Interdisciplinary Rounds

Summary

In this ICU team discussion, healthcare professionals collaborate to assess and treat a 79-year-old male patient who suffered a cardiac arrest at home. The patient, with a complex medical history, was intubated after being resuscitated. The team reviews potential causes for his condition, including pneumonia, pulmonary embolism, and heart failure, while working on a treatment plan that includes sedation and hypothermia protocol. The patient's family has expressed awareness of his end-of-life wishes, particularly regarding life support. The medical team emphasizes honoring these wishes while striving to improve his condition.

Takeaways

• 😀 The patient is a 79-year-old male with a complex medical history, including thyroid carcinoma, diabetes, and prior cardiac issues.
• 😀 The patient experienced a P.E.A (pulseless electrical activity) arrest at home due to severe respiratory distress, requiring CPR and intubation.
• 😀 Upon arrival at the ICU, the patient was unresponsive, on a hypothermia protocol, and sedated with a combination of medications including versed, fentanyl, and nimex.
• 😀 The patient’s chest x-ray showed a left lower lobe opacity, raising concerns about pneumonia, pulmonary embolism (PE), or congestive heart failure (CHF).
• 😀 The patient has a high lactate level, a slightly abnormal pH, and a normal cardiac enzyme level on his initial lab work.
• 😀 The family reported a history of shortness of breath and dry cough in the patient, with difficulty speaking and increased fatigue over the past month.
• 😀 The patient has a history of lung tuberculosis (TB) and kidney TB, which led to the removal of his right kidney at a young age.
• 😀 The healthcare team is conducting extensive tests, including cultures, dopplers for PE, and an echocardiogram to further assess the patient’s condition.
• 😀 The medical team is working to balance treatment of the patient’s critical condition while respecting his end-of-life wishes as outlined in his living will.
• 😀 The family has been encouraged to provide the patient’s advance directive, and the team reassured them that they will honor the patient’s wishes if his condition is deemed irreversible.
• 😀 The healthcare team is focused on maintaining adequate sedation and pain management to ensure the patient is comfortable while undergoing critical care.

Q & A

What is the patient's primary medical condition that led to his hospitalization?

The patient, Mr. D, was admitted after a cardiac arrest at home, following a period of worsening shortness of breath. He was resuscitated with CPR and medication, and is currently on the hypothermia protocol in the ICU.

What key aspects of Mr. D's medical history are most relevant to his current condition?

Mr. D has a history of thyroid carcinoma, diabetes, hypertension, and lung and kidney tuberculosis. He also has obstructive sleep apnea, paroxysmal atrial fibrillation, and bladder cancer, which all contribute to his overall health status and complexity of care.

What symptoms did Mr. D experience in the week prior to his cardiac arrest?

In the week before his cardiac arrest, Mr. D experienced worsening shortness of breath, fatigue, and a dry cough. He was also notably less active and had difficulty speaking loudly, suggesting respiratory distress.

What is the significance of Mr. D’s oxygen saturation being at 68% when EMS arrived?

An oxygen saturation of 68% is critically low, indicating severe respiratory distress. This low level contributed to Mr. D’s cardiac arrest, making it a critical sign of his respiratory failure and the need for immediate medical intervention.

What treatments were administered to Mr. D during his initial resuscitation?

During his resuscitation, Mr. D was intubated, received two rounds of CPR, and was given epinephrine and atropine. Return of spontaneous circulation occurred approximately 8 minutes after his pulse was lost.

What is the hypothermia protocol, and why is Mr. D being treated with it?

The hypothermia protocol is a treatment used after cardiac arrest to improve neurological outcomes. It involves cooling the patient’s body temperature to slow down brain cell damage and is typically followed for 24 hours to reduce the risk of brain injury.

What diagnostic tests and imaging were performed to assess Mr. D’s condition?

Several tests and imaging were performed, including an EKG that showed sinus rhythm, a chest X-ray showing a left lower lobe opacity, and lab tests that revealed an elevated lactate level (13). Additional cultures, including blood and urine cultures, are pending.

What are the possible causes being considered for Mr. D’s condition based on the chest X-ray?

The healthcare team considers pneumonia, pulmonary embolism (PE), and congestive heart failure (CHF) as possible causes based on the chest X-ray and the patient’s clinical presentation.

How does the healthcare team plan to further investigate Mr. D’s condition?

The team plans to continue evaluating for pneumonia, PE, and CHF. They will conduct additional diagnostic tests, including doppler studies, an echocardiogram, and possibly a perfusion scan to rule out PE.

What role does the family play in Mr. D’s care, particularly concerning his advanced directives?

The family plays an essential role in ensuring that Mr. D’s advanced directives are followed. They are encouraged to provide a copy of his living will to the medical team to ensure that his wishes regarding life support and medical interventions are respected.