5/6/2011

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Challenging & Unusual

Cardiac & Pulmonary

Case Studies

www.cherylherrmann.comcherrmann@frontier.com

Methodist Medical Center of Illinois, Peoria Class Code 157

1

49 y/o male with crushing chest pain is

enroute to your facility via ambulance

Time Is Muscle

Door to PCI time = 49 minutesAmbulance EKG to PCI time = 66 minutes

♥ Occluded RCA ♥ RCA post stent

Challenging & Unusual

Cardiac & Pulmonary

Case Studies

Case Study #1

♥ 69 y/o female comes to ED with c/o of severe chest discomfort

♥ PMH: mild HTN and hyperlipidemia♥ B/P 173/89, HR 91, RR 21

SpO2 98% on 2 l/np

16:59

EKG on admission

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♥ Rural hospital with no cath lab♥ NTG 0.4 mg SL x 3 in 30 minutes♥ ASA 81 mg po♥ Metoprolol 25 mg po

♥ Retavase

More history….

♥ A few hours earlier in the same ED, her husband came in full arrest and was not able to be resuscitated

No relief of symptomsRepeat EKG

No improvement Inferolateral leads

Transported via helicopter to hospital with cardiac cath

Labs on admission

♥ CK = 156♥ CKMB = 10.7 ↑♥ Myoglobin = 298 ↑♥ Troponin I = 2.91 ↑♥ BNP = 35

Cardiac Cath findings

♥ Normal coronary anatomy – No CAD♥ Markedly depressed LV function with

ejection fraction = 5 – 10%♥ Severe hypokinesis to akinesis of the

distal 2/3 anterolateral, apical, and inferior walls.

♥ The basal segments contract vigorously giving it very Japanese amphora shape suggestive of Takotsubo cardiomyopathy

Management

♥ Transferred to CVICU

♥ No IABP due to hemodynamically stable and recent Retavase

♥ Diagnosis: Broken Heart Syndrome or Transient Apical Ballooning

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Discharged the next day so she could attend her husband’s funeral

♥ Discharge medications

♥ Aldactone 25 mg every day

♥ Alprazolam 0.5 mg prn

♥ Altace 2.5 mg every day

♥ ASA 81 mg every day

♥ Coreg 6.35 mg every 12 hours

♥ Coumadin 5 mg po every day

♥ Lasix 20 mg every other day

♥ Lipitor 40 mg po at hs

3 – 6 weeks later

♥ EF 50 – 60%♥ Patient doing good

Broken Heart Syndrome

♥ A specific syndrome of stress-related reversible cardiomyopathy

♥ Mimics acute myocardial infarction without obstructive disease

Precipitating factorsMarked psychosocial or physical stress

Transient Left Ventricular Apical BallooningTakotsubo Cardiomyopathy

♥ 1st Described in Japanese literature in early 1990

♥ Was first attributed to simultaneous spasm of multiple coronary arteries

♥ Original name given “Takotsubo Cardiomyopathy”

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♥ Takotsubo is the narrow-necked bulging container used by Japanese fisherman to trap octopus

♥ The shape of the takotsubo pot resembles the distorted ballooning ventricle.

Etiology

♥ Unclear etiology♥ 1 – 2% of patients who have S/S AMI have

apical ballooning (Japan & USA)♥ 6-9 times more common in women♥ 6% of women with AMI have apical

ballooning♥ Most often in postmenopausal women

Pathophysiology

♥ Marked systolic ballooning of the ventricular apex

♥ Hypercontractility of the base of the heart♥ Most common in LV ---can occur in RV♥ Initial reports thought it was due to spasm♥ Now thought to be related to stunning of

the myocardium related to excessive catecholamines

♥ Since preceded by increased psychosocial or physical stress suggest an association with ↑ SNS activity

♥ Catecholamines have a toxic effect on the myocardium

♥ Catecholamine levels reported to be 7 –34 times as high as the normal 2 – 3 elevation in classic AMI patients

Other possible pathophysiology mechanisms

♥ Rupture of a nonobstructive plaque followed by spontaneous thrombolysis

♥ Microvascular coronary spasm or dysfunction

♥ Transient obstruction to left ventricular outflow

♥ Acute myocarditis

Other findings

♥ Abnormally long left anterior descending artery that courses along the diaphragmatic surface of the left ventricle

♥ But not consistent finding

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Signs & Symptoms (not consistent)

♥ Chest pain♥ ST segment changes♥ Release cardiac biomarkers♥ Syncope or near syncope♥ Fatigue/malaise♥ Palpitations♥ Dyspnea♥ Hypotension♥ Pulmonary edema♥ Cardiogenic shock♥ Lethal ventricular arrhythmias

12 Lead EKG

♥ Variable findings

♥ ST segment elevation or depression usually in the precordial leads (V2 – V5)

♥ Reciprocal changes in the inferior leads may not occur

♥ Q waves usually do not develop

or Q waves V3 – V6

♥ Deeply inverted T waves are common in the recovery period

♥ Markedly prolonged QT interval

Metzl MD et al. (2006) A case of Takotsubo cardiomyopathy mimicking an acute coronary syndromeNat Clin Pract Cardiovasc Med 3: 53–56 doi:10.1038/ncpcardio0414

A 12-lead electrocardiogram showing ST-segment elevations and T-wave inversions in the right precordial leads, which is a typical pattern observed in

Takotsubo cardiomyopathyCardiac biomarkers

♥ Only moderately elevated♥ Do not follow the typical rise-fall-pattern

seen with AMI

Echocardiogram/Cardiac Cath

♥ Systolic ballooning of the ventricle, akinetic or dyskinetic left ventricle

♥ Ejection fraction markedly decreased in the acute phase – as low as 14 – 40%

♥ No significant coronary artery disease to account for the marked left ventricular dysfunction

Normal LV on Echo

♥ Systole ♥ Diastole

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Left ventriculogram in systole (3a) and diastole (3 b) to illustrate the ballooning

65-year-old woman was admitted to a local ED due to chest pain in the retrosternal region associated w ith severe dyspnea. Before the onset of the symptoms, t he patient reported a significant stress episode fo llowing

a serious quarrel with her husband.

Metzl MD et al. (2006) A case of Takotsubo cardiomyopathy mimicking an acute coronary syndromeNat Clin Pract Cardiovasc Med 3: 53–56 doi:10.1038/ncpcardio0414

Left ventriculogram of the patient during systole showing mid, distal and apical left ventricular ballooning, with vigorous contraction of the basal segment as

seen in Takotsubo cardiomyopathy

The echocardiogram revealing apex expansion, akines ia of some segments of the left ventricle, with a severe reduction in the ejec tion fraction Nuclear stress testing

♥ Evidence of reversible myocardial injury

Diagnosis

♥ Immediately difficult to differentiate between STEMI caused by thrombosis

♥ Suspect Takotsubo Cardiomyopathy when obstructive CAD is not present to explain the LV dysfunction

♥ Confirmation of diagnosis: typical octopus morphology of LV

♥ Stressor considered supportive evidence

♥ Complete resolution of LV dysfunction weeks after the event

Mayo Clinic Criteria

♥ New ECG finds (not evident on previous ECGs or are acute changes) such as T-wave inversion or ST-segment changes

♥ Absence of any CAD♥ Transient akinesis of the left ventricular

apical and midventricular segments, including wall motion abnormality

♥ All other possible causes of the changes have been ruled out

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Management

♥ Prompt recognition of apical ballooning prevents unnecessary administration of fibrinolytics with the ST segment elevation

♥ Specific guidelines do not exist♥ Mostly managed per NSTEMI and STEMI

guidelines

♥Proceed with STEMI treatment & emergent cardiac cath

Management of Cardiogenic shock

♥ Vasopressors♥ Pacemaker♥ Intraaortic balloon pump (IABP)♥ Support until LV recovers

Supportive Management

♥ Arrhythmias � antiarrhythmic drugs♥ Diuretics � pulmonary congestion♥ B Blockers, vasodilators, ACEI,

vasocontrictors, IABP � left sided HF♥ Short term anticoagulant � prevent LV

thrombus

Prognosis

♥ Left ventricular function improves rapidly♥ Often within 7 – 30 days♥ EKG changes may be slower to resolve♥ Generally favorable prognosis

♥ Mortality of 0 – 8%

Case Study # 2

♥ 49 y/o white female came to ED because of two episodes of resting palpations associated with tightness across the midchest and in the throat, SOB and diaphoresis

♥ Symptoms subsided by the time patient arrived at ED

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EKG in ED. Troponin NormalSent home to follow up with cardiologist next day EKG during stress test in cardiologist office.

Sent directly to cath Lab

Cardiac Cath: Normal Coronary ArteriesLV apical balloning, EF = 40% Stressors

♥ Aunt died one month ago♥ Just told father has terminal illness♥ Significant other – 3 stents last week

TS: EKG day later Note: Deep T wave inversion & prolonged QT interval

Case Study # 3

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♥ 74 y/o female POD #2 rectal prolapse repair & cholecystectomy

♥ PMH– 2 coronary stents three years ago & iliac

stents.

– Quit smoking 4 years ago. Smoked 1 ½ packs x 50 years

♥ Clear lung sounds, uneventful post op course. SpO2 97% on room air

3/6 POD #2 1450

♥ Patient abruptly has respiratory distress.♥ Respirations 36 labored♥ SpO2 drops to 78% on 3 liters♥ RRT called

RRT assessment

♥ O2 increased to 7 l/min. SpO2 81%♥ BP 197/111, HR 139, Resp Rate 36

labored♥ Lungs crackles throughout♥ Color dusky

♥ ABGs:– Ph 7.45

– pC02 30

– pO2 45

– TCO2 21.8

– O2% 83

– BE -3.1

– Lactic Acid 1.9

♥ O2 increased to 100% nonrebreather. SpO2 increased to 91%

♥ Transferred to ICU at 1505

EKG at 1509

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CXR at 1535

Remember: SpO2 was 97% on room air just prior to the acute change

Cath results: Normal LAD & other coronary arteries

♥ Anterobasal & basal 2/3 of inferior wall contracts normally

♥ Rest of LV is akinetic & perhaps dyskinetic

♥ EF = 20%♥ Findings are consistent

with “broken heart syndrome/Takotsubo cardeiomyopathy”

♥ Physical stressor-surgery

♥ Patient started on Cardizem♥ Placed on BiPap 12/6♥ Given Lasix 40 mg IV♥ Albuterol/Atrovent & Pulmicort nebulization

♥ Supportive management of Cardiogenic shock

12 Lead EKG 48 hours later CXR 4 days later

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10 days later 3/20

♥ Back on telemetry unit♥ Patient abruptly goes into respiratory

distress and is diaphoretic.♥ BP 97/45, HR 131, RR 40 SpO2 92%♥ Placed back on BiPAP 14/10

3/20 1600

♥ Started on Cardizem @ 10 mg/hour♥ ABGs

– ph 7.53

– pCO2 23

– pO2 60

– TCO2 20

– O2% 94

– BE – 3.3

– Lactic Acid 4.7 (Abdomen tender)

CXR on 3/20

♥ Transferred back to ICU♥ Supportive Care of Cardiogenic Shock♥ Started having Ventricular Tachycardia --

defibrillated several times over the next several hours. Then made DNR & expired shortly thereafter.

Broken Heart SyndromeSummary: Clinical features

♥ Onset of s/s often preceded by emotional/physical stressor

♥ Most common in postmenopausal women♥ ST-segment abnormalities that mimic those of AMI♥ Mild to moderate increase in levels of cardiac enzyme

compared with the increase in AMI♥ No significant coronary artery disease to account for the

left ventricular dysfunction♥ Left ventricular “ballooning” wall motion at the apex with

hypercontractility at the base♥ Transient and reversible left ventricular changes with

favorable prognosis

Source: McCulloch B 2007: Critical Care Nurse 27(6): 20 - 27

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Broken Heart SyndromeTakotsubo Cardiomyopathy

♥ Avoid Fibrinolytics!

Case Study # 4

42 y/o white male

♥ Came to ED due to c/o substernal burning pain that radiates up chest to both arms.

♥ Becomes SOB with chest pain♥ Episodes last approx 10 minutes at a time.♥ Episodes occur more when lying flat. This

occurs several times during the night so he is not able to sleep

♥ Episodes have been occurring for last 4 months.

More History

♥ Had a negative stress test & normal GI workup.

♥ Denies any drug use of cocaine or other medications

♥ Quit Smoking 4 months ago. No other past medical history

♥ Father had some cardiac problems when he was in his 50s or 60s --- history unclear.

♥ Pain free on arrival to ED♥ Alert, Oriented♥ Skin Warm/dry

Feb 24 at 1331

♥ When laid down for EKG developed chest pain

♥ BP 122/77, HR 87, RR 20 SpO2 99%♥ Chest pain 7/10♥ Weight: 70 kg

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EKG in ED

♥ Chest pain resolved when sat up♥ BP 118/56, HR 74, RR 20

♥ At 1339 on 2-24 (6 minutes later), the chest pain was gone. Pt was sitting up at the time.

♥ Troponin < 0.4 ng/ml♥ CK = 71♥ Total Cholesterol = 161♥ Triglycerides = 66♥ HDL = 35♥ LDL = 113

♥ Called cardiologist♥ 1st EKG STEMI that resolved after a few

minutes.♥ Admit patient to CVICU. Started on ASA,

plavix, heparin drip, nitroglycerin drip, and lopressor

♥ Hold cardiac cath for now as pain free with normal EKG

Cardiac Cath Feb 25Initial Injection of RCA

70% Occlusion

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Cardiac Cath Feb 25RCA after administration of Intracoronary Nitroglycerin

10 % Occlusion after NTG

EF = 70%

Management

♥ Diltiazem 180 mg ♥ Nitroglycerin 0.4 mg Transdermal patch.

Apply at bedtime and remove at 10 am.♥ Two days later, stated, “ I am finally sleeping

at night!”♥ Discharged with

– Diltiazem 180 mg daily – Nitroglycerin 0.4 mg Transdermal patch at HS

Prinzmetal or Variant Unstable Angina

♥ Caused by a dynamic obstruction from intense vasoconstriction

♥ Unstable angina represents a transition from stable angina to an unstable state

♥ One or more of the coronary arteries are more than 60% obstructed or the symptoms have become more frequent , more severe, or occur at rest

Management

♥ Modification of risk factors♥ Vasodilators to decrease spasms

– Nitroglycerin

– Calcium Channel Blockers

Case Study # 5 37 y/o white male

♥ Came to cardiologist office as he developed rapid palpations associated with some shortness of breath while exercising with weight lifting.

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This patient’s “normal” EKG

This patient’s “normal” EKG Family history positive for CAD

♥ One uncle died suddenly of AMI♥ Three uncles -- CAD, AMI, CABG, and

angioplasty♥ Mother & all grandparents = hypertension♥ Grandfather – stroke♥ One aunt -- CAD, CABG, and stenting

♥ One cousin died of cardiac arrhythmia

PMH

♥ Moderate drinker – 6 beers per week♥ Does not smoke♥ Average BMI♥ 1st seen by cardiologist one year ago for three

episodes of resting palpitations which resided spontaneously.

♥ 12 Lead at that time: Findings consistent with left posteroseptal WPW syndrome

♥ 24 hour holter – no arrhythmia♥ Stress test: negative for ischemia♥ ASA 81 mg daily

At cardiologist office

♥ BP 120/70♥ Heart rate 160 irregular

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12 Lead EKG Direct admit to CVICU

♥ Walks to bed & placed on monitor!

♥ Tambocor 150 mg given po♥ Does not convert and BP dropped to 76/sys.♥ Cardioverted (moderate sedation) with 100

joules.

Post Cardioversion Discharge

♥ Tambocor 150 mg po bid♥ Baby ASA 81 mg daily♥ Follow up with electrophysiologist for

catheter ablation of the left posteroseptal pathway

♥ Shortened PR interval < 0.12 sec with a normal p wave♥ Wide QRS complex > 0.11 sec♥ The presence of a delta wave

♥ ST-T wave changes or abnormalities♥ Association with paroxysmal tachycardias – can be fatal

Wolff-Parkinson-White syndrome

♥ An extra electrical connection between the atria and the ventricles

Source: Marriott, H. (1983). Advanced Concepts in Arrhythmias

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Wolff Parkinson White Treatment

♥ Antiarrhythmics♥ Cardioversion♥ Atrial Ablation

Case Study # 6

41 year female presents to ED with SOB for past 2 – 3 days

♥ BP 157/95♥ HR 108♥ RR 28♥ T 96.2

♥ SpO2 95% on 5 liters/NP

♥ No history of smoking♥ No cardiac or pulmonary history♥ Family history: Grandmother- heart

disease. Mother – aneurysm♥ Two days ago was in the ED with BNP

700, received IV lasix with good response.♥ Sent home on Lasix 20 mg bid♥ Improved for one day and then increasing

SOB

Pulmonary Embolus Criteria

♥ S1, Q3 or S1,Q3, T3♥ RBBB♥ Inverted T waves secondary to RV strain may be seen in the right

precordial leads and can last for months

S in Lead 1

Q in Lead 3Inverted T Lead 3

RBBB

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Admission Labs

♥ Na 141

♥ K 3.8

♥ Bun 16

♥ Creatinine 0.9

♥ Glucose 106

♥ WBC 12.1

♥ HBG 11

♥ HCT 33.4

♥ Platelets 268

♥ BNP 938

♥ CK 71

♥ Troponin 0.01

♥ CT negative for PE

More History

♥ 1 week post partum ♥ 1st pregnancy, 48 hours in labor, vaginal

delivery ♥ Diet controlled gestitational diabetes♥ On day of discharge – post delivery,

noticed swelling of her lower legs and then had � SOB and orthopnea that brought her to the ED two days ago

Dx– Postpartum Cardiomyopathy

♥ Received IV Lasix in ED with 2 liter response and significant improvement of symptoms of congestive heart failure

♥ EF = 20%

1st CXR CXR 6 hours after IV Lasix

♥ BNP reached 1233♥ Discharged with the following medications:

– Lasix

– Potassium supplement

– Enapril

– ASA

♥ Patient wants to breast feed???

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♥ Breast feeding – Okay for Enapril

• Do not give ACEI/ARBs during pregnancy!

– Unknown for Lasix

♥ Encouraged not to breast feed

♥ Added Coreg 3.625 mg later

♥ Five months later Coronary angiogram – No occlusive coronary disease– Moderate global LV dysfunction– EF 20 – 30%

ICD inserted due to low EF & high risk for sudden cardiac death

Peripartum Cardiomyopathy

♥ Cardiomyopathy in the last month or the first five months after pregnancy – EF < 45%– m-mode fractional shortening <50%– LVED dimension > 2.72 cm/m2

♥ Incidence 1: 3000 – 4000♥ Risk Factors

– Advancing maternal age– Multiparity– Multi-fetal gestation,– Preeclampsia– Black race

Source: Moser & Riegel. 2008. Cardiac Nursing

Peripartum Cardiomyopathy Concerns

♥ Increased risk of thrombotic emboli – start anticoaguation therapy

♥ As high as 85% risk of death associated with peripartum cardiomyopathy in women with persistent LV dysfunction 6 months after pregnancy

Source: Moser & Riegel. 2008. Cardiac Nursing

Case Study # 763 y/o white male comes to ED with SOB and left sided chest pain for the past hour

♥ Woke up “feeling weird” and felt very SOB♥ The left sided chest pain began when the

SOB started ♥ The chest pain does not radiate and is

mildly sharp and stabbing in quality

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PMH

♥ COPD – wears continuous oxygen at home♥ Hx PE♥ CHF♥ AAA repair

♥ PVD♥ Idiopathic thrombocytopenia purpura♥ Antiphospholipid antibody syndrome♥ Recurrent small bowel syndrome

What is Antiphospholipid syndrome ?

♥ An autoimmune disease♥ “Antiphospholipid antibodies" react against proteins

that bind to anionic phospholipids on plasma membranes.

♥ The exact cause is not known, but activation of the system of coagulation is evident.

♥ Clinically important: antiphospholipid antibodies are associated with thrombosis and vascular disease.

Vital Signs in ED

♥ BP 136/77♥ HR 134, regular♥ RR 32♥ Temp 97 oral

♥ SpO2 91% on 15 liters nonrebreather♥ Pain 7/10

EKG 12- 2 at 2200 in ED

What diagnosis might you be thinking?

Pulmonary Embolus Criteria

♥ S1, Q3 or S1,Q3, T3 (inverted T)♥ RBBB♥ Inverted T waves secondary to RV strain may be seen in the right precordial leads

and can last for months

S1

Q3

T3

RBBB

Inverted T waves

CXR 12-2 in ED

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CXR 12-2 in ED Pneumothorax Review

♥ No lung markings♥ If large, side of chest with pneumothorax will be larger and blacker

Back to Case # 7DX: Spontaneous pneumothorax on 12 – 2

CT scan view post chest tube insertion

♥ BP 101/65♥ HR 113, regular♥ RR 20♥ SpO2 100% on

15 liters nonrebreather

♥ Pain 2/10

Chest Tube

CXR 9 hours post chest tube insertion at 0800Is the pneumothorax resolved?Pt is admitted to progressive care – what assessments would you do during your shift?

Chest Tube

12-3 at noon

♥ C/O chest discomfort, SOB, left leg tingling

♥ Now what assessment and actions would you take?

♥ Totally absent lung sounds on left

CXR on 12 – 3 at 1215 after 2nd chest tube inserted

2nd Chest Tube

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♥ Patient did not go to surgery for decoritication due to pulmonary hypertension – poor surgical candidate

♥ Sent home with Heimlich valve

For more detailed information on Air Leak Syndromes

♥ I can’t Breathe: Rapidly Assessing and Intervening in Air Leak Syndromes– Tuesday 4:45 pm

♥ As Easy As Black & White: CXR Interpretation– Wednesday 2:15 pm

Case Study # 8 78 y/o male direct admit from MD office

♥ SpO2 69% at MD office – Baseline SpO2 high 80s – 90s

♥ Progressive SOB past three weeks♥ Productive cough with green-yellow

sputum. Wheezes♥ Temp 100 oral yesterday♥ BP 155/74, HR 85, RR 22, T 98.7 SpO2

89% on 3 liters

PMH

♥ Farmer♥ Focal Seizures for past 18 years as result

of closed head injury ♥ GERD♥ Parkinson’s Disease♥ Hypothyroidism

♥ Does not smoke nor drink alcohol

Admission CXR on 3-15

♥ Bilateral infiltrates and bilateral pleural effusions

♥ Started on Zithromax and Rocephin for pneumonia

♥ Albuterol and Atrovent nebulizer

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Admission

WBC 5.8

RBC 3.08 ↓

HBG 9.2 ↓

HCT 28.2 ↓

Platelet Count 298

NEUT % 66.9

LYMPH % 16.3

MONO % 16.1 ↑

EOS % 0.2

BASO % .05

BNP 272 ↑

CXR next day 3-16

♥ ? If aspiration pneumonia due to Parkinson’s

♥ Speech evaluation –swallow test was normal

♥ SpO2 mid to high 80s on 3 liters

3-17 two days later

♥ Not much improvement in CXR with antibiotics

♥ ? If cardiac related. Echo ordered

♥ EF 66%, mild pulmonary hypertension

♥ Pulmonary consult ordered

ph 7.46

pCO2 46

pO2 62

TCO2 34

10 liters high flow

♥ Resp labored 32 - 36, abdominal breathing

♥ Placed on Bipap for night. Patient was DNR and did not want intubation

CT scan 3-18 What a normal Chest CT should look like

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Pleural effusions

Bilateral parenchymal airspace disease

Interstitial pneumonitis

Back to Case Study 3-18

♥ Right thoracentesis

♥ Drained 700ml yellow colored fluid

♥ Drastic improvement in resp– Easy and regular– Rate 24 – 28– Oxygen back to 3 liters

♥ Started on prednisone

♥ Continued antibiotics

♥ Diagnosis: – Atypical pneumonitis– BOOP

What is…..

♥ Atypical/ interstitial pneumonitis?

♥ BOOP?

Interstitial Pneumonitis

♥ The interstitium is the area around the alveoli.

♥ The interstitium becomes stiff or scarred preventing the alveoli from expanding and getting oxygen.

Interstitial PneumonitisCauses♥ Infection

– Fungal pneumonia– Atypical bacterial pneumonias– Viral pneumonias

♥ Exposure to occupational and environmental agents– Thermophilic fungi – Farmer’s Lung

♥ Idiopathic causes– Sarcoidosis– Cryptogenic organizing pneumonia– Idiopathic interstitial pneumonias

Treatment

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BOOPBronchiolitis Obliterans with

Organizing Pneumonia

♥ A rare lung condition in which the bronchioles and alveoli become inflamed and plugged with connective tissue.

♥ The disorder is also known as cryptogenic organizing pneumonia (COP).

BOOPBronchiolitis Obliterans with

Organizing Pneumonia

♥ CXR resembles infectious pneumonia that does not respond to multiple antibiotics

♥ Blood and sputum cultures are negative for organisms.

BOOP Treatment

♥ Corticosteroid therapy

Farmer’s Lung

♥ Hypersensitivity pneumonitis♥ Associated with intense or repeated

exposure to inhaled biologic dusts– Thermophilic Actinomyces species

– Aspergillus species

♥ Inhalation of dust from moldy hay, straw, or grain

Farmer’s Lung

♥ Acute– New onset of fever, chills, nonproductive cough, chest

tightness, dyspnea, headache and malaise – May resolve within 12 hours if eliminate exposure

♥ Subacute– Chronic cough, dyspnea, anorexia and weight loss

♥ Chronic– From prolonged and continuous exposure to antigen– May have irreversible lung damage– Mild to moderate hypoxemia

Grain Dust Asthma

♥ Asthma caused by inhalation of grain dust

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3-19 day after thoracentesis

Pleural fluid did not show any bacteria or fungus

CXR 3-23 on discharge 9 days later

Discharged on prednisone, antibiotics, and 2 liter home oxygen

Admission CXR

CT scan one month later

Off home oxygen, still on steroids

Case Study # 9

59 y/o white malePMH: GERD & Asthma

♥ Sitting at table after breakfast – Started feeling hot, flushed, and sweaty and heartburn sensation

♥ Passed out for 2 minutes♥ Eyes rolled back♥ Then became alert, no suggestion of

postictal state. No seizures ♥ Cardiac Markers = Negative♥ Cardiology Consult - Cardiac Cath due to chest pain to

r/o cardiac disease♥ Neruology Consult - Suggested MRI and sleep study

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Cardiac Cath = Normal except while holding his breath, this was his rhythm

♥ Unable to reproduce the asystole ♥ Carotid Massage gave bradycardia but not

significant bradycardia♥ Admitted for observation overnight ♥ Plan to schedule Echo and possibly tilt table

Patient returns to room and then when he turned his head…

Returned to Cath Lab for Pacemaker

Quiz time:What type of pacemaker does he need?

A. VVI

B.

C. DDD

D. DDD with ICD

AAI

Quiz time:What type of pacemaker does he need?

A. VVI ♥ Will cause Pacermaker Syndrome due to loss of

atrial kick from no SA node conduction

B. AAI ♥ Will stimulate sinus node

C. DDD♥ No problem with AV node so don’t need

venticular support

D. DDD with ICD♥ No ventricular arrhythmias

Sick Sinus Syndrome

♥ Degenerative changes in and around the sinus node result in a marked decline in the number and effectiveness of sinus node pacemaker cells in older adults

Manifestations of SSS

♥ Inappropriate resting bradycardia,♥ Chronotropic incompetence – the inability

to increase HR in response to increased demands imposed by normal activities

♥ Sinus pauses♥ Sinus arrest♥ Tachy-brady syndrome

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Sick Sinus Syndrome Features♥ Persistent, severe, inappropriate sinus bradycardia♥ Sinoatrial block and/or sinus arrest episodes♥ Long pauses with failure of secondary pacemakers or

failure of sinus rhythm♥ Ectopic atrial or junctional pacemaker rhythm as

replacement for NSR♥ Prolonged suppression of sinus rhythm after electrical or

spontaneous cardioversion from atrial tachydysrhythmias or bradycardia alternation with tachycardiac

♥ AF that may be paroxysmal, persistent, or permanent and may have slow ventricular rate caused by permanent silence from sinus node and other AV node disease

Source: Moser, D. Riegel B (2008) Cardiac Nursing

Diagnosis

♥ Electrophysiology studies♥ Age – Peak incidences in 70s♥ No gender difference♥ 40 – 60 % also have SVT

♥ May be reversible and self limiting IF associated with cardiac disease or medications that involves the sinus node

Treatment

♥ Temporary Pacemaker♥ Review medication list♥ Treat underlying cardiac disease♥ Permanent pacemaker

Case Study # 10

You are admitting 66 y/o male after CABG x 1, AVRPMH: Diabetes, CAD, Hyperlipidemia

Admission2122

pH 7.33

pCO2 50

pO2 79

TCO2 28

02 sat 95

BE 0.5

Hemoglobin 11.2

Hematocrit 36

Glucose 125

Potassium 4.8Based on ABGs and CXR, what do you want to do?

0245 – about 5 hours post op

♥ SpO2 drops to 90 – 91%♥ BP 95/62♥ HR 106♥ One hour prior:

– BP 118/81, HR 87, RR 12,

– Sp02 100 on 80% vent

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Clear bilateral lung sounds except diminished right upper lobe

Admission2122

0200 0248Now

pH 7.33 7.47 7.49

pCO2 50 36 36

pO2 79 81 56

TCO2 28 27 29

02 sat 95 97 91

BE 0.5 2.5 4.1

Hemoglobin 11.2 11.5 10.9

Hematocrit 36 37 35

Glucose 125 147 133

Potassium 4.8 4.6 4.4

CXR 0315

CXR at 0530 after ET tube pulled back 2 cm suctioned with mucomyst for tan secretions.

CXR at 0530 after ET tube pulled back 2 cm suctioned with mucomyst for tan secretions.

Azygos Lobe

♥ Right upper lobe bronchus comes off trachea versus right main bronchus

♥ A rare congenital variation of the upper lobe of the right lung

♥ An anatomically separated part of the upper right lobe

♥ Not associated with any morbidity but can cause technical problems in thoracoscopic procedures

Tip of ET tube

Admission CXR

Post suction CXR

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POD # 5 CXR

Case Study # 11

♥ 49 y/o white male♥ Railway Conductor – fairly strenuous

activity♥ PMH: Mild Hypertension, Non smoker♥ Family Hx: Father died suddenly in early

50’s presumably of cardiac disease

Presentation at MD Office

♥ c/o SOB with mowing lawn♥ Whenever tried to exert himself, he would

get just mildly SOB, would rest, and then continue

♥ No chest discomfort, jaw pain, shoulder or back pain. No sweating

♥ c/o more lightheadness than SOB♥ Has been occurring for a couple of weeks

if not months

Sent for Stress Test

♥ Pt later stated, “They got so excited during my stress test. I felt fine. They made me sit down and kept asking me if I was okay. I think I scared them!”

Now for the rest of the story…ST depression and then this….

Stress Test #1 0800

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Stress Test #2 0801 Stress Test #3 0802

Stress Test #4 080475 – 80% Proximal LAD, mid LAD stenosis

75 - 80% Two long tandem lesions & a distal at the bifurcationLVEF Normal

LAD with one stent deployed LAD post three (DES) stentsNote: diagonal 2 lost with stent over bifurcation

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Discharge medsTroponin normal

♥ Plavix 75 mg daily – probably for lifetime♥ ASA 325 mg daily♥ Tropol 50 mg daily♥ Crestor 40 mg daily

♥ Lisinopril & Hydrochlorothiozide 10/12.5 mg daily

♥ NTG SL prn

Anterior AMILAD occlusion

♥ Arrhythmias = VT or VF♥ Usually have the lowest EF

In Summary

Scary Coronary & Pulmonary Events

ALL chest pain is cardiac until proven otherwise

♥ Ask Questions to get a good history!♥ No fibrinolytics for Broken Heart Syndrome

Time is Muscle

58 minutes Door to PCI Time!www.cherylherrmann.comcherrmann@frontier.com