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Code Blue, Leg Edema

UnFiNiShEd CaSe CoMe BaCk LaTeR

History: You respond to a code blue for a man in his 70’s who is waiting for SNF placement after recent admission for COVID 19.  His COVID tests are now negative and those symptoms have resolved.  They were readjusting his bed position when he collapsed and became unresponsive.  An AED was attached and read “No Shock Advised”.  A monitor was attached about two minutes later and showed asystole.   CPR is in progress and 2 rounds of Epi have been given.  The nurse mentioned that his legs look a bit more swollen today and his urine output has decreased

Exam: GCS = 3, minimal respiratory effort being bagged.  You call for a pulse check and note a rhythm in the 30’s with a decent pulse.  BP is measured and is 95/55.  You request a 12 lead.

Computer Read: Atrial fibrillation with slow ventricular response, RBBB, rate = 30, QTc = 332

What is the most likely cause of the EKG findings?

  • A) Hyperkalemia
  • B) Hypothyroidism
  • C) COVID myocarditis
  • D) Hypoxic bradycardia

“BRADY” DOWN FOR THE EKG ANALYSIS & 1-MINUTE CONSULT

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QUIZ ANSWER< EKG ANALYSIS, CASE OUTCOME, 1-MINUTE CONSULT & CASE LESSONS: 

1) Quiz Answer: A

  • A) Hyperkalemia: CORRECT –
  • B) Hypothyroidism
  • C) COVID myocarditis
  • D) Hypoxic bradycardia

2) EKG/Echo analysis (check out more great EKG’s from Dr. Stephen W. Smith of Dr. Smith’s ECG Blog): shows very small P-waves that the computer is missing and so calling a-fib, and severe bradycardia.

3) Case ConclusionCase Conclusion:  After 2 amps of bicarb and 2 amps of CaCl the K is elevated at 5.7, Cr at 5.2 (baseline 2.8) bicarb is low at 21 and calcium normal at 10.0.  The old EKG shows L axis and no RBBB

4) 1-Minute Consult from the Emergency Medicine 1-Minute Consult Pocketbook & Smartphone app on the topic for this case: See highlighted areas of sample page below.

5) Case Lessons: 

  1. Always
  2. Never

6) OMI Manifesto: If you haven’t yet read the OMI manifesto, you should.  It’s long but everyone should know at least the basics of why current STEMI criteria miss about 1/3 of occlusion MI’s that would benefit from emergent reperfusion and how you can pick up those patients and get them the care they need. for more information CLICK HERE

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