I had a case last week that I can’t stop thinking about. As I listen to the latest episode of The Resus Room I started to relive the following case. The call kicked out as “bleeding” a from the catheter. The local fire department arrived on scene prior to our arrival. The patient was elderly, and the bleeding had been ongoing for the last few weeks. It had gotten worse over the last day or two thus resulting in the 911 call. Per the fire department the patient’s initial rhythm was atrial fibrillation at around one hundred sixty beats per minute, with a blood pressure around the nineties systolic, and a pulse ox of eighty seven percent.
We assumed care and transported to the local emergency department. The patient was alert with no cognitive deficits. The only complaint was dizziness. An 18 gauge was established, and fluids were hung. Now the decision point. Should I give the patient Cardizem or wait to see if the blood pressure and dizziness resolve with the fluids.
I only have around eight minutes before we arrive at the local emergency department. The patient has no history of atrial fibrillation. The follow up four lead in the back of the ride was slightly irregular and did meet the criteria to be diagnosed as atrial fibrillation. The one million dollar question: was the dizziness related to the hypotension or atrial fibrillation, or was the atrial fibrillation a result of the hypotension? Do I give the medication that could cause the patient to crump if he’s tachycardic due to hypovolemia?
I gave twenty milligrams of Cardizem. By the time we handed care to the ER staff the patient’s heart rate down to around one hundred two beats per minute. The blood pressure remained in the nineties with around three hundred milliliters infused. The pulse ox was ninety four percent or greater. Per the patient there was no real relief in the dizziness.
In the end no matter how I look at it the patient was on the brink of shock. Whether it was hypovolemic or cardiogenic the matter needs to be addressed. Hindsights 20/20 but I’m interested to hear how you would have tackled this case. Please leave a comment below.