Case for consideration

[Guest guest]

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.