Case -T1-1B CRITICAL CARE SERVICE

Essay

Case
-T1-1B CRITICAL CARE SERVICE
Dr. Sutton, emergency room physician, called in Dr. Elhart, the cardiologist on call from the local clinic, to provide critical care services to Linda Paulo. Code the services provided by Dr. Elhart in the following case.
LOCATION: Hospital Emergency Department
PATIENT: Linda Paulo
PHYSICIAN: Marvin Elhart, MD
The patient is a 23-year-old Hispanic female who took some medications to sleep tonight, including what sounds like amitriptyline and Hydrocodone. She called her husband, who came over at approximately 9:30 tonight. She slept for an hour until 10:30, and then she started having generalized seizures on and off four times, during which her husband called
911. Paramedics were on the scene in 4 to 5 minutes. The patient was immediately intubated. Monitor showed wide QRS (Q-wave, R-wave, S-wave) complexes. She received bicarbonate and was sent to the emergency room. I saw her with Dr. Sutton in the emergency room. She was actively seizing. She received multiple doses of Ativan, and then I gave her around 20 mg (milligram) of Versed and started a Versed drip. She was on a bicarbonate drip, and we gave her multiple amps of bicarbonate. Her QRS narrowed down. Unfortunately, this did not last long. The patient went bradycardic and then went into a junctional rhythm. Her blood pressure was dropping on occasion and then coming back up again. She eventually coded. We resuscitated her for more than 20 minutes. She had multiple rhythm problems including asystole, ventricular tachycardia, and pulseless electrical activity. She received multiple doses of epinephrine and multiple amps of sodium bicarbonate. She eventually recovered back in sinus rhythm after defibrillation for ventricular tachycardia.
Her ABGs (arterial blood gases) initially were pH (potential of hydrogen) 74.8 and PCO2 (partial pressure of carbon dioxide) 28. Oxygen was around 500 on 100% FiO2 (forced inspiration oxygen) with a bicarb of 18. Her bicarb went up to 23 at the end of the code when she was in sinus rhythm. She was transferred up to the floor with three IVs (intravenous) running at 999.
On the floor, her blood pressure dropped again to 50. She went bradycardic and coded. She received at least two shocks. She received again multiple doses of epinephrine and received multiple sodium bicarbonate amps, at least eight.
Discussions were held with the husband multiple times since admission with Dr. Sutton and myself. I brought him to the room while the patient was getting CPR (cardiopulmonary resuscitation) the second time. After 20 minutes, the patient was having no cardiac activity whatsoever, and after 20 minutes decided to stop CPR after discussing this with her husband.
DISCHARGE DIAGNOSIS: Cardiac arrest, tricyclic antidepressant, resulting in severe neural and cardiac toxicity and eventually resulting in death. Time spent with patient was 120 minutes.
T1-1B:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________