Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
ARREST R.Chan
Case
study
II:
Cardiac
Arrest
Rachel
Chan
Immaculata
University
Dietetic
Internship
Clinical
Rotation-
Mercy
Philadelphia
Hospital
2013
Table
of
Contents
I. Introduction...3
II. General
Information/
Social
History
.3
III. Report
on
Admission.4
IV. General
Health
History6
V. Physical
History...6
VI. Diet
History
Pre
Admission..8
VII. Pathophysiology..9
VIII. Progress11
IX. Discharge.17
X. Definition.18
XI. Illustrations...19
XII. References.......20
XIII. Appendices
21
I. Introduction
L.H.
is
a
70
year-old
African
American
male
who
was
admitted
to
Mercy
Philadelphia
Hospital
on
June
11th,
2013
for
syncope.
Upon
admission,
he
was
hypotensive
and
tachycardiac.
He
required
intubation
for
altered
mental
status
and
went
into
cardiac
arrest.
He
was
resuscitated
with
advanced
cardiac
life
support
(ACLS)
protocol
with
return
on
spontaneous
circulation.
L.H.s
hospital
course
was
most
remarkable
by
cardiac
arrest
and
possible
renal
cell
carcinoma.
After
he
received
the
inferior
vena
cava
filter,
he
was
transferred
to
the
cardiac
unit.
His
diet
order
was
cardiac
NCS
with
double
portions
of
protein
and
vegetables
because
patient
continuously
complained
of
not
having
enough
to
eat.
He
tolerated
his
diet
well
and
consistently
ate
100%
of
his
meals.
Patient
was
started
on
heparin
drip
and
Coumadin.
His
hospital
course
was
prolonged
due
to
his
international
normalized
ratio
(INR)
on
Coumadin
was
not
therapeutic.
Once
his
INR
level
reached
the
goal,
patient
was
discharged
and
was
scheduled
for
multiple
follow
up
appointments
with
his
primary
care,
urologist,
and
oncologist.
L.H.
received
diet
education
on
following
a
cardiac
and
diabetic
diet,
and
was
referred
to
a
diabetes
outpatient
program.
II. General
Information/
Social
history
lives
with
his
wife
and
daughter
at
home.
He
has
two
other
children
and
all
are
alive
and
healthy.
L.H.s
parents
both
died
from
complications
of
diabetes.
He
is
one
of
9
children
and
two
of
his
sisters
also
passed
away
from
diabetes
complications.
He
is
Function
Nutritional
side
effects
Antidiabetic,
hypoglycemic
weight
Diuretic,
antihypertensive
K,
Mg
(or
K,
Mg
supplement),
Calcium,
Na,
discontinue
Na
restriction
if
hyponatremic.
Avoid
natural
licorice
Amiodarone
Antiarrythmic
Anorexia.
N/V.
Abdominal
pain.
Constipation.
Rocuronium
Nondepolarizing
N/V
bromide
(Zemuron)
neuromuscular
blocker
Etomidate
General
anesthesia
N/V
Magnesium
sulfate
Treat
low
magnesium
Diarrhea,
nausea
and
rare
cases
of
paralytic
ileus
Calcium
chloride
Treat
low
calcium
None
Epinephrine
Narrows
blood
vessels
and
N/V
open
airways
in
the
lungs
Sodium
bicarbonate
Antacid,
alkalinizing
agent
May
increase
thirst
and
weight.
May
cause
belching,
gastric
distention,
cramps
and
flatulence.
Lasix
Diuretic,
antihypertensive
Recommend
K,
Mg
(or
K,
Mg
supplement),
cal,
Na.
N/V,
diarrhea,
constipation.
(Pronsky
&
Crowe,
2012)
protein
per
kilogram
method
to
determine
his
protein
needs.
L.H.
is
above
65
and
he
would
need
more
protein
therefore
we
chose
the
1-1.2
grams
of
protein
per
kilogram
for
this
patient.
Medication
Function
Aspirin
Lipitor
N,
dyspepsia,
abdominal
pain,
constipation,
D,
flatulence.
Famotidine
Metformin
(Glucophage)
Lasix
Diuretic, antihypertensive
Glipizide
Oral hypoglycemic
constipation.
Synthroid
Thyroid hormone
Appetite
changes,
weight.
Rare-
N/D.
Lisinopril
Antihypertensive
Metoprolol
L.H. usually eats lunch around 11:30 am. He would again eat another hamburger
with
some
type
of
canned
foods
such
as
SpaghettiOs.
Another
option
is
whatever
his
wife
cooks.
Then
he
would
also
drink
diluted
apple
juice.
Then
for
dinner
L.H.
always
tries
to
include
some
type
of
greens.
The
greens
usually
would
be
from
cans
however.
He
said
he
eats
at
least
4-5
cans
of
vegetables
each
week.
His
wife
would
cook
meats
and
it
would
usually
be
pork
chops,
beef,
or
chicken.
He
also
eats
fish
about
3
times
per
week.
His
wife
would
also
cook
Japanese
white
rice
as
a
side
dish
for
dinner.
Based
on
the
diet
history
obtained
from
patient,
it
was
not
possible
to
determine
if
L.H.
was
eating
within
his
recommended
caloric
range.
It
seemed
L.H.
does
not
eat
enough
fruits
and
vegetables.
It
also
seemed
L.H.
drinks
more
fruit
juices
than
water
and
it
may
be
beneficial
for
L.H.
to
switch
to
whole
wheat
bread
or
brown
rice
since
he
eats
mostly
white
rice.
Another
recommendation
for
L.H.
would
be
minimizing
his
intake
of
processed
foods
and
increasing
intake
of
fresh
fruits
and
vegetables.
VII. Pathophysiology
of
disease
(Pulmonary
embolism)
Pulmonary
embolism
(PE)
is
the
third
most
common
cause
of
cardiovascular
death
after
myocardial
infarction
(MI)
and
cerebrovascular
accidents
(CVA)
(pg
69,
Tarbox
&
Swaroop,
2013).
PE
is
a
potentially
fatal
condition
and
occurs
in
70
per
100
000
people
(Rudd
&
Phillips,
2013).
PEs
are
usually
undiagnosed
and
therefore
remains
a
main
reason
of
preventable
mortality.
Clinically
significant
PEs
typically
originate
as
venous
thromboembolism
(VTE)
in
the
lower
extremities
or
pelvic
veins
(Tarbox
&
Swaroop,
2013).
According
to
Kayhan,
S.,
nsal,
M.,
nce,
.,
Bakrc,
M.,
&
Arslan,
E.
(2012),
an
embolus
is
considered
acute
if
it
locates
centrally
within
the
vascular
lumen
or
if
it
blocks
and
causes
distention
of
the
involved
vessel
(pg
124,
Kayhan
et
al.,
2013).
There
are
various
risk
factors
that
could
potentially
lead
to
the
development
of
VTE.
Inherited
risk
factors
include
deficiencies
of
coagulation
inhibitors
such
as
antithrombin
(AT),
protein
C
(PC),
and
its
cofactor
protein
S
(PS).
Other
factors
strongly
associated
with
VTE
include
insufficient
anticoagulant
pathways
and
elevated
level
of
factor
of
VIII.
Acquired
risk
factors
that
are
strongly
associated
with
VTE
include
fracture
(hip
or
leg),
hip
or
knee
replacement,
major
general
surgery,
major
trauma
or
spinal
cord
injury.
Other
risk
factors
associated
with
VTEs
include
chemotherapy,
congestive
heart
failure
or
respiratory
failure,
malignancy,
previous
VTEs,
obesity
and
recent
immobilization
(Tarbox
&
Swaroop,
2013).
Wilbur
and
Shian
stated
that
the
initial
evaluation
of
patients
with
suspected
pulomary
embolism
includes
chest
radiography,
electrocardiography,
pulse
oximetry,
and
blood
gases
(2012).
This
is
similar
to
what
the
doctors
ordered
for
L.H.
when
he
was
admitted.
These
tests
are
not
sensitive
or
specific
enough
to
determine
or
diagnose
a
patient
with
PE,
but
they
are
required
for
physicians
to
evaluate
for
other
causes
of
the
presenting
symptoms
(Wilbur
&
Shian,
2012).
When
deep
venous
thrombi
detach
and
embolize
to
the
pulmonary
circulation,
pulmonary
embolism
occurs.
Pulmonary
vascular
obstruction
develops
and
leads
to
the
impairment
of
gas
exchange
and
circulation.
The
lower
lobes
of
ones
lungs
are
affected
more
often
than
the
upper
lobes
and
bilateral
lung
involvement
are
more
10
common.
Larger
emboli
typically
occur
in
the
main
pulmonary
artery
while
smaller
emboli
block
the
peripheral
arteries.
Peripheral
PE
can
cause
pulmonary
infarction
due
to
intra-alveolar
hemorrhage
(Tarbox
&
Swaroop,
2013).
As
alveolar
ventilation
exceeds
pulmonary
capillary
blood
flow,
pulmonary
arteries
occlusion
creates
dead
space
ventilation.
This
will
then
increase
pulmonary
vascular
resistance
due
to
vascular
obstruction
of
the
arteries.
Humoral
mediators
such
as
serotonin
are
released
from
activated
platelets
and
which
may
cause
vasoconstriction
in
unaffected
areas
of
the
lung.
Right
ventricular
after
load
increases
as
the
pulmonary
artery
systolic
pressure
increases.
This
will
lead
to
right
ventricular
failure
and
which
may
develop
the
impairment
of
the
left
ventricular
filling.
Lastly,
rapid
progression
to
myocardial
ischemia
may
occur
secondary
to
inadequate
coronary
artery
filling
and
this
may
lead
to
potential
hypotension,
syncope,
electromechanical
dissociation,
or
sudden
death
(Tarbox
&
Swaroop,
2013).
Warfarin
remains
to
be
the
first-line
option
for
the
treatment
of
pulmonary
embolism
as
Rudd
and
Phillips
found
in
their
research
(2013).
VIII.
Progress
L.H. was admitted on June 11th, 2013. As mentioned he was in his usual state of
health
until
the
morning
of
June
10th
when
he
lost
consciousness
at
church.
He
was
very
hypotensive
and
tachycardiac.
He
was
brought
to
the
emergency
room
at
Mercy
Philadelphia
Hospital.
He
was
found
to
be
in
atrial
fibrillation.
He
went
into
cardiac
arrest
after
attempts
were
made
to
cardiovert
and
intubate
him.
He
was
11
12
diabetes
was
poorly
managed
for
the
past
3
months.
Creatinine
was
at
1.7,
which
was
high
and
indicated
patient
had
acute
kidney
injury.
L.H.
received
an
inferior
vena
cava
vascular
filter
placement
on
June
13th.
The
procedure
was
done
via
his
right
common
femoral
vein
with
radiological
guidance.
The
placement
was
successful
and
L.H.
received
a
6
French
trapease
filter
in
the
infrarenal
inferior
vena
cava.
This
procedure
was
done
to
prevent
future
significant
PE
arising
from
a
DVT.
He
was
scheduled
to
the
cardiac
unit
as
he
became
more
medically
stable.
A
nutrition
follow-up
was
done
on
June
14th
to
assess
if
patients
diet
order
could
be
advanced.
Patient
was
doing
well
and
diet
order
was
advanced
to
cardiac
with
no
concentrated
sweets
(NCS)
by
the
physician
in
CCU.
The
cardiac
diet
is
a
low
sodium
and
low
fat
diet.
This
diet
with
the
no
concentrated
sweets
(NCS)
was
suggested
due
to
patients
medical
conditions
of
diabetes,
coronary
artery
disease
(CAD),
congestive
heart
failure
(CHF)
and
high
cholesterol.
Placing
patient
on
a
diabetic
cardiac
diet
may
be
too
restrictive
for
his
age
and
condition.
Patient
was
tolerating
diet
with
good
intake.
Patient
was
unavailable
for
education
at
time
of
visit.
Significant
lab
values
on
this
day
include
chloride
level
of
109,
carbon
dioxide
of
20
and
glucose
was
148,
which
remained
high
but
was
much
lower
comparing
to
his
glucose
levels
on
admission
and
the
day
before.
Creatinine
returned
to
baseline.
Cardiology
consult
was
done
on
the
same
day
and
the
cardiology
physician
found
no
obvious
event
that
provoked
to
L.H.s
thrombosis.
Recommendation
includes
13
14
Nutrition
follow-up
was
done
on
the
same
day.
Patient
was
resting
on
bed
and
appeared
well
nourished.
He
described
his
appetite
as
good
and
complained
of
not
having
enough
food
to
eat.
His
initial
nutrition
diagnosis
(altered
nutrition-related
labs)
was
not
resolved
at
the
time.
Interviewed
patient
and
provided
diabetes
education.
Patient
was
also
referred
to
outpatient
diabetes
program.
Patient
was
diagnosed
with
diabetes
20
years
ago,
therefore
he
was
aware
of
the
basics
of
carbohydrate
counting
and
the
education
session
focused
on
serving
sizes
because
patient
was
not
able
to
verbalize
correct
information
regarding
serving
sizes.
Diet
order
on
this
day
was
NPO
due
to
tests.
Nutrition
recommendation
was
changing
diet
back
to
cardiac
NCS.
He
was
allowed
to
get
double
portions
of
protein
and
vegetables.
On
June
21st,
physicians
had
noticed
L.H.s
levels
of
BUN
and
creatinine
were
trending
up
for
a
few
days.
Recommendations
were
to
institute
gentle
hydration
if
the
levels
continue
to
elevate.
Physicians
continued
to
monitor
patients
INR
levels.
Another
nutrition
follow-up
was
done
on
the
21st
to
see
if
patient
had
any
questions
on
handouts
or
diet
education.
Patient
expressed
he
had
no
further
questions.
On
June
26th,
INR
was
at
1.9
and
physicians
planned
to
discharge
patient
once
his
INR
level
becomes
2.
June
28th,
patients
INR
was
2
and
he
was
discharged
to
go
home.
Medications
Functions
Possible
nutrient
interactions
Reactions
seen
in
patients
Coumadin
Antithrombotic
agents,
None
15
anticoagulants
Humalog
Antidiabetic,
hypoglycemic
Weight gain.
None
Lisinopril
Levemir
Antidiabetic,
hypoglycemic
Weight gain.
None
Antiflatulent
Gas-x
(simethicone)
Belching
None reported
Heparin
Anticoagulant
Prilosec
Proton
pump
inhibitor,
antigerd,
antiulcer,
antisecretory
Levothroid
Patients
calcium
level
dropped
on
June
14th
but
remained
stable
for
the
rest
of
his
hospitalization
16
Sliding
scale
insulin
Antidiabetic,
hypoglycemic
Weight gain.
None
Metoprolol
Antihypertensive,
antiangina,
CHF
treatment,
MI
treatment,
cardioselective
beta-blocker
None
Senna-plus
Laxative
Electrolyte
imbalance,
increased
intestinal
peristalsis,
N/V,
cramps,
diarrhea
Electrolyte
imbalance
on
June
14th
Amlodipine
None
IX. Discharge
Patient
L.H.
was
discharged
on
June
28th.
Discharge
plan
was
to
schedule
patient
to
check
his
INR
levels,
MRI
for
his
abdomen
and
pelvis
in
ten
days
to
determine
if
patient
has
renal
cell
carcinoma.
He
was
also
recommended
to
schedule
17
appointments
with
his
primary
care
in
5
days,
urologist
in
10
days,
and
oncologist
in
14
days.
He
was
told
to
start
taking
warfarin,
arixtra
and
amlodipine
besylate.
He
was
told
to
continue
taking
metoprolol
tartrate,
metformin
HCl,
synthroid,
glipizide,
Lipitor
and
Aspirin.
He
was
to
continue
taking
lisinopril
but
the
dose
of
this
medication
was
changed
from
40mg
to
5mg.
L.H.
was
recommended
to
resume
a
cardiac
(low
fat
and
low
sodium)
and
diabetic
diet.
At
time
of
discharge,
patient
was
eating
100%
of
his
meals
and
tolerating
diet
well.
He
had
normal
bowel
movements
and
slept
well.
Patient
was
also
provided
with
information
on
following
a
cardiac
diet.
He
had
no
questions
regarding
the
diet.
He
was
encouraged
to
share
the
information
with
his
family
since
he
had
good
family
support
and
this
would
help
to
motivate
patient
to
adhere
to
his
dietary
restrictions.
Patient
was
receptive
to
diet
education.
At
the
time
of
discharge
patients
labs
were
normal.
His
glucose
level
was
still
high
but
it
was
relatively
lower
than
his
glucose
level
when
he
was
first
admitted.
X. Definition
of
medical
terms
Cardiovert-
a
procedure
to
restore
a
fast
or
irregular
heartbeat
to
a
normal
rhythm
(US
Department
of
Health
and
Human
Services,
2012)
Pulseless
electrical
activity
(PEA)-
continued
electrical
rhythmicity
of
the
heart
in
the
absence
of
effective
mechanical
function.
May
be
result
of
cardiac
damage
with
respiratory
failure
(Mosbys
Medical
Dictionary,
2009)
Pulmonary
embolism-
blockage
in
one
or
more
arteries
in
the
lungs.
In
most
cases
it
is
caused
by
blood
clots
that
travel
to
the
lungs
from
another
part
of
the
body.
Pulmonary
embolism
is
a
complication
of
deep
vein
thrombosis
(DVT)
(Tarbox
&
Swaroop,
2013)
18
Advanced
cardiac
life
support
(ACLS)-
clinical
interventions
for
the
urgent
treatment
of
cardiac
arrest
(AHA,
2010)
XI. Illustrations
Image 1. http://integrisok.com/upload/images/Pulmonology/pulmonary-embolism.gif
Image 2. http://ahmedshokry.files.wordpress.com/2012/04/pe.png
19
XII. References
Kayhan,
S.,
nsal,
M.,
nce,
.,
Bakrc,
M.,
&
Arslan,
E.
(2012).
Delays
in
diagnosis
of
acute
pulmonary
thromboembolism:
clinical
outcomes
and
risk
factors.
European
Journal
of
General
Medicine,
9(2),
124-129.
Mosbys
Medical
Dictionary.
(8th
ed.).
(2008).
St.
Louis,
MO:
Mosby.
Nelms,
M.,
Sucher,
K.,
Lacey,
K.
&
Long,
S.R.
(2011).
Nutrition
Therapy
&
Pathophysiology.
(2nd
ed.).
Boston,
MA:
Cengage
Learning.
Neumar,
R.W.,
Otto,
C.W.,
Link,
M.S.,
Kronick,
S.L.,
Shuster,
M.,
Callaway,
C.W.,Morrison,
L.J.
(2010).
Part
8:
Adult
advanced
cardiovascular
life
support.
2010
American
Heart
Association
guidelines
for
cardiopulmonary
resuscitation
and
emergency
cardiovascular
care.
Circulation,
122,
S729-S767.
doi:
10.1161/
CIRCULATIONAHA.110.970988
Potts,
K.
(2012).
Assessment
of
a
patient
presenting
with
suspected
pulmonary
embolism.
British
Journal
of
Cardiac
Nursing,
7(10),
483-489.
Pronsky
&
Crowe.
(2012).
Food
Medication
Interactions.
(17th
edition).
Birchrunville,
PA:
Food-Medication
Interactions.
20
Rudd,
K.M.
&
Phillips,
E.M.
(2013).
New
oral
anticoagulants
in
the
treatment
of
pulmonary
embolism:
efficacy,
bleeding
risk,
and
monitoring.
Thrombosis,
(2013),
1-11.
Retrieved
from
http://dx.doi.org/10.1155/2013/973710
Tarbox,
A.
&
Swaroop,
M.
(2013).
Pulmonary
Embolism.
International
Journal
of
Critical
Illness
and
Injury
Science,
3(1),
69-72.
U.S.
Department
of
Health
and
Human
Services,
National
Institute
of
Health,
National
Heart,
Lung
and
Blood
Institute.
(2012).
What
is
Cardioversion?
Retrieved
from
http://www.nhlbi.nih.gov/health/health-topics/topics/crv/
Wilbur,
J.
&
Shian,
B.
(2012).
Diagnosis
of
deep
vein
thrombosis
and
pulmonary
embolism.
American
Family
Physician,
86(10),
913-919.
XIII.
Appendices
Reference
ranges
(Mercy
Philadelphia
Hospital)
Constituent
WBC
Hemoglobin
Hematocrit
Sodium
Potassium
Chloride
Carbon
Dioxide
Anion
gap
BUN
Creatinine
Glucose
Calcium
Phosphorus
Magnesium
Albumin
Reference
range
4.5-11.0
13.5-17.5
g/dL
41-53%
136-147mEq/L
3.5-5.0mEq/L
98-108mEq/L
23-32mmol/L
6-16
6-25mg/dL
0.8-1.4mg/dL
70-99mg/dL
8.8-10.5mg/dL
2.5-4.5mg/dL
1.8-2.4mEq/L
3.6-5.2gm/dL
21
Prealbumin
20-40mg/dL
Lab
data
from
June
11
to
June
28
Na
K
Chloride
Carbon
dioxide
Anion
gap
BUN
Creatinine
Glucose
Calcium
Phosphorus
Magnesium
11-Jun
139
2.5L
98
24
17H
15
1.3
569H
10
4.4
2.9H
12-Jun
13-Jun
14-Jun
15-Jun
16-Jun
17-Jun
136
146
140
142
138
140
5.5H
3.6
3.2L
3.4L
3.7
3.8
98
109H
106
104
103
103
22L
20L
25
26
26
24
16
14
14
12
9
13
21
18
14
12
14
12
1.7H
1.2
1.1
1.1
1.1
1.1
695H
148H
140H
139H
215H
174H
9.1
8.9
8.2L
8.9
8.6L
9
3.3
2.3L
3.3
2
1.7L
2
Na
K
Chloride
Carbon
dioxide
Anion
gap
BUN
Creatinine
Glucose
Calcium
Phosphorus
Magnesium
18-Jun
20-Jun
21-Jun
24-Jun
27-Jun
28-Jun
138
136
139
139
137
138
4.3
4.6
4.4
4.2
4.2
4.1
102
100
101
102
103
103
22L
22L
25
25
24
24
14
14
14
12
10
11
17
22
25
23
26H
24
1.1
1.4
1.5H
1.4
1.3
1.4
297H
289H
188H
216H
171H
200H
9.2
9.4
9.3
9.1
9
9.2
3.9
3.3
3
3.7
2.2
2.1
2
1.8
Abbreviations
N-
nausea
V-vomiting
D-
diarrhea
K-
potassium
Mg-
magnesium
22
Ca-
calcium
Na-sodium
23