I'm wondering if there would be any interest in a "case study" that would take a patient from presentation and through treatment. There would not be any right/wrong - just an exchange and hopefully an opportunity to improve all of our abilities to critically think and be able to work through patient complaints, history and interpret the data. Also, we can look at treatment - so anyone up for it??
Brief example:
You are working in adult ED triage 74 year old female patient presents ambulatory with minimal assistance to the ED at 1500 c/o fever and feeling bad. Patient has 2 very concerned daughters and this is the 4th ED visit this week - (the other visits were at other ER's - but, the family volunteers that they were idiots working in the other ED's --- so we came here instead). Pt does not appear in acute distress.
Patient is alert but confused. (Family states this is near normal for her).
Vital Signs:
BP 104/64 HR 104 RR 22 SaO2 95% on RA Oral Temp 100.6F
History:
Hypertension
AMI 3 years earlier - placed 2 stents.
GI bleed 5 years ago -required 6 unit transfusion
NIDDM
GERD
Osteo-Arthritis/Chronic Pain
Hysterectomy at age 43
Basal cell carcinoma removed 2 years ago
Medications:
NKDA (does "break out" from adhesive tape)
Lisinopril
Atenolol
Prilosec
Plavix
Baby ASA
Duragesic Patch
Metformin
Now what? How do you proceed? Questions?
Anyone interested in participating in case studies?
Sepsis might be a factor, but it is not the most urgent problem at this time. The patient is in V-tac, that is a life threatening arrhythmia - and must be dealt with.
The most likely cause is hyperkalemia and her renal insufficiency. That must be dealt with first. It will kill her before the sepsis (if she is septic) does.
I made some suggestions how to deal with the vtac and the cause of v-tac in a previous post, I agree, seeing the labs would be a great help.
If she begins to show serious signs/symptoms from the VT, she'll need cardioversion. I would prepare for that.... Meanwhile, I would expect that we would treat her with a IV bolus dose of 150 mg Amiodarone over 10 minutes. I would be very hesitant to treat for suspected hyperkalemia without the evidence to backup any suspicion.
So now what are her labs? Specifically ABG, lytes, and CBC. I agree with the amiodarone so far. Oh and what are her recent VS? Is BP stable, or do we need to caridovert?
Specializes in cardiac, ortho, med surg, oncology.
I think she has metabolic alkalosis from the diarrhea and vomiting. I think her BP is decreased from loss of body fluids. Her temp d/t UTI, slight tachycardia from increased temp, low BP, and probably dehydration. The metabolic alkalosis could cause the arrhythmia. Think she should be getting hydrated with lactated ringers. Treat the cause of the alkalosis and treat the UTI. The vomiting could be cause by the oral potassium. I think the albumin should be checked for nutritional status.
She's not slightly tachycardic, she is in V-tac, a lethal rhythm. I wish we could get some lab results. I agree she is probably dehydrated, but we have potentially conflicting info on her. She has had vomiting and diarrhea, which would lead to hypo-everything incluing hypokalemia. However, her K-lor con Rx was issued a day or two before, and nearly all are gone, so she has been taking to much K+ - so - she could be hypokalemic, or if she ingested all that K+, hyperkalemic.
If we have to treat her, which it looks like we have to do, based upon her symptoms - with her V-tac being the most life threatening at the moment, what do we do?
I'm assuming hyperkalemia, and I vote for amnioderone, insulin and dextrose.
Specializes in cardiac, ortho, med surg, oncology.
Slighty tachy upon admission. Now V-tach. With the vomiting she could still be losing K. Metabolic alkalosis could be causing the V-Tach. Need labs back fast.
I don't disagree, it could go either way. I'm just choosing a coorifice of treatment that we could easily rectify if we were wrong. Amnioderone is indicated either way.
Just wanted to add as a SN, I don't know what the heck most of what you are talking about, but this is like "Dungeons and Dragons" for nurses (Yeah, I went there), fun to watch, and I can't wait to see how this plays out. I think that something like this could be developed into an entity of its own. I am going to roll for the LOL a 1d20 saving throw for Atypical MI...... (very esoteric, sorry). Daytonite/mods must be watching this thread with interest.
I don't disagree, it could go either way. I'm just choosing a coorifice of treatment that we could easily rectify if we were wrong. Amnioderone is indicated either way.
But if there is a chance that the patient is hypokalemic, amiodarone is contraindicated. Any mention of an initial 3 lead strip to help determine the K+ status before the V-tach occurred?
Also, if there is renal failure involved, lidocaine and procainamide dosages have to be adjusted. Until labs come in, I would advocate for cardioversion. It just seems too risky to start with the medication route for stable v-tach on this patient (although I have to admit I have not read through this thread completely).
Your point is well taken. I don't believe the patient is hypokalemic. The OP made a point of letting us know, in the last update, patient had that new Rx for klor-con, and most of it was missing- I know, could have dropped into the toilet, but it was insinuated that patient may have taken it.
Wilth the patient renal failure, which in and of itself can cause hyperkalemia, elevated K+ just seemed the most likely reason for the V-tac. We do have an EKG showing V-tac a page or two back.
Much like PEA, the patient is in V-tac for a reason, if the underlying cause isn't treated, even if cardioversion is done, it probably won't work, or won't last for long. It's not that cardioversion is a bad idea, I just don't think it is the best idea.
Speaking of which, all of us are throwing out ideas. All have validity. Right now, we really need to hear from the OP, it's been a couple of days since we've heard anything. Need those labs.
Your point is well taken. I don't believe the patient is hypokalemic. The OP made a point of letting us know, in the last update, patient had that new Rx for klor-con, and most of it was missing- I know, could have dropped into the toilet, but it was insinuated that patient may have taken it.
Wilth the patient renal failure, which in and of itself can cause hyperkalemia, elevated K+ just seemed the most likely reason for the V-tac. We do have an EKG showing V-tac a page or two back.
Much like PEA, the patient is in V-tac for a reason, if the underlying cause isn't treated, even if cardioversion is done, it probably won't work, or won't last for long. It's not that cardioversion is a bad idea, I just don't think it is the best idea.
Speaking of which, all of us are throwing out ideas. All have validity. Right now, we really need to hear from the OP, it's been a couple of days since we've heard anything. Need those labs.
Blessings
Agreed that the labs are needed. That was the point I was unsuccessfully trying to make was opting for cardioversion until the labs come in. Although, that 12 lead you referred me to does indicate hyperkalemia. A pre v-tach 3 lead would have certainly helped determine the K+. Also, did you notice that on a couple of the leads, there may be torsades? Some hypomagnesemia, too????? Makes sense with what you just told me.
You are absolutely right, labs are needed to procede. Can't justify further treatment on the patient without them. But, some insulin and dextrose while waiting could be justified on more than just inferring the K+ status (a CYA approach). But, I would opt to hold the amiodarone until the labs came in.
Babs0512
846 Posts
Sepsis might be a factor, but it is not the most urgent problem at this time. The patient is in V-tac, that is a life threatening arrhythmia - and must be dealt with.
The most likely cause is hyperkalemia and her renal insufficiency. That must be dealt with first. It will kill her before the sepsis (if she is septic) does.
I made some suggestions how to deal with the vtac and the cause of v-tac in a previous post, I agree, seeing the labs would be a great help.
Blessings