How would you do this case?

[Crash cart]

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(I am in private practice)

Getting ready to go home last week and the pager goes off. TEE / CV. No problem, easy money, will still be able to get my son to basketball practice as promised (until I look in the EMR)...

51 year old male, STEMI 2 days ago. Occluded branch of the RCA, ballooned open, no stent (not sure why). loaded with 300 plavix and therapeutic lovenox (was given lytics at OSH but not sure which drug). Cath reveals EF < 10%. Currently in rapid afib between 130 - 150 / min.

Patient is in NAD other than feeling very weak - awake and talking, VS essentially normal, good airway. No know PMH, but he hasn't seen a physician in "35 years" by his own admission. Occasional smoking, nothing crazy. Significant ETOH intake (cardiology notes suggest alcoholic CMP as a possible etiology). Not obese but clearly doesn't take care of himself.

Labs show an increased troponin (3.96), normal H/H, normal renal function, minimally increased lactate, normal coags.

How would you do this case?

Note: I posted this for 2 reasons:

1) Interesting case

2) An illustration to the residents that private practice does not = healthy patients! A wise resident seeks out sick patients to "practice" with and focuses on developing responsible management of really sick people because THEY ARE EVERYWHERE! Even in private practice...

 

[fakin' the funk]

(I am in private practice)

Getting ready to go home last week and the pager goes off. TEE / CV. No problem, easy money, will still be able to get my son to basketball practice as promised (until I look in the EMR)...

51 year old male, STEMI 2 days ago. Occluded branch of the RCA, ballooned open, no stent (not sure why). loaded with 300 plavix and therapeutic lovenox (was given lytics at OSH but not sure which drug). Cath reveals EF < 10%. Currently in rapid afib between 130 - 150 / min.

Patient is in NAD other than feeling very weak - awake and talking, VS essentially normal, good airway. No know PMH, but he hasn't seen a physician in "35 years" by his own admission. Occasional smoking, nothing crazy. Significant ETOH intake (cardiology notes suggest alcoholic CMP as a possible etiology). Not obese but clearly doesn't take care of himself.

Labs show an increased troponin (3.96), normal H/H, normal renal function, minimally increased lactate, normal coags.

How would you do this case?

Note: I posted this for 2 reasons:

1) Interesting case

2) An illustration to the residents that private practice does not = healthy patients! A wise resident seeks out sick patients to "practice" with and focuses on developing responsible management of really sick people because THEY ARE EVERYWHERE! Even in private practice...

How big is the LA on his TTE?

 

[B-Bone]

How big is the LA on his TTE?

what is the case?

 

[PainDrain]

Is it for a TEE? I'm confused.

Anyway, what are his vitals? Is he hemodynically stable or is his pressure 80/30? If he is normotensive then I would topicalize the hell out of him with hurricane spray, place zoll pads on him, make sure I have a decent IV, give him 4mg versed and hold on tight.

 

[Crash cart]

The case is a TEE + Cardioversion. VS are essentially normal, 100 - 120 systolic, 60 - 70 diastolic. Hemodynamically stable. No IABP.

 

[GasOrBust]

Looks like the case is a TEE and cardioversion...is that right? What I don't understand is whether this is actually indicated at this time if he is hemodynamically stable, which I'm assuming he is given his "essentially normal" vitals. Why not just rate control him with drugs?

 

[Spinach Dip]

Retrograde wire.

Next!

 

[lazypanda]

fentanyl + versed. or propofol bolus. or lidocaine lube for the probe + leather strap to bite on when cardioverting.

 

[TIVAndy]

versed + gentle alfentanil. propofol too dangerous in this situation. agree with rate control though. sounds like someone who will cardiovert and then go back into a fib again.

 

[GA8314]

(I am in private practice)

Getting ready to go home last week and the pager goes off. TEE / CV. No problem, easy money, will still be able to get my son to basketball practice as promised (until I look in the EMR)...

51 year old male, STEMI 2 days ago. Occluded branch of the RCA, ballooned open, no stent (not sure why). loaded with 300 plavix and therapeutic lovenox (was given lytics at OSH but not sure which drug). Cath reveals EF < 10%. Currently in rapid afib between 130 - 150 / min.

Patient is in NAD other than feeling very weak - awake and talking, VS essentially normal, good airway. No know PMH, but he hasn't seen a physician in "35 years" by his own admission. Occasional smoking, nothing crazy. Significant ETOH intake (cardiology notes suggest alcoholic CMP as a possible etiology). Not obese but clearly doesn't take care of himself.

Labs show an increased troponin (3.96), normal H/H, normal renal function, minimally increased lactate, normal coags.

How would you do this case?

Note: I posted this for 2 reasons:

1) Interesting case

2) An illustration to the residents that private practice does not = healthy patients! A wise resident seeks out sick patients to "practice" with and focuses on developing responsible management of really sick people because THEY ARE EVERYWHERE! Even in private practice...

Give 1 mg Versed, and titrate in 25 mg Ketamine at a time. Go very slow, and allow for looooonnnnng circulation times. Have him gargle viscous lidocaine prior to TEE placement and "sedation". Some IV Lidocaine to blunt his gag reflex may help too while maintaining some hemodynamic stability. Let him know that with his sick heart, he may recall the event, but that you will try to keep him not only safe, but also as comfortable as possible.

Once the probe clears his throat, maintenance won't be as difficult. Of course have pressors and inotropes on hand. I'm assuming he'll come down on a Diltiazem drip with that rate. If his hemodynamics don't tolerate it, you can always DC that since he'll likely get cardioverted within a few minutes. Then, get him back to the CICU STAT.

 

[Noyac]

I assume it's a CV first then TEE.
I would gently sedate for CV then let him wake up a bit for TEE.
What's the issue. 😉

 

[nimbus]

I assume it's a CV first then TEE.
I would gently sedate for CV then let him wake up a bit for TEE.
What's the issue. 😉

Typically we do the opposite. TEE to exclude presence of LAA thrombus, then CV.

 

[fakin' the funk]

what is the case?

It may not be a case at all.

 

[fakin' the funk]

How would you do this case?

Ugly substrate gets an ugly anesthetic.
- topicalize w/ LMA MADgic and 8ml 4% lido
- 2mg versed
- 20 ketamine
- propofol cc by cc while the f**k around with the TEE and take screenshots of it with their phone.

Not sure why we think cardioverting this guy will help.
a) he may well go back into Afib
b) ain't they gonna anticoagulate anyway with an EF that low?

 

[Ezekiel2517]

You keep repeating that vital signs are essentially normal but stated the pt is in rapid AFib with rates 130-150's. Anyways, there is a reason the pt is saying he feels very weak. Whatever you decide to use, go slow. This guy won't need much.

 

[bcat85]

I think it's also important to ask whether he needs the TEE at all. Was he in Afib when he was admitted? If not, he has already been therapeutically anticoagulated and it would be OK to proceed with CV with a TTE to further evaluate function.

 

[Planktonmd]

Topicalize the pharynx, then give him some sort of sedation without causing too much hypotension or apnea, do a quick TEE then cardiovert him.
(Quick TEE means no F**ing around, only rule out a clot and pull out).
You can still get to the basketball game on time.

 

[PainDrain]

With an EF that low he is likely to get a pacer/AICD in the next few days. That is probably the more difficult case; especially if they will test the AICD. I know they don't have to test per se but we used to have a cardiologist who insisted on testing the AICD function every case.

 

[Noyac]

Typically we do the opposite. TEE to exclude presence of LAA thrombus, then CV.

My thoughts were that he was already anticoagulants and they want to assess function after CV. But this is why I asked which one first because I wasn't sure. Personally, if they are doing TEE to assess clot then I don't think it is necessary. Am I wrong?

 

[Stank811]

TEE to rule out clot and then CV. Go slowly with propofol and follow hemodynamics closely...if he is tolerating RVR a slow propofol titration shouldn't bury him...he is a heavy drinker so give propofol until he is at his happy place (slurring and barely able to keep his eyes open) and then proceed. Intermittent small boluses throughout remainder of TEE and once TEE is finished CV.

 

[deleted171991]

This is why people do a critical care fellowship. Piece of cake. 😛

Seriously, I had to intubate a sick 5-10%-er in cardiogenic shock just a couple weeks ago. I used versed and propofol.

 

[amyl]

In my institution we do sedation cases like this with propidate - 1:1 mixture of propofol and etomidate. I love ketamine but rvr afib is a time I'd skip it.... Titrate versed In upfront - he made need more as an alcoholic.... Agree with swish gargle swallow lidocaine.
Had a cardiologist tell me IV lido raises the cv threshold so I usually skip it although no cards since have questioned me on it since that one guy....

 

[Planktonmd]

In my institution we do sedation cases like this with propidate - 1:1 mixture of propofol and etomidate. I love ketamine but rvr afib is a time I'd skip it.... Titrate versed In upfront - he made need more as an alcoholic.... Agree with swish gargle swallow lidocaine.
Had a cardiologist tell me IV lido raises the cv threshold so I usually skip it although no cards since have questioned me on it since that one guy....

I never understood why some people like to mix Propofol with Etomidate!

 

[nap$ter]

Getting ready to go home last week and the pager goes off. TEE / CV. No problem, easy money, will still be able to get my son to basketball practice as promised (until I look in the EMR)...

51 year old male, STEMI 2 days ago. Occluded branch of the RCA, ballooned open, no stent (not sure why). loaded with 300 plavix and therapeutic lovenox (was given lytics at OSH but not sure which drug). Cath reveals EF < 10%. Currently in rapid afib between 130 - 150 / min.

Patient is in NAD other than feeling very weak - awake and talking, VS essentially normal, good airway. No know PMH, but he hasn't seen a physician in "35 years" by his own admission. Occasional smoking, nothing crazy. Significant ETOH intake (cardiology notes suggest alcoholic CMP as a possible etiology). Not obese but clearly doesn't take care of himself.

Labs show an increased troponin (3.96), normal H/H, normal renal function, minimally increased lactate, normal coags.

How would you do this case?

Note: I posted this for 2 reasons:

1) Interesting case

2) An illustration to the residents that private practice does not = healthy patients! A wise resident seeks out sick patients to "practice" with and focuses on developing responsible management of really sick people because THEY ARE EVERYWHERE! Even in private practice...[/QUOTE]

verify a thorough attempt at rate control has been made (if bp is still stable likely not enough has been tried).

topical is your friend for the tee. tell him he will have recall (if he does, he thinks you know what you're talking about and if he doesn't you exceeded expectations win-win).

no fentanyl. no versed. ultraslow dosing of propofol augmented with ketamine 10 at a time. pressor/inotrope of choice prn.

in and out clot or not. no dinking around by cards dude. cardioversion.

do all this in CICU.

drive son to practice.

 

[Arch Guillotti]

My thoughts were that he was already anticoagulants and they want to assess function after CV. But this is why I asked which one first because I wasn't sure. Personally, if they are doing TEE to assess clot then I don't think it is necessary. Am I wrong?

I think the patient has only been anticoagulated a very short period of time.

 

[dhb]

TEE to rule out clot and then CV. Go slowly with propofol and follow hemodynamics closely...if he is tolerating RVR a slow propofol titration shouldn't bury him...he is a heavy drinker so give propofol until he is at his happy place (slurring and barely able to keep his eyes open) and then proceed. Intermittent small boluses throughout remainder of TEE and once TEE is finished CV.

Circulation time is slow in this guy so be careful with those prop boluses and yes the patient doesn't need to be very deep to CV.