Peaked T-Waves

What is this?

Go to Medscape and find out. This is a good learning experience.

A 70 yo woman came to the ER. She had chest pain. VS 97.3-42-14-162/96. SpO2 was 92% on room air. She was in no acute distress. The pain was along her left mid-clavicular line at the 5th ICS. She described the pain as strong (10/10), radiating through the back, and had the sensation of "an elephant" on her chest. Her EKG was unremarkable (other than the bradycardia). O2 was started at 2L/min nasal cannula. An IV was started, lab was drawn, and fentanyl 75mcg was given. Her past med hx included pancreatitis,hypertension, MI, 9 (yes nine) cardiac stents, and 1 pancreatic stent. Her meds included metoprolol 100mg, clonidine 0.1 mg, plavix 75 mg, and norvasc 5 mg, lisinopril 25 mg, ranitidine 150mg, crestor 10 mg, lexapro 20 mg, and diclyclomine 10 mg.

Her troponin was 0.01, CBC was hgb 12.2, hct 37.4. Na+ was 137, K+ was 3.9, BUN 22 Cr 1.1. Amylase and lipase were normal.

The fentanyl gave only short acting relief, so a nitro drip was started at 10 mcg, and she was admitted to ICU.

When I saw her the pain was gone, she was comfortable and in no distress. Her VS were OK except her blood pressure was 91/48. I took the nitro down to 5 mcg and waited one hour. BP at that time was 99/52. She was pain free, so I stopped the nitro. Her MD showed up shortly thereafter, increased her blood pressure meds notibly her clonidine went from 0.1 mg to 0.3 mg. He planned to send her home later that afternoon after I monitored her, ambulated her, and gave the increased dose of antihypertensives. He felt the pain was due to the elevated BP putting stress on her heart.

A couple hours after giving the Clonidine 0.3 mg, I noted her BP to be 79/48, no chest pain, no c/o except feeling tired. Well, I monitored her, got her to the chair (I didn't want to ambulate her with her SBP's in the 70's and 80's). Her pain had came back. I gave her 25 mcg of fentanyl, then another 25, then another 25 before there was any relief. I was afraid to give the whole dose of fentanyl, because I didn't know what would happen to her BP. Then I called her doc back with my assessment.

He decided to keep her overnight. Her 2D echocardiogram report came back (at the top of this post). Well, an ejection fraction of 8% and the internist measuring found it to be 20%. Because of this, the weakness, and continual low BP, he elected, and she agreed to be transported to her cardiologist.

Note the chest wall action in the report. I hope all goes well.

Sinusitis into sepsis

It's been awhile since I posted, but most of what has come through was pretty routine: high risk surgeries, trouble extubating after surgery, Over doses, electrolytes imbalances, etc.

This case, however, was a little different. This patient had a sinus infection under treatment by her physician for over one week. Her relatives found her on the floor, unconscious, and laying in vomit. They brought her to the hospital. VS were 97.0-130-28-40/0. She had cyanotic extremities. O2 was started at 15+L/min on nonrebreather mask. The first ABG's and CMP are shown. An art line was started with difficulty. She was bolused with 3L of NS and brought to ICU. The morning came, she was put on nasal cannula after her first gases. She was awake, warm and dry, pain free, no resp distress. Pretty remarkable after only a few hours. Her morning CBC and ABGs are shown. Her antibiotic was changed to clindamycin. She was stable enough to be moved out to the floor.

Ringo

This is Ringo. I named him that because of his accident. He is a mixed breed, young rooster from our flock. We had a broody hen that we allowed outside the chicken coup. She had a wire cage over her plus other armament, but one night a coon dug under everything, killed the hen, a keet, and stripped the skin off all around Ringo's neck.

The poor guy had no skin or feathers around his neck, but he was alive, so in the house he came. He wanted to eat and drink, so, OK, we'll give him a chance. Triple antibiotic, food, and water.

Well, he had done pretty well as you can see. The hole in his neck is healing nicely and scar tissue is growing well. He spends the day on his perch (a cardboard box with newspaper), and the night in a box with cross-hatched cover (for plenty of air) at night. If we are not in the room, he calls out to us.

I told my wife, "Maybe we could liter train him and keep him inside." Well, I'm sure you know what she thought of that plan. "Won't it be cool to have an chicken inside for a pet; visitors would love him." Well, I'm sure you know what she thought of that as well.

Well, Ringo, another week or so and back to the flock you go.

I'm sure by now most have seen and/or heard the comments made by James Fagan, Democratic Massachusetts State Representative, concerning "Jessica's Law" legislation.

I wrote him an e-mail:

I read your comments and saw the Fox video on your comments about Jessica's law.

You said, "And I'm [going to] rip them apart. I'm [going to] make sure that the rest of their life is ruined -- that when they're eight years old, they throw up; when their 12 years old, they won't sleep; when they're 19 years old, they'll have nightmares. And they'll never have a relationship with anybody."

You want to "ruin their life"?

You should be ashamed of yourself. I can't believe you want to ruin the lives of these children.

I'm a RN and have been in nursing for 33 years. I have seen children whose lives have been ruined by physical abuse, verbal abuse, and emotional abuse. These are the very abuses you plan to do?

Here's the video:

A great site for anatomy

If you want a easy start on radiological anatomy, I think you'll like this site. It has drawings, images of the body in cross-section, and CT images. The images are labeled so you can relate what you're seeing to what it is. Next time you look at some CT scans you'll know what you're looking at. This is in pdf format.

Boi

If you want to read a remarkable story about a little boy with a big problem, read here about Boi. I heard it from one of the nurses that took care of him.

Well, what have we here?

Things have been busy in the ICU but nothing out of the ordinary.

I feel truly sorry for an older patient in the ICU the other day. This person was another nurse's patient, but I started the IV. Even though the patient was very old, he/she was as sharp as a tack. I don't know what his/her H & H was, but he/she was white as a ghost. The patient had a number of bruises on each arm and some petechiae. I asked about it, and the patient said, "Oh, don't worry about it honey; I have lots of those, and they've been around a long time." I started the IV with no problem. This was about 1815, so I didn't know what happened until the next day.

The night RN gave the first unit of blood and sent her LPN to get the next unit. When the LPN returned the RN said, "You need to take it back." The LPN was confused but found out the patient died. Turned out the platelets were only 10,000 mm3. If the patient only had gone to the physician a little earlier.

On Wednesday, I was trying to finish my assessments and help my GN as well (We had 4 patients). A little after 7 one of the LPN's on the Med/Surg floor came back and said, "We are moving a patient back for respiratory failure. His heart rate is 130 to 140, his RR is 40, and I can barely wake him." During the night shift the resp therapist had tried to get the agency nurse to call the doc, but he didn't.

So here they come. This patient was pale, would barely arouse for me with hard stimulation. The AP was 130 to 140, RR 40. Warm and clammy with red cyanosis of the extremities, thready pulse, the whole works. The monitor showed sinus tachy. SPo2 was 85% ( on bipap). SBP was 100's (I can't remember for sure now what the exact VS were). I put the patient in high fowler's position, the resp therapist started bipap at 19/6 and 70% O2. The patient settled down a little except for the heart rate and RR. Breath sounds remained very diminished.

The doctor came and decided to intubate, since the patient was wearing out (no lie). Resp therapist got the vent, I got everything else. The doc had trouble getting the ET tube, so the ER doc did.

There was a big clot partly obstructing the airway. He suctioned that out and was successful.

Vent was set at AC/Vt 800/70%/RR 12/Peep 5. The patient settled down even more. I had to give a lot of drugs to relax the patient. If I remember right I gave a total of 10 mg of Versed, 200 mcg of Fentanyl, 100 mg of Sux. I started the propofol with a 10 ml push and the drip at 35 mcg. That didn't hold at all. I eventually increased it to 65 mcg to keep the patient at a Ramsey's scale of 4. Whew!

Then we found out the patient was a Do Not Resuscitate. The patient didn't code, just had bad pneumonia, and we couldn't just let the patient die. Well, now what. There was no kin that anybody knew of.

We found a written DNR that was only for "Outside the hospital", so we were covered other than the night MD had written a DNR.

Thursday I tapered off the propofol for the trials (no order but that is what we do). When the patient was awake (about 10 minutes later), the Resp Therapist started Cpap to see if the patient could make it on his own (with 15 Peep for pressure support). His doc came in and asked him about the ET tube, "No, I don't want it. Take it out," the patient wrote. But then, "I want to live." Well, this went back and forth for at least 30 minutes. (I couldn't anything else done or help my GN (I'm responsible for her, you know), so another RN from Med/Surg came back to help her). Finally, the ER doc who had put in the ET tube wrote: "Do you want the tube out" and wrote "yes" and "no". "Circle which you want." The patient circled the "Yes". So, I get ready to call the resp therapist to get the tube out, but before I left (the ER doc had already left the room), the patient's doc asked one more time, "Do you want to live?" The patient nodded a "yes" vigorously. So I got an order to sedate and maintain the Ramsey scale at 4, so I bolused the patient with 10 ml of propofol, and the patient was out in seconds.

Meanwhile because of all the confusion, the CNO (used to be called Director of Nurses, but now Chief Nursing Officer) and our risk management RN came over to sort things out. She got on the phone and made lots of phone calls. The risk management RN finally found a relative who lived in town no less. This relavtive would visit weekly, agreed to come in, and help us figure out what the patient really wanted.

On the relative's arrival, I turned off the propofol, and 10 minutes, or so, the patient was awake. The family talked, the patient wrote, and agreed to leave the ET tube in, continue treatment, and be transferred to the care of a pulmonologist near by.

The patient's XRay is AP projection taken on Wednesday in ICU. Pretty bad, huh? I seen them worse of course, but the patient was getting worse, too. Seeing the XRay, a CT was ordered. I was too busy and couldn't leave my GN anyway, so RT bagged the patient through the CT. The CT pictures are pretty yucky. No wonder the patient was having trouble breathing. When I saw those, I knew why I took a lot of time suctioning blood and pus from the ET tube.

So finally the patient was shipped out to the pulmonologist. I hope the patient makes it.

Busy Day

Busy day! I know that a big city ICU has a lot more than we do, but these cases were interesting.

Patient 1 is a severely retarded person who now receives a tube feeding. Jevity is spit up, vomited, or the patient works to get it up all over herself. We need to get this patient off the TPN. I tried ProSoBee and it stayed down. Weird.

Patient 2 came to us in severe, end stage COPD. Tthe first rhythm strip I thought was a-flutter with 2:1 capture. The MD wanted to start Cardizem per protocol, so I bolused the patient with 20mg just after I started the drip at 5mg/h (5ml/h). No result. I increased it to 10mg/h, no result. I increased it to 15mg/h; the rate dropped to 100 for about 15 seconds and then back to 170-180. I rebolused with 25mg with no result. The SBP was in the 120's so I didn't worry about it and watched the monitor while I went about my other work. After a few hours with no result, I thought I would try Morphine 4mg IV, thinking the patient might be anxious. No result after 30 minutes, so I called the MD who was also watching the rhythm in ER (it was his patient); he said to wait a little longer. Finally, everything worked, and you can see the second rhythm strip.

Patient 3 is a chronic smoker, past CABG, insulin dependent diabetic, etc. Those are the XRays. The patient called EMS stating had a hard time breathing, by the time the patient got to ER the patient was in respiratory failure and needed to be intubated. What do you think was the unlying cause?

The patient was awake when he/she came to us. I used propofol for about 35 minutes but decided the patient was cooperative enough that I stopped it, figuring the patient was ready to be extubated. Respiratory therapist checked up on the patient and stated it would be ok to go on pressure support. The patient did well, but would occassionally have apneic periods up to 20 seconds. The vent alarm would wake the patient up. Because of that respiratory thought it best to keep the patient on the vent until the morning; the patient agreed to the plan.

Today they plan to extubate, but I'm not working. I'm sure they will be successful.

Prosthesis Artist

This shows you what a good practitioner of cosmesis can do.

These are from L. Daniel Eaton, B.C.O., I.M.F.T.
Web Site is http://www.ldanieleaton.com/image_testimonials.htm

The BCO stands for Board Certified Ocularist. I'm not sure what the other stands for.

Here are two write-ups of him.

"Daniel Eaton is currently an assistant clinical professor in the department of surgery at the University of Arkansas for Medical Science. He was previously an assistant professor in the department of Otolaryngology, Head and Neck surgery, UAMS.

He received the “Legends” award for cancer research from the American Cancer Society and the recipient of four medical technology and design awards. Eaton is a board certified ocularist and his education includes undergraduate; Arizona State University, graduate; University of Cincinnati, College of Medicine, Hemlock, MI., (biomaterials) and Sahlgren’s Hospital, Gothenberg, Sweden, where he studied Osseointegration under Professor Ingvar Branemark.

At present he is also in the private practice of alloplastic facial reconstruction and is a research and development consultant for ContourMed, Inc.

Eaton is a member of the National Examining Board of Ocularists, the American Society of Ocularists, and the Institutional Animal Use and Care Committee at UAMS, and is a principal for the National Collaborative Melanoma Study. He is a member of the American Association of Medical Sculptors, the International Academy of Oculofacial Prosthetologists, the Society of Illustrators, the Institute of Maxillofacial Technologies , the American Alloplastic Association and Pi Kappa Alpha.

Eaton earned a master’s degree in medical illustration with a minor in human gross anatomy from the University of Cincinnati College of Medicine. He earned his undergraduate degree from Arizona State University . Eaton has obtained more than 250 hours of post-graduate training in gross anatomy, oculofacial prosthetology, elastomer chemistry and maxillofacial osseointegration."

If you a person needing this type of skill, it is available.

Severe Constipation

This is from the "New England Journal of Medicine".

"A 46-year-old man with a history of cerebral palsy presented with difficulty in breathing, which had gradually increased during the previous 2 weeks. He was admitted to the intensive care unit with a diagnosis of sepsis, for which he received intravenous fluids, antibiotics, and mechanical ventilation. Computed tomography of the abdomen showed a severely distended colon with fecal stasis compressing the abdominal organs and elevating the diaphragm. There were no signs of colonic perforation. After initial conservative measures were unsuccessful in evacuating the impaction, multiple enemas with the use of sodium phosphate and soapsuds finally dislodged the blockage after 2 weeks. The patient's recovery was unremarkable."

I've seen various images of constipation by this beats all. I'm glad there was total recovery.

The link is here: http://content.nejm.org/cgi/content/full/358/22/e26/F1

Sick Patient

Tuesday afternoon I admitted a patient who had fallen at home. The herdmans had found the patient, called EMS, and brought to our ED. The only real complaint was shortness of breath. After a workup and refusal to be transferred to a cardiologist, the patient came to me. The only complaints were shortness of breath and 8/10 pain LUQ midclav line with tenderness to light palpation. Exam showed bibas crackles, HR of ~125, warm face, cool extremities, and abrasion L knee. Rest was normal.

The images show a rhythm strip, 12 lead EKG, and XRay.

What do you think?

Troponin was 1.65. D-Dimer was 0.30 - 0.60.

As the evening wore on urine output went to 10ml/h. RR ~30 and slightly labored. SpO2 was 97% with nonrebreather mask, and pain. Pain was controlled with morphine 2mg IV. I don't expect the patient to last 24 hours.

Welcome To Monday

I was getting report and saw this on the monitor. What do you think? I went and gave adenosine 6 mg with no effect, so I gave 12mg with the result shown in the second image. The patient was asymptomatic.

A wee bit slow

Here is a rhythm strip from a patient who had a lap chole. Some ST changes were noted in surgery so the patient came to ICU. I took care of this patient the next day. Fentanyl drip had been started the day before. The heart rate kept getting slower over the coarse of the day. Until the patient started having pauses as you can see--lots of them, up to 3 a minute. If I count right, it is over 8 seconds long. Totally asymptomatic, so I didn't treat. You can be sure that my atropine was on hand. The internist got worked up, even though I had stopped the Fentanyl drip, and he had her shipped out to a cardiologist. After a few more hours the pauses stopped. I figured it was due to the Fentanyl which is lipophilic. What do you think?

Nausea and Vomiting with dizziness

One of my co-workers took care of a middle woman who's chief complaint was nausea and vomiting with dizziness. She would turn over in bed just a little or waves of nausea would come over her. Zofran only would help for a short time. An MRI was done. Can you see the tumors? The zone of darkness around the tumor is fluid/edema. She was shipped out to a neurosurgeon.

My Saturday and Monday

The ICU was closed for the past few days, so I worked the Med/Surg floor. I took care of a couple of interesting patients (I had a total of 4 patients one day and 5 the next). One patient came with cellulitis. Someone had outlined the redness on the right lower extremity a few days before. The redness was gone except for a hard, hot, red, raised area approximately 10cm square. Over the next 12 hours this grew to be 20cm long and 10cm wide and increasingly tender. An Ultrasound was performed, and it looked like 2cm of fluid under the skin--surgery time! On Sunday (I was gone, strange scheduling) the surgeon did an I & D, packed it with dakin's soaked gauze and dressed it. When I came in Monday, no one had changed the dressing. When I looked at the wound the dressing was dry and hard. It hurt pretty bad when I took it out, but the patient did OK. The next dressing I guided the patient's relative--my hand on that hand to feel the edges of undermining, so the relative wouldn't pack it too tight. The patient thought it would hurt, but it didn't because the dressing was still wet. The family member thought she/he would puke, so this person wanted the trash can close by. The family member did just fine though--even through the sucking sound it makes when you pull out the packing.

Another patient was end stage Parkinson's disease. The family decided to have a PEG tube placed. The patient didn't handle the tube feeding well though. I needed to run it a hour, then shut it off for 20 minutes to keep the residuals under 60ml. That worked well as the patient finally got to the point of 0ml residual. I couldn't get this patient up to the RD's recommended 50ml/hour though. Maybe the GI system will start to handle it better. I've seen the stomach react by going to "sleep" for a few days before starting to handle tube feeding correctly.

Another patient had noticed some dizziness before going to bed. At midnight the patient could hardly make to the bathroom, so called a family member (who was in the medical field) to take to the hospital. My morning assessment on the neuro check showed a 4/5 weakness in the LUE, nothing else. Smile, shrugs, eye brow lift, lower extremity, you name was OK, until I stood the patient up. Wow, what a left lean. It took 2 of us to keep the patient standing. No visual changes, no room spinning, just no balance. I was too busy to look at the MRI/MRA. The CT was clean except for some age related atrophy.

Another nurse had a patient with multiple bruises, no rhabdo. These bruises came from running from two police officers and falling. What the patient was doing, wouldn't say, but there was a warrant out for an arrest. The patient didn't was to go to the pokey, so told the nurse he/she wanted to kill him/herself; OK, a psych consult, and... faking it to get out of jail. To jail this patient went.

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I plan to have medical related material here.