What would you do?

[spacetygrss]

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Here's the scenario:

Patient presents with pulmonary edema and is intubated in the ER. EKG shows massive anterior infarct, so patient is taken for emergent cath and stented. Post-cath patient is doing well in CCU. Approximately one hour later the RN calls saying that the blood pressure is 50s-60s systolic.

What's going through your head? What do you do?

 

[zippy2u]

Tell her she needs to call the cardiologist and let him deal with it. You got paid for providing MAC for the pt. while the stenting took place and you did a fine job at that. ----Zippy

 

[2ndyear]

CCU so they're already on tele, take a look at the screen and determine the basics: rate, rhythm, ST changes. If it's rhythm then electricity is the answer if it's shockable. Quick history is important, ie, did they just pull the femoral sheath out and the patient vagaled down to near death. This caused me a few moments of terror my intern year. Atropine is then the fix, glyco if it wasn't as urgent or bad, but this sounds ugly by the description. Look at the patient, probably non-responsive but intubated or not is important. If the patient looks clinically way too good to have a pressure of 60/30 then press the button and cycle another pressure. If they are vented are the peak pressure alarms sounding, etc. All of this should take about 3 seconds as you enter the room.

What's going through your head now is, shock. Septic, not likely. Spinal, no trauma. Hypovolemia, sure if when they pulled the sheath out the patient bled 2 liters which you should notice on your quick survey of the room. Also with the pulmonary edema slamming in fluid is not something that is fun without a swan. That pretty much leaves cardiogenic. But how could they re-infarct on the heparin drip, plavix, aspirin, etc? Could be a coronary dissection during the PTCI. Also could be a coronary steal if they stented across a good vessel and occluded flow. What about wall rupture and the subsequent tamponade?

In the meantime this is a code situation. If ACLS protocols are applicable, then follow them. If not call for some epi if you have no swan, and I'm assuming you don't. Call the code, call your resident, call the family.

 

[undecided05]

While thinking of hypovolemia as a source of the shock, don't forget to think of retroperitoneal bleed if the cardiologist went too high in the femoral stick. Saw that happen three times in one day with one fellow.

 

[powermd]

If the patient is having acute-onset pulmonary edema I wouldn't be thinking hypovolemic shock. My first thought was acute stent closure secondary to hypotension secondary to cardiogenic shock from the big AWMI. I would want to throw a balloon pump in there fast to unload the heart and transfer the patient back to the cath lab to get the stent open again. While waiting for the cardiologists to take control, I would treat this as a code situation as well. The EKG ought to tell you if the patient is having acute stent closure, assuming they aren't awake and clutching their chest while chewing on the endotracheal tube.

 

[nitecap]

Intubate with mech ventilation.
Give amp of Cacl, start either vaso or norepi drip if dilated out. Albumin if hgb ok, bld if needed. EPi maybe, especially if loosing kick. Swan if doesnt have so can judge fluid status and CI. If this doesnt fix problem call surg are cardio for IABP.