Case Study

Case study
Dr. Prathiba Prasad

Accident and emergency Masafi Hospital
79 year old man brought to the Emergency Department by his son after having found with
sudden onset of weakness and dizziness and fall to the floor while he was trying to get
himself seated, followed by involuntary passage of bowels. On arrival, patient was
conscious, however disoriented.
Patient is a known case of Ischemic heart Disease and Chronic kidney disease stage 3.On
receiving to the Emergency Department his Heart Rate was around 200-250 with
alternating Ventricular Tachycardia, and irregular rhythm, his Blood pressure was not
recordable. With a history of old CVA/ hypertension & Ischemic heart disease he also has
an Implanted automatic cardioverter/defibrillator.
His latest echo report revealed an ejection fraction of 21% with a
large fixed perfusion defect.
Past history
 Hypertension
 Coronary artery disease, Ejection fraction of 21% with
aneurysm of the apex
 H/O: CVA
 Chronic kidney disease Single Left Kidney, Right
nephrectomy 10 years
 Pulmonary edema, NSTEMI
 Diabetes mellitus
 Permanent pacemaker (2015)
 Old Ischemic stroke with right-sided hemiplegia
Vitals at receiving center:
On receiving the patient to the Hospital, patient was conscious but
disoriented with a GCS of 13/15,
 Sp02-92%
 Pulse-52/min
 Blood pressure-Non recordable
 Respiratory rate-20/min
Hospital course
Oxygen mask placed, ECG leads connected cannula inserted, blood drawn
↓
E C G –alternating wide and narrow complex tachycardia
↓
Patient shifted to Resuscitation Room with-Ongoing Ventricular
tachycardia and a palpable Carotid Pulse
↓
Heart Rate 160-190 with VT &VF alternating irregular rhythm, BP not
recordable Faint palpable pulse.
↓
D.C shock of 200Joules given
Pulses not palpable, CPR started, Injection Amiodarone 300mg and Magnesium 2g in 100
ml Saline started, Rhythm returned to sinus
↓
Patient in Cardiac arrest with ventricular fibrillation
↓
SHOCK-250J delivered
↓
CPR with bag and mask ventilation
↓
In view of low Blood Pressure and altered sensorium , patient intubated and started on
mechanical ventilation. Fluid bolus given and started on inotrope support.
↓
ROSC achieved
CARDIOGENIC SHOCK
Definition- persistent hypotension and tissue perfusion due to cardiac dysfunction in

the presence of adequate intravascular volume and left ventricular filling pressure.
Hemodynamically- persistent hypotension (systolic blood pressure <80-90 or mean

arterial pressure OR 30 mmHg lower than baseline. With severe reduction in cardiac
index < 1.8 L without support or less than 2.0 to 2.2 with support and adequate or
elevated left filing pressure
STAGES OF CARDIOGENIC SHOCK
Stages of Cardiogenic shock-
Signs and symptoms
 The diagnosis of cardiogenic shock can sometimes be made at the bedside by observing the
following:
 Hypotension
 Absence of hypovolemia
 Clinical signs of poor tissue perfusion (ie, oliguria, cyanosis, cool extremities, altered
mentation)
 Skin is usually ashen or cyanotic and cool extremities are mottled
 Peripheral pulses are rapid and faint and may be irregular if arrhythmias are present
 Jugular venous distention and crackles in the lungs are usually (but not always) present;
peripheral edema also may be present
 Heart sounds are usually distant, and third and fourth heart sounds may be present
 The pulse pressure may be low, and patients are usually tachycardic
 Patients show signs of hypoperfusion, such as altered mental status and decreased urine output
 Ultimately, patients develop systemic hypotension (ie, systolic blood pressure below 90 mm Hg
or a decrease in mean blood pressure by 30 mm Hg)
Lab values
Course at Advanced care facility
Patient developed acute renal failure with significant rise of creatinine exceeding
600 micromoles per L with anuria despite Lasix infusion
There was severe cardiogenic shock with profound hypotension that was not
responding to 3 inotrope at maximal doses
Patient started to have shock with elevated of liver enzymes.
Disseminated intravascular coagulopathy was noticed in the laboratory with drop

of the platelet function to be less than 60,000
Patient developed multi-system organ failure
The condition of the patient continued to be deteriorating ,sinus rhythm was

maintained but he had profound hypotension
Patient developed Later electromechanical dissociation ,code blue was

announced cardiopulmonary resuscitation was performed according to ACLS
protocol but the patient could not survive.
During hospitalization:
Patient was managed initially conservatively and was put on mechanical ventilator and
positive inotrope
Patient had coronary angiography done which showed critical ostial RCA lesion which was
intervened as high-risk intervention using 2 drug-eluting stents
After the procedure the patient stayed in cardiogenic shock with multiple frequent episodes
of ventricular tachycardia electrical storm
Electrical storm was managed with intravenous amiodarone shots of intravenous lidocaine
plus multiple DC shocks were given to the patient
Profound hypotension was managed using 3 inotrope at large doses but unfortunately the
patient was not responding and echocardiography showed that ejection fraction not
exceeding 5%
Patient kept deteriorating and development of multi-system organ failure including acute
kidney failure acute heart failure and sepsis and disseminated intravascular coagulopathy
On 29/9 of October at 18 o'clock the patient arrested and resuscitation according to ACLS was
performed but the patient could not achieve ROSC
Merits in patient care
 Timely involvement of specialist

 Step wise management in patient care
 Early Identifying of the correctable/reversible causes of Heart failure
 Timely recognition of decompensated airways and beginning of supports
 Inotrope infusion
 Early involvement of cardiologist in patient care
 Minimal wastage of time in transfer of patient care to advanced facility.
Challenges faced:
 Lack of intensive care specialist and facility in Masafi
Hospital
 Non Availability of I.C.U beds
 Limited knowledge of Portable ventilator settings
 Time consumed for patient in receiving Bed at advanced
care facility.
Measure for Improvement
 Frequent training of medical staff
 Hands on training on ventilator settings
 Conducting monthly cardiac Emergency drill.
 Case presentation in form of MDT meeting to highlight merits and
pitfalls in patient care for future improvement.
Reference:
 https://www.heart.org/
 https://www.jacc.org/guidelines
 https://www.uptodate.com/login
 https://www.webmd.com/hypertension-high-blood-pressure/side-effects-hig
h-blood-pressure-medications

Case Study

Uploaded by

Copyright:

Available Formats

Case Study

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Case Study

Uploaded by

Copyright:

Available Formats

Case study

Dr. Prathiba Prasad

Definition- persistent hypotension and tissue perfusion due to cardiac dysfunction in

Hemodynamically- persistent hypotension (systolic blood pressure <80-90 or mean

Patient started to have shock with elevated of liver enzymes.

Disseminated intravascular coagulopathy was noticed in the laboratory with drop

Patient developed multi-system organ failure

The condition of the patient continued to be deteriorating ,sinus rhythm was

Patient developed Later electromechanical dissociation ,code blue was

 Timely involvement of specialist

You might also like