AF w/RVR + AS.
One of our staff calls up from the ED to the floor (gag) where I have to work for three more long weeks with an 'interesting case'. A fib with RVR is common; my first week, we had, like, seven of them, old people with underachieving, scatter-brained atria fibrillating away and ventricles that responded too quickly, leading to usually mild badness like relative hypotension, shortness of breath, weakness, and so on. This one, though...
He came in as a trauma, having fallen off of his bike. EMS did CPR for 'a minute or two' with a stated GCS of 4 initially, and then 9. He was hypotensive with an irregularly irregular pulse, and a harsh, mechanical murmur over the right and left chest. He had old, old fistulas on his right arm for dialysis.
Now A fib doesn't seem so benign. The irregularity keeps the ventricles from being able to pump well; first, they're chaotic, and second, they lose the 'atrial kick' that is often needed to fill them. This gentleman's murmur sounded like aortic stenosis, adding one more problem; the same ventricle that lost it's sidekick atrium also has to push against a tiny, hardened valve.
He comes to the ICU with a rate of 150 or so, and a pressure of 70/48. He won't answer me. He won't open his eyes. He won't do anything. He also doesn't respond to pain. But he's breathing. Thank goodness my ED staff from the department had warned me that he's got mental retardation, too; and thank goodness his mom was there to tell me that he hates hospitals, and ignores everyone. If I hold his eyes open, he looks at me. Cautiously, I decide that he's wide awake, just faking it. Usually this doesn't bother me to assume, but when his pressure is now, hmm, 72/50, it makes me nervous.
What to do? He gets a fluid bolus. He gets pads put on. Now I'm stuck. If I give him too much fluid, that floppy heart pushing against the valve will get filled like a water balloon and lose it's strength from being stretched. The rhythm I can try to fix with a shock, but I don't know if he has a clot in there that could shoot up into his scon-box and infarct a bunch of brain. Even if I shock him, he has a fixed outflow obstruction from the valve--a class of problems that can cause shock because blood is blocked. Other similar lesions include massive PEs, and tension pneumothorax, although the obstructing mechanisms are vastly different. He has two IVs, so we just watch him. Watch him, and worry.
I start explaining to his mother how he'll probably need surgery, and he yells 'no!' from the bed, then 'no, no, no!' just to make sure. Ironically, he looks strikingly like a bald Dustin Hoffman, making the comparison to Rain Man complete. I feel much better with my retarded, hypotensive, irregularly irregular, stenotic, and syncopal patient who is now vociferously negative. Thank you for your lack of cooperation, sir. Keep it up.
Review his labs; the EKG is irregularly irregular but no ST elevations; the chest x-ray, unfortunately, has a hugely wide mediastinum, but 'no!' is also the answer to my inquiry about chest pain, so perhaps this can wait. His troponin is 0.5, which is elevated but not yet in the NSTEMI territory (that is, he doesn't have a heart attack, yet).
As the Fat Man says, the delivery of good medical care is to do as much nothing as possible. So we do nothing. We watch. We wait. And at 7 am, when the team arrives, and the post-call sigh of relief occurs, my retarded, stenotic, hypotensive, irregular, contrarian friend is in a regular rhythm (on his own), has a pressure of 94/62, and still shouts 'no!' whenever surgery is mentioned, now opening his eyes and sticking out his bottom lip to make the point. More to come. I want to see that valve when it gets hacked out (he NEEDS it).