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Reading the shock or not shock post made me think of a case I had as an intern and some of the thoughts i've had on the matter since:
Case: Elderly female comes into the ED with impressive acute pulmonary edema, normotensive, mild tachycardia (120-140's) and mod resp distress. EKG shows afib. No med records, no known meds, no history from patient (can you say, "veternary medicine?).
The thoughts at the time were this: Patient is "relatively" stable; that is, sytolic bp 100-110 and not yet altrered. The afib might be chronic and, in light of the only mild ventricular response, may not soley be responsible for the pulm edema.
What I did at the time: gave the patient dilt and BiPAP. She turned right around and was admitted for a tune-up.
My thoughts now: This seemed a little risky for a few reasons. One, the calcium channel blocker could have tipped her pulm edem over the edge (does it reverese all that quickly with CaCl? Would pre-medicating with CaCl help or be self-defeating?), was the afib really the issue here? Shock and try converting it (embolism risk)? Amioderone (pretty poor response rate with that drug)? A gram of procaine over an hour (would she make it that long)? How about dilt PLUS dopamine prn??
Dive in...
Case: Elderly female comes into the ED with impressive acute pulmonary edema, normotensive, mild tachycardia (120-140's) and mod resp distress. EKG shows afib. No med records, no known meds, no history from patient (can you say, "veternary medicine?).
The thoughts at the time were this: Patient is "relatively" stable; that is, sytolic bp 100-110 and not yet altrered. The afib might be chronic and, in light of the only mild ventricular response, may not soley be responsible for the pulm edema.
What I did at the time: gave the patient dilt and BiPAP. She turned right around and was admitted for a tune-up.
My thoughts now: This seemed a little risky for a few reasons. One, the calcium channel blocker could have tipped her pulm edem over the edge (does it reverese all that quickly with CaCl? Would pre-medicating with CaCl help or be self-defeating?), was the afib really the issue here? Shock and try converting it (embolism risk)? Amioderone (pretty poor response rate with that drug)? A gram of procaine over an hour (would she make it that long)? How about dilt PLUS dopamine prn??
Dive in...