.

Gene G.

[Guest guest]

with the rash there could be a case made for sepsis. that could help explan the

heart rate and the low blod pressure. Prehospital, care? Support the bp as

needed with a fluid bolus

20mg/kg see how that helps the bp maybe but with the rales that maynot be the

best course, dopamine to support bp and maybe even an epi drip. Of course the

abc's and the basics will be covered with constant monitoring for any changes.

If it is sepis caused by the rash, finding what the rash is and ts cause will be

important but probaly not something that could be done in the unit unles the

patient states he has an allergy to insectcides or such. If possible a good

phyisical exame may even yield some sort of bite.

Just a guess.

Subject: Case for consideration

To: texasems-l

Date: Friday, October 2, 2009, 2:56 AM

 

This scenario is based upon a combination of cases. This is a fictional

patient and a fictional situation.

EMS brings a 75 year old patient to a small-town rural ER. The patient's

complaints are dyspnea, dizziness, and infections in both legs.

The patient is on O2 at 12 lpm/NRB, applied by the ambulance crew which

includes one basic EMT and one Paramedic.

Examination reveals a patient with a GCS of 15, very restless and afraid,

with a rapid and irregular heart rate and rapid respirations. He states

past medical history of congestive heart failure, Stage 4 chronic kidney

disease, and Type II diabetes. He states that he has had an implanted pacemaker

for the last 4 years. BP is 84/40. BGL is 103. Lung sounds are clear

bilaterally except for mild rales in the bases. S1, S2, and S3 are heard.

Temp is 37. Pupils are PEARLA, HEENT negative, chest expands equally

bilaterally, abdomen is soft, non-tender to palpation, and non-distended, legs

have a rash that appears to be " weeping " and infected.

ECG shows a wide complex tachycardia at a rate varying from 95 to 124. It

is interpreted by the ER physician as VT.

An IV of NS is started and dopamine drip begun, which results in his BP

spiking to 154/88. VT continues, and the dopamine is discontinued. BP falls

into the toilet, and the dopamine is restarted. The patient is very

restless, states that he " cannot get comfortable " and is given morphine 4 mg,

which results in his going to sleep. He is transferred to the ICU.

I have the following questions:

If you had been the EMS crew, what would you have done? What should the

prehospital treatment goals for this patient be? Assume that your ambulance

has dopamine, epinephrine, Levophed, and dobutamine as vasopressors. Also

assume that your transport time to the hospital is 45 minutes to 1 hour and

that helicopter EMS is not available.

Without seeing an ECG, what are your thoughts about the patient's probable

dysrhythmia? What can be going on with his implanted pacemaker? What

rhythm is he most likely in? VT or something else?

Given his Hx of stage 4 kidney failure, was his treatment in the ER

appropriate? If so, why? If not, why not?

This is a scenario that my students are working on. I will appreciate

your thoughts and will pass them on to my students.

Thanks in advance.

Gene G.

[Guest guest]

Based on your scenario,

SAMPLE good, but lacking information...

1. First increase o2 15 lpm.

2. start iv give fluid challenge and recheck VS.

3. as for squeezers--- epi, levo i would hold off on them cause of the bp is

not < 70mmhg. dobutamine would be nice but u have to have a bp starting better

than 110mmhg. dopamine is contraindicated in uncorrected tacharrhythmias.

4. some dialysis patients can live with sbp of 80's as their norm.

5. if he is still anxious, and c/o sob, neb tx could be done.

As for the implanted PM, could be mechanical failure. Irregular heart rate could

be associated with A-Fib w/ rvr.

Now if the doctor says it's Vtach, meds could be initiated til syn.

cardioversion available.

As for weeping infection in the legs, sepsis could be a enemy especially with

all this MRSA and VRE.

_________________________________________________________________

Hotmail: Trusted email with powerful SPAM protection.

http://clk.atdmt.com/GBL/go/177141665/direct/01/

[Guest guest]

Based on your scenario,

SAMPLE good, but lacking information...

1. First increase o2 15 lpm.

2. start iv give fluid challenge and recheck VS.

3. as for squeezers--- epi, levo i would hold off on them cause of the bp is

not < 70mmhg. dobutamine would be nice but u have to have a bp starting better

than 110mmhg. dopamine is contraindicated in uncorrected tacharrhythmias.

4. some dialysis patients can live with sbp of 80's as their norm.

5. if he is still anxious, and c/o sob, neb tx could be done.

As for the implanted PM, could be mechanical failure. Irregular heart rate could

be associated with A-Fib w/ rvr.

Now if the doctor says it's Vtach, meds could be initiated til syn.

cardioversion available.

As for weeping infection in the legs, sepsis could be a enemy especially with

all this MRSA and VRE.

_________________________________________________________________

Hotmail: Trusted email with powerful SPAM protection.

http://clk.atdmt.com/GBL/go/177141665/direct/01/

[Guest guest]

,

Thanks. Very insightful.

The dobutamine thing is interesting. I put this out on one of the ER docs

list, and a bunch of them went with dobutamine in spite of the BP. So I

went to the books and the circular on dobutamine says nothing about a minimum

BP for administration. It's an ACLS thing. I'm not sure where that

comes from. Any ideas?

The other thing that I learned about dobutamine that might make me change

my mind is that it enhances conduction through the AV node; thus, in AF it

could result in rapid ventricular rate, which is what I guessed was already

going on. So now I'm not sure.

Nile, can you jump in here and speak to this?

If dobutamine improves contractility and also ups the rate, why would there

be a minimum BP requirement for using it?

Anybody?

GG

>  

>

> Based on your scenario,

>

> SAMPLE good, but lacking information. S

>

> 1. First increase o2 15 lpm.

>

> 2. start iv give fluid challenge and recheck VS.

>

> 3. as for squeezers--- epi, levo i would hold off on them cause of the bp

> is not < 70mmhg. dobutamine would be nice but u have to have a bp starting

> better than 110mmhg. dopamine is contraindicated in uncorrected

> tacharrhythmias.

>

> 4. some dialysis patients can live with sbp of 80's as their norm.

>

> 5. if he is still anxious, and c/o sob, neb tx could be done.

>

> As for the implanted PM, could be mechanical failure. Irregular heart rate

> could be associated with A-Fib w/ rvr.

>

> Now if the doctor says it's Vtach, meds could be initiated til syn.

> cardioversion available.

>

> As for weeping infection in the legs, sepsis could be a enemy especially

> with all this MRSA and VRE.

>

>

> ____________ ________ ________ ________ ________ ________

> Hotmail: Trusted email with powerful SPAM protection.

> http://clk.atdmt.http://clk.http://clkhttp://clk

>

>

[Guest guest]

The effective infusion rate of dobutamine varies widely from patient to

patient, and titration is always necessary. Precipitous decreases in blood

pressure have occasionally been described in association with dobutamine

therapy. There has been hypotensive response during stress test that have been

reported.

Maybe the abnormal responses to dobutamine can be explained by microvascular

dysfunction in the coronary circulation by decreased coronary flow reserve

(CFR). http://linkinghub.elsevier.com/retrieve/pii/S1053249802004448

To: texasems-l

From: wegandy1938@...

Date: Sat, 3 Oct 2009 03:19:06 -0400

Subject: Re: Case for consideration

,

Thanks. Very insightful.

The dobutamine thing is interesting. I put this out on one of the ER docs

list, and a bunch of them went with dobutamine in spite of the BP. So I

went to the books and the circular on dobutamine says nothing about a minimum

BP for administration. It's an ACLS thing. I'm not sure where that

comes from. Any ideas?

The other thing that I learned about dobutamine that might make me change

my mind is that it enhances conduction through the AV node; thus, in AF it

could result in rapid ventricular rate, which is what I guessed was already

going on. So now I'm not sure.

Nile, can you jump in here and speak to this?

If dobutamine improves contractility and also ups the rate, why would there

be a minimum BP requirement for using it?

Anybody?

GG

>

>

> Based on your scenario,

>

> SAMPLE good, but lacking information. S

>

> 1. First increase o2 15 lpm.

>

> 2. start iv give fluid challenge and recheck VS.

>

> 3. as for squeezers--- epi, levo i would hold off on them cause of the bp

> is not < 70mmhg. dobutamine would be nice but u have to have a bp starting

> better than 110mmhg. dopamine is contraindicated in uncorrected

> tacharrhythmias.

>

> 4. some dialysis patients can live with sbp of 80's as their norm.

>

> 5. if he is still anxious, and c/o sob, neb tx could be done.

>

> As for the implanted PM, could be mechanical failure. Irregular heart rate

> could be associated with A-Fib w/ rvr.

>

> Now if the doctor says it's Vtach, meds could be initiated til syn.

> cardioversion available.

>

> As for weeping infection in the legs, sepsis could be a enemy especially

> with all this MRSA and VRE.

>

>

> ____________ ________ ________ ________ ________ ________

> Hotmail: Trusted email with powerful SPAM protection.

> http://clk.atdmt.http://clk.http://clkhttp://clk

>

>

[Guest guest]

The effective infusion rate of dobutamine varies widely from patient to

patient, and titration is always necessary. Precipitous decreases in blood

pressure have occasionally been described in association with dobutamine

therapy. There has been hypotensive response during stress test that have been

reported.

Maybe the abnormal responses to dobutamine can be explained by microvascular

dysfunction in the coronary circulation by decreased coronary flow reserve

(CFR). http://linkinghub.elsevier.com/retrieve/pii/S1053249802004448

To: texasems-l

From: wegandy1938@...

Date: Sat, 3 Oct 2009 03:19:06 -0400

Subject: Re: Case for consideration

,

Thanks. Very insightful.

The dobutamine thing is interesting. I put this out on one of the ER docs

list, and a bunch of them went with dobutamine in spite of the BP. So I

went to the books and the circular on dobutamine says nothing about a minimum

BP for administration. It's an ACLS thing. I'm not sure where that

comes from. Any ideas?

The other thing that I learned about dobutamine that might make me change

my mind is that it enhances conduction through the AV node; thus, in AF it

could result in rapid ventricular rate, which is what I guessed was already

going on. So now I'm not sure.

Nile, can you jump in here and speak to this?

If dobutamine improves contractility and also ups the rate, why would there

be a minimum BP requirement for using it?

Anybody?

GG

>

>

> Based on your scenario,

>

> SAMPLE good, but lacking information. S

>

> 1. First increase o2 15 lpm.

>

> 2. start iv give fluid challenge and recheck VS.

>

> 3. as for squeezers--- epi, levo i would hold off on them cause of the bp

> is not < 70mmhg. dobutamine would be nice but u have to have a bp starting

> better than 110mmhg. dopamine is contraindicated in uncorrected

> tacharrhythmias.

>

> 4. some dialysis patients can live with sbp of 80's as their norm.

>

> 5. if he is still anxious, and c/o sob, neb tx could be done.

>

> As for the implanted PM, could be mechanical failure. Irregular heart rate

> could be associated with A-Fib w/ rvr.

>

> Now if the doctor says it's Vtach, meds could be initiated til syn.

> cardioversion available.

>

> As for weeping infection in the legs, sepsis could be a enemy especially

> with all this MRSA and VRE.

>

>

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>