This is a great case sent in my a reader who wishes to remain anonymous. We hope you find it as intriguing as we did!
After clearing up from a routine interfacility transfer, you're dispatched for a 77 year old female who is unresponsive at a local extended care facility. A BLS engine crew is enroute as well and has a few minute lead on your unit.
As you're arriving the engine crew hails you on a tac channel and relays that the patient is unresponsive, but breathing and they have put her on a NRB and are checking her blood glucose level.
You're directed to the room where the engine crew is completing their assessment of the patient. The facility staff states the patient was alert and oriented at 0600 when they did their rounds. However, when they came back at 0900 to give the patient breakfast and her morning medications they found her unresponsive.
Apparently, EMS is called frequently for this patient becoming unresponsive, although she does not know why. She hands you the patient's paperwork as the captain from the engine gives you the patient's vitals:
- GCS: 8 (E2 M2 V4)
- Pulse: 60, weak at the radials
- BP: 118/56
- RR: 16, clear bilateral lung sounds
- SpO2: 82% on room air, 94% on a non-rebreather
- BGL: 102 mg/dL (5.6 mmol/L)
As your partner helps the engine crew move the patient to your stretcher you read over her paperwork:
- PMHx: hypertension, osteoarthritis, renal cysts, urosepsis, advanced parkinson's disease, history of UTIs, dementia, history of plueral effusion, COPD
- Meds: hydrocodone, sorbitol, ferrous sulfate, dulcolak, prednisone, albuterol, ativan, heparin, aspirin, colace, sinemet, synthroid, tylenol, furosemide, potassium chloride, aricept, multi-vitamin, claritin, lactulose
- Allergies: cipro, septra, florinef, bactrim, levaquin, zoloft, gentamicin
A quick physical exam reveals moaning to painful stimuli, pinpoint pupils, whole body tremors, a foley catheter with adequate output amber in color. The remainder of the exam is unremarkable.
In the back of the unit you place the patient on nasal capnography while your partner places the patient on the monitor:
At this point your partner grabs the 12-Lead cable and begins placing electrodes while you acquire an IV.
You're 10 minutes from a local hospital, and 15 minutes from a cardiac center.
- What is our patient's rhythm?
- What does the patient's 12-Lead show?
- What are your treatment priorities?
Leave your answers below!
Looking for the conclusion? 77 year old female: Unresponsive – Discussion.
I have been out of the game a while (back injury in 08) so I'm a bit rusty. But what I saw there was A-fib with a ton of artifact. The key tomy treatment is the fact the palpated HR was 60. Toys can be fooled. I agree with the diagnosis of many of the people who posted before, I think this is an unintentional opiate OD so I would start my treatment with Narcan, and maintain the O2 since her sats aren't great, I would also consider droppin a tube on her. But I was always really agressive with airway and the docs around here let me get away with it.
ECG shows motion artifact from tremors. She's got Parkinsons and is noted to be having tremors. The ECG is worthless in this case. The radial pulse is 60 which doesn't correspond to any type of tachyarryhtmia which confirms motion artifact on the ECG. She has ALOC and hypoxia with clear lungs sounds and pinpoint pupils which to me is suspicious for opiate overdose. maintain open airway, continue O2 with SpO2 monitoring, start a saline lock, transport.
I'm in the same camp as Mike Sheriff and Jason Roediger, and I think that's pretty good company to be in. Nice case!
I think the answer is in front of us? GCS of 8….. Eyes (to pain) 2…….. Verbal (confused) 4…………Motor (decerebrate) 2… Im looking at another cause for pin point pupils… ? Stroke (previous history of altered LOC -?TIA) or intra cerebral bleed (in the pons) causing the pin point pupils. Just a different option…
With a perfusing heart rate of 60 with artifacts i would stay away from cardioversion (electrically of chemically) as well as no amiodarone.
The narcan probably would not do any harm if it was not an opiate OD. But her EtCO2 , resp rate and SpO2 dont really indicate too much going on there after the the O2 admin
How about a constipated parkinsonian woman with a decent tremor and vagal ACS from being so bound up from her opiate sledgehammer. She appaers to be laxative positve so depite the slow k she might be the proud owner of an electrolyte imbalance.
I can't get over the keenness to chuck antiarythmics and every other part of the cardiac cycle drugs at this lady.
Too much artifact to really get a good sense of cardiac function. Pinpoint pupils and decreased LOC suggest opiate OD, but respiratory effort isn't impaired. Hx of COPD explains O2 sat. ETCO2 is almost shark finned like an asthma attack, but lungs sound clear. The way the urine output is described seems a little dark, but that can happen with kidney diseases. That could also mean that an eletrolyte imbalance is causing a cardiac event.
Support respirations. Saline lock. Monitor vitals including lung sounds. Transport to the local hospital for stabilizing treatment. We may be going back to transfer her to the cardiac center later.
I agree with everyone so far. Artifact makes the EKG useless, but pinpoint pupils, frequent unresponsiveness and now again following 0600 meds screams medication issue. Narcan and transport. Support her respirations with the NRB for a few and give the narcan time to work. Reassess as needed.
Afib with RVR. her 02 saturation is good with the nrb and she does not have any respiratory depression. My first thought is cardioversion but im very hesitant on cardioverting a-fib… Depending on your peotocols i would do one of two things. She has renal disease so half dosing of cardizem IVD 0.125mg/kg or 5mg lopressor slow ivp. I would not give adenosine because this is rapid a-fib its not going to work. As far as the opioid OD is concerned granted she is on opioids she has also not gotten her morning meds yet but pushing narcan isnt going to hurt I would just do it after taking care of her heart.
Lead III obviously has a lot of artifact, where were the leads placed? "Whole body tremors" sounds a little severe to be causing that much artifact…maybe more so in the left arm which would effect lead III more than lead II? Lead II looks like a pretty clear tracing, never seen "artifact" produce that clear of QRS complexes consistently, which also matches up with the rate of QRS complexes in most of the leads on the 12 lead. She has a-fib RVR with aberrancy. With a rate of +200 and aberrancy, I'm not surprised that she only has 60 palpable beats/minute. She is still perfusing so her problem doesn't seem to be a "Rate Problem."
Even with her presentation of altered LOC and pinpoint pupils, she still has an adequate RR and her O2 sats came up to 94%, which should reverse any altered LOC due to decreased ventilatory drive/hypoxia from an opiate OD…plus she hasn't been given her meds this morning (but who can trust that information at a nursing home really?) Pretty confident 1mg of Narcan won't do anything, but why not try before you choose to intubate. If she is currently being anti-coagulated, electrical cardioversion is my next step to terminate the arrhythmia because a normal perfusing rhythm will not hurt her. If not, I would be hesitant for the fear of throwing a clot if she has been in a-fib for a prolonged amount of time. IV's and cautious with fluids. If cardioversion did not improve her condition I would RSI (not with sux for potential hyperkalemia with possible worsening renal failure and inadequate medication control, plus sorbitol can exacerbate hyperK) and protect her airway since she is already obtunded and is presumably not going to improve in the near future, pending labs and CT.
Also, she has deteriorated sometime in 3 hours without her medications being administered. Although she does have pinpoint pupils, her RR does not indicate opiate overdose. The GCS reported seems odd – how many patients are decerebrate posturing with whole body tremors but still responding confused? Was it supposed to be reported as E2 V2 M4 and instead she is withdrawing from pain and moaning, like how it is usually reported? (Not E.M.V. like above). I am thinking CVA, pontine hemorrhage would cause miosis and altered level of consciousness. Is there a concomitant electrolyte abnormality that caused her RVR A-fib and altered LOC? Has she been in the a-fib for awhile unnoticed and threw a clot (is she currently on the heparin or was that still on her record from 2 years ago for DVT prevention? Her med list does not indicate she is on any anti-arrhythmics so I am assuming this a-fib is new. Lastly…Sepsis, Sepsis, Sepsis…after all she is in a nursing home with a history of UTI, amber colored urine in her Foley, decreased loc, tachycardia…almost seems picture perfect. Or pneumonia with 82% RA sat although lungs were "Clear," which is a weird finding in a patient with a baseline history of COPD, but it doesn't take a bilateral lung infiltrate to make a little old lady septic from it.
I would try to get a cleaner EKG to rule out any of this "artifact," R.S.Ekg right? Just kidding.
Great case!
atrial flutter with 3;1 block.. with af intermittent af … should have thrown some emboli into d brain stem… if she doesnt look like hypoventilating will wait for intubation, maintain d oxygenation with 02 as she s holding with non rebreathing mask, will take an ABG ..it s not wrong in intubating fr protecting her airway…. echo to r/o any thrombus and ct brain to look for hemmorrhage / embolus.. as her vitals are stable i wont cardiovert and at d same time her gcs is very low need to be evaluated .. CT BRAIN and ABG / echo might helpful to narrow down ur differential diagnosis..
I agree whole heartedly with GR. Afib RVR is clear even with the artifact. Lead II on your first strip is fairly argumentative. Though she has an altered mental status at this time, I agree with withholding agressive treatment for her afib since her other vitals are stable. This patient needs to have the cause identified at the ED prior to antiarythmics or cardioversion unless she decompensates. Otherwise I fear the afib will be refractory.
The septic picture is important to keep in mind with this kind of history and alteration in oxygenation status. Though she is maintaining her BP on her own at this time, I wouldn't hesitate to start fluid resuscitation en route. The ED will most likely bolus her prior to her labs resulting. Without access to an ABG, systemic oxygenation is very concerning since it's possible she has been hypoxic for upto 3 hours.
Though there is a long list of priorities to rule out (very well listed above I might add) my gut says that this pt is probably having episodes paroxysmal afib rvr, possibly from altered fluid and electrolyte status, possibly underlying tachy-brady syndrome, possibly altered thyroid levels, infections, etc. She is very much in danger of embolic complications. I'd say that she's bought herself a stay on a monitored unit at the very least. ICU admission is certainly possible depending on the clinical course.
Side note: If available the ECF needs to provide code status and medical directive papers. Code status at the very least. I would want to know of the pt had directives against intubation.
all these upright complexes, wide qrs…. am I alone in saying I would treat this as vtach for fear of being wrong and pushing my pt. into vfib? Lots of people are not believing the rate because of the heart rate someone told them, I'd certainly be aquiring my own check on the pulse. There is no way I'd give a calcium channel blocker.
I’m amazed there are so many diagnoses of this ecg. Poor tracing, non-diagnostic quality. None of us should attempt to base any treatment off this.
For those who arnt relying on the EKG, you could always assess for a pulse deficit, compare your apical rate while you palpate your radial pulse. An extreme perfusion deficit or lack there off may clarify this discussion, especially in light of artifact which we may not be able to get rid of in this pt without sedation
In telemetry i've noted lead III is more "stable" vs artifacts.
Rhyhtm is SR at 60's
12L has a lot of background noise and I believe still SR
Watch out for seizure enroute and differentiate tremors from clincal seizure and partial siezure with generalization (and/or epileptia partialis contnua)