Think Before You Freak Out!

The other night I was getting report from the say nurse on a post-pacemaker placement patient (try saying that 5 times fast!) who was all in a tizzy.  Scattered and doing things that really didn’t make a whole lot of sense.  It had been a busy day, but it seemed like she was making more work for herself than she needed.  Almost like running in circles.  Not productive at all.

When the excreted fecal matter hits the proverbial air oscillator, I make sure I take a moment to assess the situation.  Following the Fat Man, I check my pulse and then begin to gather the situational information.  It seems that the ability to do this was lost upon my colleague and she went from zero to “Holy Shit!” in about 30 milliseconds.  Over what?  A simple 5 beat run of V-Tach.

Yes, V-Tach is bad.  We all know V-Tach is bad.  5 beats though?  Self-limiting in a patient who just come back from getting a pacemaker?  With a slightly low potassium?  Not all that surprising.  But no, flew off the handle she did. Called for labs, called the doc and worked herself into the fore-mentioned tizzy,  Through this the patient is fine.  Happily chatting with his wife about this or that.  He’s on the monitor, already has a K-rider infusing and is about as content as one can be in the hospital.  Why the drama?

Because all to often people don’t think before they act.  Had the nurse been thinking things through and not reacting several things should have gone through her mind.  First, the ventricular ectopy in the form of multiple PVCs and a single run of VT was caused by two different things, the hypokalemia – the patient was 3.6 on the AM labs and the fact that the cardiologist has just been poking and prodding and electrified piece of wire inside this dude’s right ventricle.  Or in other words they had been pissing it off.  Second, she already was correcting the hypokalemia with the running rider and if she really wanted a magnesium level, a quick add to blood still in lab would have sufficed.  Third, she needed to look at the patient.  Vitals OK?  Feeling OK?  No chest pain or discomfort?  Yes, yes and no were the answers.  Simple isn’t it?

I think why this got under my skin so badly was that the nurses isn’t exactly new.  She’s been a nurse far longer than I and has been in cardiology for nearly the entire time:  she should know better.  But it seems that my day shift has been functioning in the fight or flight mode for so long that any little issue, real or imagined, gets turned into a full-scale shit storm.  It’s like when the LOLs with delirium are extra hyper-alert that the slightest thing sets them off.  So it is with the day shift.  They forget to think.  Unfortunately many nurses are in the same boat, we’re running scared and rile ourselves up faster to make sure Bad Things© don’t happen.  So stop, think, then act.

As for the pacer dude, well, things worked out just fine.  All that drama for nothing.

hmmm…drama for nothing and chest pain free… h/t Dire Straits

Time For a New Hobby?

Middle-aged guy comes in complaining of chest pain.

He had been sitting down to a nice recuperative meal after running a leg in a relay race.  ED work-up reveals elevated troponin and some signs of mild dehydration and thus is admitted for monitoring overnight.

When he gets to the floor he tells us that he actually started to have chest pain while he was running, but at the end of his leg, it went away.  Usual suspects:  male, age in 50’s, ex-smoker, overweight – check to all of them.  Then he drops the bomb:  he’s had a stent before.  After he had “mild” heart attack 5 years ago across the country.  And what was he doing then?  Running a half-marathon!

Having flash-backs to Jim Fixx as we’re hanging Integrillin and heparin.  He goes to the cath lab and we go home.

I just wish I could have shared a word of advice:  maybe running isn’t your thing!

(Un)expected Reasons For an ICD

A recent post from Dr. Wes, News You Can Use: Sex and Your Defibrillator, reminded me about a patient I had taken care of in the recent past.

He was relatively young but suffering from dilated cardiomyopathy.  He had been admitted after a successful VT ablation and ICD placement and was recuperating overnight on our floor to ensure that the interventions had been successful.  As I got report the nurse gossiped to me that she had been told that he had passed out during sex and ultimately ended up getting the ablation and ICD.  But the off-going nurse didn’t have all the details. I had to find out.  How do you get from passing out to ablation and ICD?  Besides the obvious?  (here’s the ACC/AHA Guidelines for reference)

So as I was doing my initial assessment I asked, “What caused you to get to this point?”  I figure, give the ability to obfuscate and deny, or come clean.

“Well, you probably heard rumors from the other nurses, so I should start from the top…” he said and told me the colorful story.

He had been dealing with effects of the cardiomyopathy for some time and it was cramping his, er, style.  So he decided one evening to buy some herbal marijuana analogue and take it with his wife and see what happened.  In the middle of he act, he passed out cold.  Unresponsive for a good 20 seconds.  Scared the Hell out of his wife, he said.  She freaked out, called EMS who took him to the ED for treatment.

That started the cascade of events which the end was him getting ablated and an ICD placed.  He looked up at me and said, “A guy’s gotta’ do what he needs?  Right?  The doc doesn’t know if it was the K2 or the underlying issue I already had with my heart.  So he decided to fix it.  Now I’m good to go!”

We both got a good chuckle out of it, but it turned serious when he asked about restrictions.  Gave him the usual spiel and pointedly asked him to talk to his EP doc about it.  Just to be safe.

“Now I just have to convince my wife that it’s OK to have sex again.  I scared her too bad and she’s a little hesitant now.” he said to end.

“Just be careful,” was all I could tell him.  And, “No, I won’t tell her!”

So often we get guys who are asking when they can resume relations after heart attacks, stents, pacemakers and even after open heart surgery.  I guess certain priorities take precedence in life!

How to Scare a Tele Nurse

Or, “oh shit!  That VT isn’t stopping!”

I’m walking into the nurses station the other night when I hear the “oh shit!” alarm ringing in the tele cave.  Y’know the one, that incessant, high-pitched dinging that is saying “Pay attention!”  Reflexes trained by my years on a tele floor I look up expecting to see someone bradying down, or maybe some nasty artifact, but instead I see this starting – and it’s not stopping!

Do I…
A.) Start screaming like a little teeny-bopper freaking out and run in circles?
B.) Shit my pants?
C.) Drop what I’m doing and high-tail it to the room in question?

Believe it or not, C is the correct answer.  Sphincter slams shut as I haul ass down the hall.  I bust in the room expecting to find a dude laying there, unresponsive, not breathing or generally not doing well.  Instead I see dude and his nurse clamly chatting.  I breathlessly ask, “Were you shaking the leads?”

“No” she replies, “What’s up?

Dude looks up and says, “Is my heart racing again?”

“Uh, yeah, he’s in VT.”  I say, amazed that he’s sitting there calmly chatting.  “Do you feel funny or anything?”

“Yeah, my heart feels like it’s going pretty fast.  But I’m used to it, it’s happened many times before, no big thing.” he replies nonchalantly, basically amused with the gaping look on my face.

So we hook him up to the bedside monitor, and sure enough, there it is VT, rate in the 150’s, BP is 100/53, he’s pink (ok, kind of yellow), warm and dry.  No light-headedness, no dizziness, he does admit to a little bit of chest pain, but in reality he’s in better shape that half the floor, except that he’s in this particular rhythm.

Prehospital 12-Lead ECG has a great quote on their wide complex tachycardia page, “If it’s a wide complex rhythm (fast or slow) it’s ventricular until proven otherwise!”  And that’s how we were treating it.  So we grab some labs, call the ICU team to come assess him and a 12-lead EKG.  Should we have called a Rapid Response?  Maybe, but we felt we didn’t have to.  He was stable.  He has had this many times before.  And he was sitting there cracking jokes with us.

So here’s the 12-lead:

So what to do now?  The ACLS algorithm for tachycardia with pulses starts with determining if the patient is stable.  Check.  He’s cool.  Establish IV access.  PICC line left upper arm.  Check.  Wide or Narrow complex?  Duh.  Obtain 12-Lead EKG.  Check.  Expert consultation advised.  Check, ICU team is here now.  Amiodarone if ventricular tachycardia or unknown, adenosine if SVT with abberancy.  Oh, wait…he has a history of WPW and 3 failed ablations.  Now what?

This is where expert consultation is really a good idea.  In our case, he’s now cracking jokes with the ICU team as well.  He’s still rolling along between 145-160 BPM.  We grab some labs.  Turns out his potassium sucked, magnesium sucked and his calcium critically sucked.  The Team decides that amiodarone would be a good idea and getting his electrolytes sorted out might help as well.  So we’re hanging amio, mag and they’re calling cardiology.  Mind you this is 2130 on a Friday night.  Do you think a cardiologist is going to come in at that hour?  Nope.  She says, “Oh, just have one of the ED docs cardiovert him and call it good.”

He gets packaged and ready to roll to the ICU, ’cause by this time he was pretty much a 1:1 and the nurse had 3 other patients she was already neglecting.  Grab the defib off the code cart, because with our combined luck (this nurse and I have a history of codes/RRTs) dude will decide to stop having a pulse once we’re between floors in the elevator.

The rest is rather boring.  A little bolus of propofol (yeah, we MJ’d him good!) and the judicious application of 100 joules of DC electricity fixed him right good.  One shock and back into sinus.  But it was a good thing he was in the Unit as they spent all night getting his ‘lytes repleted.

What could have been a very bad thing ended up being a very, well, fun thing.  Too often on our floor a busy night consists of incontinence, wrangling demented patients back into bed 30 times an hour or chasing naked psych patients down the hall, so dealing with a true cardiac issue was a rather refreshing change of pace.

Stupid Patient Tricks

I heard about this from a friend of mine.

Dood comes in to the ED with chest pain.  Prior history of cardiac issues including prior stenting.  And a raging drug habit.  Dood gets the million dollar workup showing he’s probably got some new issues with his coronary vasculature and ends up taking a trip to the cath lab.  Lone behold there’s a new blockage and he gets a shiny new stent to fix him up right good.  But here’s where the fun begins.

Claiming he’s having a “reaction” to the Versed he becomes a raging asshole and as soon as the nurse steps out of the room to get supplies he bolts.  With an arterial sheath still in place!

Many times the cath lab sends the patients out to the floor so the sheaths can be pulled on the floor thereby increasing throughput or something like that.  An arterial sheath is a large bore introducer that is used to gain access (in many cath lab cases) to the femoral artery so that diagnostic and interventional catheters can be passed up the femoral into the aorta and then the coronary arteries.

So dood is on the loose outside our facility with a 2-3mm hole in his femoral artery plugged with the introducer which really isn’t built for a whole lot of movement.  If that was to come out, there might be issues…  Security is called, who then call the local PD to find this guy.  They find him (I’m guessing it was at our local watering hole…) and bring him back to the ED where the sheath is pulled.  But the ED docs want him monitored for  any complications post-pull.  Y’know, like bleeding, hematoma, occlusion of the artery.  Minor things.  But dood is still a raging asshole and demands to leave.  And for once, the docs see that to keep him around will only cause issues, they cowboy up and let him roll.  You still have to shake your head and wonder what was so important to get up just after having a stent placed, with a large hole in your femoral artery to decide you wanted out.  Guess we’re adding Versed as an allergy for dood now!

Just because you’re smart

Doesn’t mean you get to be a dick.  Case in point happened the other night.

My friend and co-worker pages the on-call doc and when he calls, the following conversation ensues:

Nurse: Yes, I’m calling about Mr. Jones, a 55 y/o male admitted today with hypertensive urgency related to changes in medication to his intra-thecal pain pump..

On-call Doc: interupting His what? already pissed off

Nurse: Intra-thecal pain pump.  They’ve been tweaking his clonidine dosing.  His blood pressures have been running anywhere from 200s over 110’s to 180’s over 90’s.  Right now, after 200mg of Toprol XL he’s still at 188/105.  He has a history of a AAA repair less than a year ago and I’m a little uncomfortable having him run so high.  All the Toprol did was drop his heart rate.  He’s also been having episodes of chest pressure that’s been relieved…

On-call Doc:  You’re uncomfortable?  I’m OK with that pressure.

Nurse:  Even with the AAA repair and his increasing episodes of chest pressure?

On-call Doc: smugly Well it sounds like we need to modulate his angiotensin system then.  Do you know what drugs do that?

Nurse:  Isn’t that your job?  It’s why I’m calling you…

On-call Doc: breaking in again It’s enalapril.  Do you need me to spell it for you? A-N-A-L-I-P-R-I-L. nurse repeats aloud 10mg, PO BID, 1st dose now.  Good night.  hangs up

Nurse: to me Don’t you mean E-N-A-L-A-P-R-I-L?  Dumbass.  Too bad he hung up.  That was fun, maybe he could have been a litle more condescening…

Ahhh, smug docs.  Always a favorite.  Especially when they do or say something truly stupid.

Hmm… patient got analipril (snerk), his pressure went down and his chest pressure magically went away.  I love it when you note you’re uncomfortable with a patient’s assessment/orders and the doc says, “I’m not.”  All I can ever think about, but never say is, “Of course you’re OK with that.  You’re not here to deal with it when they go south.”  But I guess when you’re “smart”…

Yikes!

Sphincter-Clenching Case

via ER stories.  It’s pretty damn awesome.

I seem to forget that many times when you have an inferior infarct, odds are pretty good that there is RV involvement.  I remember having an intern literally babysit a patient on the floor one night because she though he was having a RV infarct and was kind of freaked out about it.  She just hung out at the nurses station for hours waiting for the shit to hit the fan, but it never did.  If I remember right, we did a right-sided EKG and it was benign as well.

What bugs me is that during our unit education/skills validation sessions, it’s all LV infarcts.  Which of course means that using nitro is pounded into our heads, but no one stops to ask, “What about RV involvement?”  Sure, it is relatively rare, but it is something that we need to know about.  Granted, LV infarcts are far more common and we need to know how to treat them (at least to keep them alive until they can get cathed…), but I wish the educators would look a little deeper.

Evolution

We don’t often get to see evolving MIs.  Usually they go to cath lab and the ICU so serial EKGs are not available.  In this case, intervention had already been attempted but due to the nature and type of lesion no intervention was possible.  In a case such as this, surgical revascuarlization was the primary modality, but due to multiple co-morbid conditions including age, severe aortic stenosis (valve area in range of 0.55 cm²) and general deconditioning none of our surgeons would touch them.  Notice the subtle changes especially through the precordials.

20:00, Day 1

So, what do we see? First, Q-waves in leads V1, V2 and V3.  Second, ST-elevation in V1 and V2.  Third, ST-depression in V4 (slight), V5, V6 and flipped T-waves in Leads I and aVL.  Also present is probable left atrial enlargement and  Left Axis Deviation with an axis of around -30°.  Based on this you could theorize that the LAD and Circumflex arteries have some sort of lesion.  The patient is actually hemodynamically stable at the moment.  Previous to this, they had been in atrial flutter with a rate of 110-130’s with some instability.  The cardiologist who was on the floor at the time decided to cardiovert the patient, but as we were prepping to do so they spontaneously converted back to sinus rhythm.  Teetering on the knife edge of stability they enjoyed a nice nap thanks to the Versed we had pushed while prepping for the cardioversion.  It was a reminder to follow the checklist, including ensuring that the patient is still in the rhythm you’re going to shock them out of prior to giving drugs and shocking.  The cardiologist in the last rhythm  check notices that it looks different and at that very moment the tele tech comes running in saying, “They’re in sinus!  They’re back in sinus!”

Next, 24:00 Day 1, patient c/o 5/10 substernal chest pain.

Nothing too different, although you could say that there is a slight elevation in V3.  The other leads actually look a little better, especially the lateral leads.  No change to axis.  This was after one SL nitro though, so that dilation may have helped, one reason we try to get a 12-Lead prior to giving nitro.

06:00, Day 2

Now there appears to be ST-elevation in V3.  The lateral leads have calmed down, with just a touch of depression in V5, V6 and I, with flipped T-waves in aVL.

14:00, Day2

Kind of ugly now, eh?  Now we have questionable Q-waves in V1-V4 (there is a pip right before the wave drops), but fairly significant ST-elevation in the precordials.  Depression and inverted T’s in the lateral leads has returned.  Again this was during an episode of chest pain.

Later that night the patient started to decompensate fairly rapidly.  They had a drop in LOC accompanied by a drop in SPO2 to the low 80’s on 15L non-rebreather.  Lungs we very wet, obviously filling with fluid.  The nurse called the on-call cardiologist who ordered 80mg of Lasix IV, in addition to the 60mg given previously during the day that only got an output of 200ml.  Everything was starting to shut down.  We ended up calling a RRT to get a doc at the bedside, if nothing more than to see if there was anything within the patient’s advanced directive to help.

About a week prior to this, the patient had gone to the cath lab in the failed attempt mentioned above.  Angiography show a 99% occlusion of the left main and distal disease in the RCA, LAD and circumflex arteries.  The left main lesion was so bad that they interventionalist was unable to even pass a wire through, which means it was very, very tight.  They minimal blood flow the heart and absolutely no reserve.  With that in mind, the doc on the RRT realized that we could not fix the underlying problem that was causing the distress.  She spoke with the patient’s family who in the end realized that the patient didn’t have much longer, and made the patient comfort care.  They ended up expiring about an hour later.

Looking at these EKGs one could argue that the ST-elevation is actually LVH with a strain pattern. It certainly fits the criteria, especially when considering the patient had endured previous infarctions and had aortic stenosis, but I’m not completely convinced.  I’m no cardiologist, so I’m going with what I know.  But I am open to other suggestions.  It’s a sad case, especially as the family was still saying how they wanted to talk to the surgeon about open heart surgery the morning of Day 2.  Luckily, we were able to use the means available, notably medication, to give some comfort at the end for the patient, even if we couldn’t’ fix what was wrong.

It’s an Infarct

I was taking care of a patient awhile ago, post-angio.  Currently chest pain free, normal sinus, hemodynamically stable, a good outcome.  But then I took a look at the EKG they shot right after his trip to the cath lab.

click to enlarge

So what do we have?  ST-elevation in V1-v4, and flipped T-waves in V5, V6, I and aVL.  Looks nasty, like an anterolateral MI, right?  Maybe some issues with the Left Anterior Descending and Left Circumflex arteries?  Nope.  According to the cath lab report, angiography showed several “hazy” luminal irregularities in the LAD, but nothing stentable.  The patient was kept overnight for aggressive anticoagulation and initiation of statin therapy.

So what’s the deal?  It could be a couple of things.  First, being a taller, young man, this could be a normal variant on his EKG, unfortunately there was no prior EKG to compare it to.  Second, he could have had a vessel spasm causing acute ischemia, but this would be transient and as several EKGs done over a course of several hours showed this same view , it is not a transient phenomenon.  Finally, this could be an example of microemboli showering from a plaque rupture into the distal circulation served by the LAD.

Microembolic showering highlights some contentious issues in coronary artery disease, the issue of the large vessel versus small vessels.  Too often the distal circulation is overlooked in favor of dealing with the larger supply vessels.  We tend to focus on the big pipes, but where the real perfusion happens in the small distal arterioles that supply the myocardium.  One reason is that why can’t adeuately visualize these small vessels.  We can shoot all the dye we want and still see nothing.  This also delves into the scene where the pipes are clear, but the patient is still experiencing chest pain:  the distal portion is not getting enough blood.

Looking at the tracing, one would expect to have either a complete blockage of at least one artery or a subtotal occlusion, not a minimal irregularity.  Whether or not this gent dodged a bullet remains to be seen, but odds are they’ll be back.  Unfortunately.

*UPDATE*  Thanks to great discussion and several well-informed comments I have learned a great deal.  LVH?  Sure thing.  Not too suprising either considering the patient had a long-standing history of hypertension.  A small caveat though:  I’ve only been taught to identify basics on 12-leads, but I am learning.  Things like his help me learn and increase my skills and knowledge, which is why I share these cases for discussion.

Young MIs

How I survived a heart attack at age 43 – CNN.com

Seen it.  Took care of a patient who had their CABG at 49.  Scary.  Sounds like familial hypercholestemia to me.  This blew my mind:

The oddest thing about the angioplasty was that for six hours they told me not to move my foot, and I didn’t know why.

I know whenI’m taking care of post-angio patients, the whole, “you had a large hole in your femoral artery” is the first thing I bring up when doing post-angio instruction.