Chest Pain/Dyspnea Case 1

Obese 39yof, presenting with chest pain and shortness of breath for 6 hours.

HR/Rhythm: sinus tach 122 BP: 100/62 RR: 32 SpO2: 85% --> 94% on NRB 15Lpm T: 37 Glucose: 100 Weight: 100kg

Critical actions: Obtain full set of VS including temp, glucose and WEIGHT (patient may need weight based medications e.g. heparin drip) place patient on monitor set BP cuff to cycle q3 mins establish 2 large bore IVs move to resus bay if available

HPI: pain is constant, severe, sharp, R sided, nonradiating, worsens with inspiration. Feels very short of breath. Recently returned from flight to Japan. No recent surgeries, no h/o clots, no h/o cancer. No family hx of clots. No hemoptysis PMH: HTN, DM, smoker 1ppd, takes OCPs

Physical Exam: Gen: appears tachypneic and in pain Lungs: clear CV: tachy but otherwise unremarkable Abd: unremarkable Ext: pulses equal. BLE 1+ edema, RLE tenderness in the popliteal fossa. (WYD) [Ultrasound images]

Critical Actions: obtain pertinent history, perform physical exam with attention paid to lungs for MS4s/Interns: discuss Wells criteria and when to use wells and PERC Perform BSUS of heart, lungs and RLE (DVT) obtain EKG order CXR but verbalize to not wait for CXR before proceeding to CT order CT PE study start heparin drip based on U/S, if not already started empirically order labs: CBC, BMP, Troponin, BNP, VBG notify pharmacy of potential need for tPA Discuss reasoning for ordering the BNP (assess for R heart strain) and troponin (assess for heart strain and severity of PE) Discuss PESI score and the anticoagulation regimens - heparin drip vs enoxaparin vs tPA Discuss accuracy of POC US for PE

CT says there's two traumas that are already in line for the scanner While awaiting CT, patient goes into AF RVR rate 170s, BP drops to 86/40 [sedate and cardiovert, ineffective until cardioverting at 200J ] BP improves to 98/60   [echo ultrasound images] [LE compression ultrasound images]

Critical actions: recognize need for electrical cardioversion recognize the potential need to infuse tPA if BP does not improve after cardioversion should have pharmacist prepare the tPA and have it ready to go if need be discuss sedation regimens for cardioversion (see below, reference: mostly uptodate) methohexital IV: dose: 0.75-1.5mg/kg (according to retrospective review of sedation in ED, avg dose 1.4mg/kg) onset: immediate duration: 5-15 mins etomidate IV: dose: 0.15-0.3 mg/kg onset: 30-60s duration: 2-15 mins metabolism: 76% protein bound, primarily hepatic metabolism ketamine IV: dose: 1-2 mg/kg onset: 30-60s duration: anesthetic effect 5-10mins, full recovery 1-2 hours midazolam IV: dose: 0.5mg-2mg initial dose then additional doses q2-3min. Usual required dose 2.5-5mg onset: 3-5 min duration: 1-2 hours (dose dependent) Discuss PESI score and the anticoagulation regimens - heparin drip vs enoxaparin vs tPA Discuss accuracy of POC US for PE

If intern: patient codes in the ED prior to going to CT scanner If senior resident: You go with the patient to CT scan, as the patient is on the table in the scanner, you see the monitor go into VT. Critical actions in the following order: start CPR and direct someone to place CPR board on stretcher connect pads to defibrillator and charge defibrillator place pads on patient pulse and rhythm check [pulseless VT] deliver shock pull patient onto stretcher with CPR board ??turn heparin drip off so tPA can be given?? resume compressions return to ED with patient and compressions ongoing delegate someone to charge the defibrillator at 1:50

Once returned to ED it has been approx 2 minutes. Critical actions in the following order: charge defibrillator at 1:50 pulse and rhythm check [pulseless 3rd degree heart block] resume CPR and disarm defibrillator push 1mg  epinephrine hang tPA [discuss tPA dosing and continuing compressions for several minutes even if ROSC achieved] _____ does tPA need to be delivered through CVC? intubate patient place femoral arterial line [link to art line video]

approaching the next 2 minute mark.  charge defibrillator at 1:50 pulse and rhythm check [sinus tach 128 with a pulse] evaluate BP [60/38] start norepinephrine drip @10mcg/min (can titrate up or down as needed) evaluate mental status [localizes to pain but does not follow commands] put on ventilator and start fentanyl drip for analgesia start post-arrest care (does not have to be in order): elevate head of bed to prevent vent associated pneumonia obtain CXR to confirm tube placement obtain repeat EKG place NGT initiate hospital's hypothermia protocol admit to ICU  

For bonus points: if patient were to be refractory to the norepinephrine, what would you do? max norepi, start vaso, start epi drip how do you make a dirty epinephrine drip? inject 1mg of the 0.1mg/mL (code) epinephrine into 1L bag of NS to give 1mcg/mL concentration of epinephrine If patient remained profoundly hypotensive despite multiple pressors and there was still evidence of R heart strain on POCUS, what would you do? start VA ECMO and have patient go for either catheter directed lysis or thrombectomy depending on the preference of the surgeon/IR team

Pulmonary Embolism Management References/Resources: