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CARDIAC

ARREST R.Chan










Case study II:
Cardiac Arrest










Rachel Chan
Immaculata University Dietetic Internship
Clinical Rotation- Mercy Philadelphia Hospital
2013

CARDIAC ARREST R.Chan

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















CARDIAC ARREST R.Chan

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

Patient L.H. is a 70 year-old male. He is African American. He speaks English and

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

CARDIAC ARREST R.Chan

retired and family responsibilities include walking to Center City of Philadelphia to


pay utility bills. He denies alcohol or drug use. He does not smoke. Patient L.H. is a
Jehovahs witness.
III. Report on admission

L.H. was admitted on June 11th, 2013. He was in his usual state of health until he
lost consciousness in the morning of the same day. He had multiple episodes of loss
of consciousness and was diaphoretic when it happened. When he was brought to
the Emergency Room (ER) of Mercy Philadelphia Hospital, he was found to be in
atrial fibrillation and hypotensive. Patient was cardioverted then intubated, and
immediately after he went into cardiac arrest and had pulseless electrical activity
(PEA). He was revived successfully and transferred to the Critical Care Unit (CCU) for
further care. Before being transferred to the CCU, computed tomography (CT) scan
of the brain and chest were done. CT chest showed massive bilateral pulmonary
emboli while CT brain showed no acute abnormalities. L.H. became
hemodynamically stable shortly after and woke up. Patient was oriented to person
and place but not the time. He was not sure what happened yesterday (June 11th)
and could only recall being weak in the morning.
In the ER, patients overall review of system was positive for fatigue, syncope,
cardiopulmonary arrest, diarrhea for 1 week, hyperglycemia over the last week in
the 400s, dizziness and fall. All other systems were reviewed and appeared to be
negative. L.H. was in no apparent distress upon the physical examination. He
presented with decreased range of motion of back. L.H.s admitting diagnoses

CARDIAC ARREST R.Chan

include bilateral pulmonary embolism, cardiac arrest secondary to pulmonary


embolism, atrial fibrillation secondary to pulmonary embolism, poorly controlled
diabetes, acute kidney injury, and pulmonary infarctions.
At admission, physician ordered echocardiogram, ultrasounds on lower
extremity, cardiology consultation and heparin drip. Diet order was nil per os (NPO),
which is nothing by mouth. Medications ordered on June 11th include sodium
chloride, dextrose, insulin protocol, furosemide, amiodarone HCl, zemuron, amidate,
magnesium sulfate, calcium chloride, epinephrine, and sodium bicarbonate. Consult
was placed for critical care unit (CCU) intensivist and neurology.
Medication
Insulin
Furosemide

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)

CARDIAC ARREST R.Chan

Table 1. Medications administered to L.H. at the Emergency Room.




Lab values Reference range Indication
Hemoglobin 15.2
13.5-17.5 g/dL
WNL
INR
1.0
2.0- 3.0

Creatinine 1.3
0.8-1.4mg/dL
WNL
Potassium 2.5
3.5-5.0mEq/L

Glucose
569
70-99mg/dL

Table 2. Patient L.H.s lab values at the Emergency Room.
IV. General Health History
Mr. L.H. was in his usual state of health before he was admitted to the hospital.
According to patient, he had a regular bowel movement, slept well, and was active
daily. However patients medical record indicated he had diarrhea for 1 week. He
works on his house daily and considers that as his exercise. He also does auto
mechanic work. Otherwise sometimes he walks from West Philadelphia to Center
City Philadelphia to pay bills. However L.H. stated he did not eat on the day he
presented with a syncope episode at church.
V. Physical history
Patient L.H.s past medical history is significant for hypertension, high
cholesterol, coronary artery disease (CAD), congestive heart failure (CHF), diabetes
and hypothyroidism. Past surgical history includes appendectomy and coronary
stent a few years prior. Medications prior to admission can be seen in the chart
below. L.H.s is 6 feet and 2 inches tall and weighs about 193lb. His BMI is 24.8,
which means he is at a healthy weight. We used the calorie per kilogram method to
determine his calorie need and L.H.s caloric need ranges from 1760-2200 calories.
His protein needs range from 88-106 grams per day. We used the 1-1.2 grams of

CARDIAC ARREST R.Chan

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

Nutritional side effects

Aspirin

Analgesic, antipyretic, antiarthritic,


nonsteroidal anti-inflammatory drug, to
prevent cerebrovascular accident (CVA) or
myocardial infarction (MI)

May cause sudden,


serious gastric
bleeding. N/V,
dyspepsia, black tarry
stools.

Lipitor

Antihyperlipidemic, to prevent or reduce


risk of cardiovascular events, to slow
progression of atherosclerosis

N, dyspepsia,
abdominal pain,
constipation, D,
flatulence.

Famotidine

Antiulcer, antigerd, antisecretory

Reduce gastric acid


secretions, increase
gastric pH, N/V/D,
constipation. May
iron and vitamin B12
absorption.

Metformin
(Glucophage)

Antihyperglycemic agent, biguanide

Lasix

Diuretic, antihypertensive

Glipizide

Oral hypoglycemic

cal if weight loss


needed. May
weight. Fol and
vitamin B12
absorption.
Recommend K, Mg
(or K, Mg supplement),
cal, Na. N/V, oral
irritation, cramps,
diarrhea, constipation.
or appetite.
weight. Dyspepsia,
nausea, diarrhea,

CARDIAC ARREST R.Chan

constipation.

Synthroid

Thyroid hormone

Appetite changes,
weight. Rare- N/D.

Lisinopril

Antihypertensive

Metoprolol

Antihypertensive, antiangina, CHF


treatment

Insure adequate fluid


intake/ hydration. May
recommend reducing
sodium and calcium
intake. Avoid salt
substitute. Caution
with K supplement.
Avoid natural licorice.
Dry mouth, N/V,
dyspepsia, flatulence,
D, constipation.

(Pronsky & Crowe, 2012)


Table 3. L.H.s outpatient medications.
VI. Diet history based on pre-hospitalization intake
L.H. did not eat on the day before he was admitted to the hospital. Therefore a
24-hour food recall would not be helpful and provide any information about what
his usual diet is like. However L.H. was able to recall what he normally eats on a
regular weekday. He usually eats hamburgers in the morning for breakfast, with
ketchup and lettuce or spinach. He might eat the hamburger might be with or
without the bun. Sometimes he would eat it with wheat bread. L.H. also drinks juice
diluted with water in the morning. He also eats white rice with eggs for breakfast
sometimes.

L.H. usually eats lunch around 11:30 am. He would again eat another hamburger

CARDIAC ARREST R.Chan

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

CARDIAC ARREST R.Chan

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

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CARDIAC ARREST R.Chan

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

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CARDIAC ARREST R.Chan

successfully intubated but he went into PE arrest, which required cardiopulomary


resuscitation (CPR) with ACLS protocol with return on spontaneous circulation.
L.H. was then transferred to the intensive care unit. CT of the brain showed no
acute abnormalities and CT chest PE protocol showed bilateral pulmonary
embolisms in the distal ends of the pulmonary arteries. Patient woke up after being
transferred to the intensive care unit and tube was taken out due to being
dislodged. L.H. was doing fine and oxygenated on 2 liters nasal cannula.
Neurology, CCU intensivist and nutrition were consulted on June 12th. Neurology
consult found that patient noticed he tends to walk on the left for the past 2
months. He was also very sleepy during interview but was arousable. L.H. was
believed to have abnormal gait due to severe polyneuropathy from diabetes and
thyroid disease. Nutrition consult suggested to remain NPO while on insulin drip as
prescribed by the physician, then to advance diet once subcutaneous insulin was
started. Nutrition recommendations include to manage blood sugar and initiate
nutrition within 24-48 hours. His nutrition diagnosis was altered nutrition related
lab values related to endocrine dysfunction as evidenced by altered A1C and was
placed at level 1, which means he is at a high nutritional risk. CCU consult suggested
to continue with heparin drip, fluid resuscitation, monitor intake and output and
insulin infusion. Significant lab values on June 12th include glucose of 695, potassium
level of 5.5, carbon dioxide level of 22, triglyceride level of 49, low density
lipoprotein (LDL) of 108, and A1C level of 13.3. This A1C level indicated patients

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CARDIAC ARREST R.Chan

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

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CARDIAC ARREST R.Chan

hypercoagulability workup and check for protein C or protein S deficiency,


antithrombin 3 and factor V Leiden mutation and prothrombin gene mutation.
Patient L.H. was suggested to be on anticoagulation for 6 to 12 months, to remain
on heparin and to start on Coumadin. L.H.
On June 17th, L.H. complained of dark colored urine. However there is no frank
hematuria or blood loss. Patient was assessed and active problem list included acute
PE, left renal mass, acute DVT, type 2 diabetes and accelerated hypertension. Plan
was to titrate L.H.s antihypertensive regimen to control blood pressure. He is also
on heparin drip and Coumadin. Plan is to continue to bridge until INR gets
therapeutic. CT of the abdomen and pelvis showed left side renal mass was
suspicious of renal cell carcinoma. Plan is to perform MRI for abdomen and pelvis
and to consult urology. However L.H. was status post inferior vena cava filter
placement during his hospital course therefore he was to wait for 6 weeks before he
could receive an MRI.
On June 19th, patients cytoscopy yielded no abnormality. Patient L.H. was
diagnosed with mild hematuria, which physicians thought was most likely secondary
to the heparin drip. Suggestions were to continue heparin drip due to the massive
PE. They determined that the risk of discontinuing heparin drip and anticoagulation
outweighed the benefit of cessation of anticoagulation. Therefore plan was to
continue heparin drip and Coumadin and closely monitor labs for evidence of gross
hematuria.

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CARDIAC ARREST R.Chan

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,

Taste changes, nausea,


vomiting, cramps, diarrhea.

None

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CARDIAC ARREST R.Chan

anticoagulants
Humalog

Antidiabetic,
hypoglycemic

Weight gain.

None

Lisinopril

Antihypertensive Insure adequate fluid intake/ None


hydration. May recommend
reducing sodium and calorie
intake. Avoid salt substitute.
Caution with K supplement.
Avoid natural licorice.

Levemir

Antidiabetic,
hypoglycemic

Weight gain.

None

Antiflatulent
Gas-x
(simethicone)

Belching

None reported

Heparin

Anticoagulant

Nausea, vomiting, abdominal None


pain, GI bleed, constipation,
black tarry stools.

Prilosec

Proton pump
inhibitor,
antigerd,
antiulcer,
antisecretory

May decrease absorption of


iron. Decrease absorption of
vitamin B12. Calcium
supplement may be advised.

Levothroid

Thyroid hormone Take Fe, Ca, or Mg


None.
supplement separately from
drug by more than or at 4
hours. Decreased absorption
with soy, soy milk, walnuts,
cottonseed meals, and high
fiber foods. Caution with
grapefruit/related citrus.
Appetite changes, weight
loss. Nausea, diarrhea.

Patients calcium
level dropped on
June 14th but
remained stable
for the rest of his
hospitalization

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CARDIAC ARREST R.Chan

Sliding scale
insulin

Antidiabetic,
hypoglycemic

Weight gain.

None

Metoprolol

Antihypertensive,
antiangina, CHF
treatment, MI
treatment,
cardioselective
beta-blocker

Decrease Na and decrease


calorie intake may be
recommended. Dry mouth,
N/V, dyspepsia, flatulence,
diarrhea, constipation

None

Senna-plus

Laxative

Electrolyte imbalance,
increased intestinal
peristalsis, N/V, cramps,
diarrhea

Electrolyte
imbalance on
June 14th

Amlodipine

Antihypertensive, Decrease Na and decrease


antiangina, Ca
calorie intake may be
channel blocker recommended. Dysphagia,
nausea, cramps

None

(Pronsky & Crowe, 2012)


Table 4. Medications L.H. was on while being hospitalized.
PES statements
1. Altered nutrition-related lab values related to endocrine dysfunction as evidenced
by altered level of A1C and blood glucose.
2. Food- and nutrition-related knowledge deficit related to lack of prior nutrition-
related education as evidenced by reports of patient verbalizes inaccurate or
incomplete information.

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

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CARDIAC ARREST R.Chan

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)

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CARDIAC ARREST R.Chan

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

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CARDIAC ARREST R.Chan


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.

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CARDIAC ARREST R.Chan

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

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CARDIAC ARREST R.Chan

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

CARDIAC ARREST R.Chan

Ca- calcium
Na-sodium



23