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VentWorld Case Studies
JK: MYOCARDIAL INFARCTION AND RESUSCITATION
Published August 8, 2000
William French and Michelle Burke
Lakeland Community College, Kirtland, OH
www.lakeland.cc.oh.us/index.htm
Contents (click to jump directly to that section, or scroll down
to read the case)
INTRODUCTION
JK, an 82 year old male, presented to the emergency department
with severe progressive chest pain, dyspnea, and syncope. There
was also evidence of an acute inferoposterolateral myocardial infarction
and possible cardiogenic shock. Upon arrival, JK required resuscitation
and defibrillation for ventricular fibrillation. He was intubated
and stabilized on ventilatory support. Initial diagnoses included
acute myocardial infarction and coronary artery disease.
CASE PRESENTATION
JK was transported to the intensive care unit where he was placed
on a Puritan-Bennett 7200 ventilator and had a Swan-Ganz catheter
inserted. Initial ventilator settings were: SIMV mode, respiratory
rate 8 breaths/minute, tidal volume 800 mL, FiO2 50%, PEEP 5 cmH2O,
pressure support 5 cmH2O. Arterial blood gases on these settings
were:
| pH |
7.47 |
PaO2 |
102 mmHg |
| PaCO2 |
43 mmHg |
SaO2 |
99% |
| HCO3 |
19.7 mEq/L |
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Initial readings from the Swan-Ganz catheter were:.
Initial medications included: Dopamine at 5 mg/Kg and Versed at
2 mg/Kg. He was also ordered on 2.5 mg albuterol via small volume
nebulizer Q4 hours.
By the next day, JK's condition had stabilized and he had become
responsive. At that point, he was changed to CPAP through the 7200
at the following: FiO2 40%, CPAP 5 cmH2O, pressure support 5 cmH2O.
ABGs at these settings were:
| pH |
7.42 |
PaO2 |
88 mmHg |
| PaCO2 |
34 mmHg |
SaO2 |
97% |
| HCO3 |
21.8 mEq/L |
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Because his spontaneous ventilator parameters met criteria, JK
was extubated and placed on a nasal cannula at 5 Lpm. At this point,
his medications included: Lasix 40 mg, morphine 2 mg, atropine 6
mg, magnesium sulfate 2 gms, Kcl 40 mEq/100 mL.
The next day (two days after initial presentation) JK had another
episode of ventricular tachycardia and hypotension. Cardioversion
was attempted at 200 Joules; this resulted in bradycardia and eventually
asystole. Cardiac compressions were initiated and he was given 1.5
mg of atropine with good response. Subsequent cardioversion converted
the ventricular tachycardia. However, the patient was apneic. He
was reintubated and placed back on ventilatory support with a Lidocaine
drip He was also unresponsive. Initial ventilator settings were:
CMV mode, respiratory rate 12 breaths/minute, tidal volume 700 mL,
FiO2 100%. ABGs on these settings were:
| pH |
7.09 |
PaO2 |
160 mmHg |
| PaCO2 |
30 mmHg |
SaO2 |
98% |
| HCO3 |
8.9 mEq/L |
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Immediately following this ABG analysis, he was given 2 ampules
of NaHCO3. In addition, his blood urea nitrogen was 105 and creatnine
was 5.8. A neurology screen revealed encephalopathy. Subsequent
MRI indicated a spinal cord stroke.
Thus, at this point, the patient's condition included anoxic encephalopathy,
aspiration pneumonia, and status post cardiac arrest. Shortly after,
a conference was held with the family and the decision was made
to do a terminal wean from ventilatory support.
DISCUSSION:
Do you think the staff recognized and managed the case appropriately?
Post your thoughts or ask other questions related to this case.
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