Here’s an unusual case submitted by Linuss from Confessions of a Baby Medic.
EMS is dispatched for a local nursing home for a seizure.
On arrival, the patient is found awake in bed in no apparent distress. She is able to converse, answers questions appropriately, and doesn’t appear to be post-ictal.
The nurse states she walked in to find the pt shaking for a short time.
The patient denies chest pain or discomfort, denies nausea, denies shortness of breath, denies weakness… denies everything.
Vital signs are assessed.
RR: 20
Pulse: 80 and irregular
BP: 98/68
SpO2: 100 on RA
A 12-lead ECG is captured.
The patient is moved to cot and covered with blankets.
The patient quickly kicks the blankets off. When asked if she’s uncomfortable she replies, “I don’t know”.
Suddenly the patient’s head angles to left, eyes still open, breaths rapidly and shallow at a rate of 40, shakes for about 3 seconds, and after the shaking, mumbles when trying to speak, with slight facial droop, and doesn’t follow commands.
The episode lasts about 20 seconds, she goes back to normal mentation, and the facial droop resolves.
The patient is rolled outside to the ambulance. The patient comments that it’s chilly (ambient temperature is 40F).
Suddenly, the patient stops breathing. She is a DNR.
A change is noted on the monitor and an additional 12-lead ECG is obtained.
A carotid pulse is absent.
What would you do?
At work in a hurry! But I’m going to take a stab and say that with an R Wave progression reversal, incomplete RBBB and just some large amplitude inferior leads we’re seeing a RV strain pattern and she probably threw a PE.
I’d tuck her in, contact the doc/coroner and her family.
Snap judgment but I’m tired, don’t judge me Tom haha
DNR if valid, Nothing to do. Like Mike, unfortunately tuck her in call the family and the coroner.
DNR
Turn off the LP15 it doesn’t matter cause you patients dead and you have a long chart to write.
Nothing. DNR means DNR!!!
Palliative care, she is DNR. We’re going to have to hang around incase she turns around. Looks like an evolving MI.
I would soil myself, then regroup and come up with a better plan.
Well in the mormon stronghold, I mean Utah, our DNR’s are sometimes not a full DNR. We don’t have Do Not Intubate orders, its a part of the DNR but can have a trial of CPR and ACLS drugs. Plus a lot of people don’t remember that when they surrender there power of attorney, they also surrender there previous DNR. Utah folks are pretty special
When in doubt over DNR the best advice to give is contact Medical Command let they have the final say. That is their job and what they are there for.
Sadly, with a DNR we are not going to do any interventions here in VA. Advise the family accordingly.
Yes she is a DNR with no Carotid Pulse. Is she sitting up or flat on the cot? The EKG could be PEA or it could be indeed a heartbeat with just poor perfusion. Whatever one wants to call it, the DNR states things we are not allowed to do but there are still things we can do. The most important is to transport the patient to the ER. Let the ER decide if she has expired. I would rather a person who is believed to be dead, sit up and ask for water, while sitting on a hospital bed rather than my cot.
provide comfort care. Call the family and coroner. May contact med control for advise. If the DNR is in order. Had same case the other day. Patient had a major MI. Was able to get him back and to the cath. lab.
Troy: A patient who has a power of attorney enacted can still make their own decisions provided they have capacity. A power of attorney, in no way, makes the patient’s wishes null and void.
What’s up with the axis? Is the lead placement correct? Agreed with supportive care and take her to the hospital.
Agree with the treatment of comfort measures do to the DNR, but the events leading up to the end result are very Interesting. I saw were someone said a PE, seems like a possibility but with the neurological effects that the pt. Exhibited (shaking, facial droop, mumbling, and AMS) it leads me to believe that maybe the pt. Had a massive stroke, possibly a hemmorhage at or near the brain stem. I think the second EKG is a strain pattern as someone said earlier, purely do to the lack of 02 now that spontaneous resporations have stopped, if anybody else agrees or disagrees with my theroy make another comment this particular case really interests me and I’m a younger newer medic and I like to learn from things like this.u
open the airway, contact med control and transport. she is already on the cot. something is definately fishy. still in class.
I would do nothing; a DNR is a DNR!
Well, definately interesting.
Firstly, lay the pt supine, reassess LOC listen for heart sounds. If no mechanical output wait to print a strip of asystole etc.
If there is output or increase LOC transport/treat accordingly. Read the DNR – our DNRs are all different with caveats depending on pt preference. For example it may say no CPR but may allow shocks. Specifically for this pt it may allow ventilations/airway adjuncts. Definately not black and white over here.
Provisional Dx haemmorhagic stroke. I think the second 12 lead ST changes probably due to hypoxia.
No specific changes for PE there (S1Q3T3) – just to rule that one out.
Just a quick thought, nickinbrisbane — I don’t know if there’s a PE here, but the S1Q3T3 is not a very sensitive finding at all (under 50% I believe), so I’d never say that its absence rules anything out. As far as I’m aware, in fact, nothing on the ECG is especially predictive for PE, so it’s always just got to lurk around as a clinical suspicion… such a drag…
I would be more apt to think towards a proximal occlusion of the RAD with extensive MI. PE makes sense but the seizure and symptoms could all be related to the hypoxia and instantaneous drop in the pressue do to the drop in the preload as she just had a widow maker MI.
The fact that she has no pulse changes us to thinking PEA but this by all definintions indicates an acute MI involving Right Side of heart and has extension due to ST segment in v leads. If this was a patient that was workable (not DNR) determining the cause I would get a right sided V4R and see how involved the R Coronary artery is and if there diagnostically give a bolus of 500 cc to see if we would get presure back. I have seen way to many MI patients present with cerebral signs (Stroke like) as seen here that were simply hypoxia due to loss of stroke volume due to prime on the pump in this case. Very interesting EKG….
I would think that it is possible that there could be hemorrhaging in the brain, causing fluid loss witch would lead to hypoxia to the heart muscle, and also making the preload problem worse; however, I would lean towards the fact that the lady was having an MI that caused hypoxia to the brain. The last episode that the patient had may have been an acute full acclusion of the left main, causing major hypoxia and muscle necrosis. If i saw the paper work for the DNR, I would call medical control to let them know the situation and call it.
i think there is some info missing here…
so, a carotid is absent WITH this ECG??
if not, and the ECG changed to a flat-line
then,
Why is this such a “strange” situation?? the pt is 91 y/o (first off) the article does not state ANYTHING about her PMHx, in some rare conditions, so i have read, i believe a stroke (some TIA’s and full CVA’s) can actually cause some seizure-like activity, the pt may have just “stroked-out” and died…and since the pt is a DNR, and as long as it is present and valid, then follow your local protocols…what is the issue here, and again, why is it such a “strange” situation?? (not to mention it looks like your ECG was all over the place (note the acute MI suspected) furthermore, explaining how a 91 y/o pt’s body might not have been able to handle everything going on.
would it be a “strange” situation if somebody that had a cardiac hx ended up just falling unconscious and becoming “flat-lined”? and if this cardiac Pt had a DNR, what would you do??
Lots of paperwork.
Im going with the dx posted above – haemorrhagic CVA. The 12 shows perfect ST elevation for both inferior and anterior MI, so either she has thrown off multiple clots at once to occlude a large proportion of her coronary arteries – seems unlikely in this context, or she experiencing wide spread ischaemia and infarction due to hypoxia – due to brain stem bleed. Fits with the reported symptoms of convulsion and CVA style facial droop etc. All academic however because as long as the DNR is valid there is nothing to be done.
Under the law of our state, if a medical person treats a person who is DNR, there is no accrual of liability.
This reminds me of a patient that I saw back in 1983, mid-50′s, experienced severe chest pain while cutting grass, came in lay down on his bed and become unreponsive. Upon our arrival he had wide ventricular complexes at a rate of 25 and no palpable pulses, no responses. Well, naturally you’re going to work this one but when I dug around the neck to confirm that I hadn’t missed a pulse, he moaned… I still didn’t feel the pulse which at a rate of 25, won’t surprise any of you.
So for this patient, if the DNR states “no CPR” then no CPR it is but I’d lie her flat, contact medical control and see what they say to do in this case. The “not breathing” is more at issue to me here than the “no pulse.” No detectible pulse is one thing – doesn’t mean there’s not some level of circulation. The “not breathing,” she’s 91, deterioriated to the point that a DNR has been signed, and she’s in a nursing home – what are we trying to do here?
Well, the first question I would ask would be “Where am I?” I’ve heard from lots of different people around the country that the term DNR means many different things.
Here in Massachusetts, its pretty self explanatory. No intubation, no CPR, and nothing that would be deemed as a “heroic measure” which does leave some room for thought.. As long as you have the patient’s valid Comfort Care DNR paperwork or they are wearing a DNR bracelet, you should not start CPR.
Now, what would I do in the situation personally?
1. I’d load my patient up and start transporting, as she might “turn around” at this point I doubt its going to happen, but hey you never know.
2. Check for heart tones for a good 30 seconds with my scope.
3. If they’re absent, I’d assume at that point that the patient had expired.
Am I being rather simplistic? Yes. But I’d rather be thorough and not wheel the patient back into the NH only to find that my pulse check was inadequate.
I really see no need to contact medical control in this instance. A DNR is a DNR.
i wonder if she was having pericarditis giving the elevation in all leads??? seizure from possible infection that went on to long? who knows. just know that she is dead now and a DNR is a DNR. call corner
how about pericarditis???
disregard last post didnt realize the depression on some leads. but ya dead is dead.
don’t think i’d want to interfere with god’s plan.
Bow Hunter’s Syndrome?
Wide complex beats like that at exactly 80 BPM…
I’ll be she has a pacemaker that’s generating enough electrical activity to show the rhythm, but the pacemaker didn’t capture before she expired. Ring magnet should suspend the pacing beats long enough to assess the underlying rhythm if I’m right…
From the patient’s presentation, I would agree with the working diagnosis of CVA. The changes on the EKG are secondary to the CVA.
Dependant on the DNR, I would contact Medical control for consult and act accordingly.
Any update on this one? Who gets the cookie?
Listen to lung sounds and heart tones…confirm their absence.
Contact medical control
Wish her well on her journey
Return her to bed in SNF
well depends on what type of DNR order… I know in ct when dnr’s are present ushually its now on the persons wrist or ankle. but if you are truly in doubt and its not clearly on the wall or on an wrist band begin compressions and contact the doc’s for verification. if they give you the go ahead disscontinute compressions and let nature perverbiably take its course… remember we are hear to do no harm or in absence of that to cause no further pain or suffering. and as far as the law gose the docs allways have final say. just remember to document document document!!!!