VentWorld Case Studies
JK: MYOCARDIAL INFARCTION AND RESUSCITATION
Published August 8, 2000
William French and Michelle Burke
Lakeland Community College, Kirtland, OH
www.lakeland.cc.oh.us/index.htm
Contents (click to jump directly to that section, or scroll down to read the case)
INTRODUCTION
JK, an 82 year old male, presented to the emergency department with severe progressive chest pain, dyspnea, and syncope. There was also evidence of an acute inferoposterolateral myocardial infarction and possible cardiogenic shock. Upon arrival, JK required resuscitation and defibrillation for ventricular fibrillation. He was intubated and stabilized on ventilatory support. Initial diagnoses included acute myocardial infarction and coronary artery disease.
CASE PRESENTATION
JK was transported to the intensive care unit where he was placed on a Puritan-Bennett 7200 ventilator and had a Swan-Ganz catheter inserted. Initial ventilator settings were: SIMV mode, respiratory rate 8 breaths/minute, tidal volume 800 mL, FiO2 50%, PEEP 5 cmH2O, pressure support 5 cmH2O. Arterial blood gases on these settings were:
| pH | 7.47 | PaO2 | 102 mmHg |
| PaCO2 | 43 mmHg | SaO2 | 99% |
| HCO3 | 19.7 mEq/L |
Initial readings from the Swan-Ganz catheter were:.
| CVP | 12 mmHg |
| PCWP | 14 mmHg |
Initial medications included: Dopamine at 5 mg/Kg and Versed at 2 mg/Kg. He was also ordered on 2.5 mg albuterol via small volume nebulizer Q4 hours.
By the next day, JK’s condition had stabilized and he had become responsive. At that point, he was changed to CPAP through the 7200 at the following: FiO2 40%, CPAP 5 cmH2O, pressure support 5 cmH2O. ABGs at these settings were:
| pH | 7.42 | PaO2 | 88 mmHg |
| PaCO2 | 34 mmHg | SaO2 | 97% |
| HCO3 | 21.8 mEq/L |
Because his spontaneous ventilator parameters met criteria, JK was extubated and placed on a nasal cannula at 5 Lpm. At this point, his medications included: Lasix 40 mg, morphine 2 mg, atropine 6 mg, magnesium sulfate 2 gms, Kcl 40 mEq/100 mL.
The next day (two days after initial presentation) JK had another episode of ventricular tachycardia and hypotension. Cardioversion was attempted at 200 Joules; this resulted in bradycardia and eventually asystole. Cardiac compressions were initiated and he was given 1.5 mg of atropine with good response. Subsequent cardioversion converted the ventricular tachycardia. However, the patient was apneic. He was reintubated and placed back on ventilatory support with a Lidocaine drip He was also unresponsive. Initial ventilator settings were: CMV mode, respiratory rate 12 breaths/minute, tidal volume 700 mL, FiO2 100%. ABGs on these settings were:
| pH | 7.09 | PaO2 | 160 mmHg |
| PaCO2 | 30 mmHg | SaO2 | 98% |
| HCO3 | 8.9 mEq/L |
Immediately following this ABG analysis, he was given 2 ampules of NaHCO3. In addition, his blood urea nitrogen was 105 and creatnine was 5.8. A neurology screen revealed encephalopathy. Subsequent MRI indicated a spinal cord stroke.
Thus, at this point, the patient’s condition included anoxic encephalopathy, aspiration pneumonia, and status post cardiac arrest. Shortly after, a conference was held with the family and the decision was made to do a terminal wean from ventilatory support.
DISCUSSION:
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