em2177
Expert
Need some assistance coding this scenario. 93454,92980RC,33967??
PROCEDURE(S) PERFORMED: Left heart catheterization, possible angioplasty and
stenting.
REASON FOR EVALUATION: Acute Ml
HISTORY OF THE PRESENT ILLNESS: This patient is a 39-year-old gentleman with
multiple cardiovascular risk factors, who awoke with the sudden onset of chest
discomfort and multiple symptoms. The patient had a 911 call.
Inferior-posterior ST elevations were diagnosed and code AMI was called. I
arrived to the emergency room. The patient was in shock. I explained the
risks, benefits, and alternatives of left heart catheterization and possible
angioplasty and stenting with the patient and the family, and the family agrees
to proceed.
PROCEDURE: The patient was brought to the catheterization lab emergently and
prepped and draped in a sterile fashion. Lidocaine was placed to the right
common femoral area, and a 7-French sheath was placed to the right common
femoral artery using Seldinger technique. Next a JL4 was used to engage the
left main with multiple-view angiography followed by 7-French JR4 with side
holes guide catheter. I engaged the right coronary ostium. Angiography was
performed.
At this time Angiomax was started per protocol. I increased the IV fluids due
to hypotension and started the patient originally on 5 of dopamine due to
hypotension. I was able to take a Luge wire across into the posterolateral
branch. Predilatation with a 2.0 x 15 Apex over-the-wire balloon was performed
and repeat angiography was performed. Posterolateral branch did not appear to
be an extremely large branch. However, there was now a large posterior
descending artery.
At this point the patient's blood pressure dropped further. He had continued
ectopy. His systolic blood pressure was in the 40-60 range. He had altered
levels of consciousness. Thus, we called anesthesia emergently for support of
intubation, and Dr. immediately arrived to help control the airway. The
patient had significant nausea and vomiting and was suctioned. The patient did
have ventricular fibrillation cardiac arrest requiring 200 joules of shock with
reestablishment of sinus rhythm. The patient awoke at that time. However, due
to the complexity, the hypotension, and the shock, as well as his nausea and
vomiting, I felt that to control his airway was more prudent. Thus, Dr. Buese
sedated the patient and intubated per standard protocol without complication.
At this point the patient remained in cardiogenic shock. Thus, I used
lidocaine to the left common femoral area and put in a 6-French sheath. This
6-French sheath was then exchanged, per standard protocol, for an intraaortic
balloon pump, and this was placed under fluoroscopic guidance to the descending
thoracic aorta and hooked to 1:1. At this point the patient's blood pressure
only minimally improved with augmentation. He was on full IV fluids as well as
dopamine of 15.
At this point there were discussions regarding the need for emergent coronary
artery bypass grafting due to 3 vessel disease. We attempted to cali
cardiothoracic surgery. However, there was going to be a delay in care. Thus,
I felt more prudent at this time to stabilize the right coronary artery in this
distal segment and perform stenting with a 3.5 x 18 Integrity non-drug-eluting
stent. Status post stenting there was TIMI-3 flow and 0% residual stenosis.
There was now a large PDA which is widely patent with grade 2 collaterals,
filling a chronic total occlusion of the LAD. Multiple-view angiography was
performed. Wire and catheter were removed.
Next, at this point the patient remained in cardiogenic shock and was
hypotensive. I was worried about the high dose of dopamine, and the
intraaortic balloon pump was not supporting the patient. Thus, through the
right common femoral area we did angiography. This was followed by insertion
of the Impella device which was placed into the LV under fluoroscopic guidance
and prepped in standard protocol and reestablished adequate pressure. Then,
through the left common femoral artery we placed a wire through the intraaortic
balloon pump. The intraaortic balloon pump was removed and we placed a
9-French sheath to the left common femoral area. The patient was
hemodynamically stable. We were able to reduce dopamine. At this time he is
intubated and airway is controlled. He is in critical condition.
PROCEDURE(S) PERFORMED: Left heart catheterization, possible angioplasty and
stenting.
REASON FOR EVALUATION: Acute Ml
HISTORY OF THE PRESENT ILLNESS: This patient is a 39-year-old gentleman with
multiple cardiovascular risk factors, who awoke with the sudden onset of chest
discomfort and multiple symptoms. The patient had a 911 call.
Inferior-posterior ST elevations were diagnosed and code AMI was called. I
arrived to the emergency room. The patient was in shock. I explained the
risks, benefits, and alternatives of left heart catheterization and possible
angioplasty and stenting with the patient and the family, and the family agrees
to proceed.
PROCEDURE: The patient was brought to the catheterization lab emergently and
prepped and draped in a sterile fashion. Lidocaine was placed to the right
common femoral area, and a 7-French sheath was placed to the right common
femoral artery using Seldinger technique. Next a JL4 was used to engage the
left main with multiple-view angiography followed by 7-French JR4 with side
holes guide catheter. I engaged the right coronary ostium. Angiography was
performed.
At this time Angiomax was started per protocol. I increased the IV fluids due
to hypotension and started the patient originally on 5 of dopamine due to
hypotension. I was able to take a Luge wire across into the posterolateral
branch. Predilatation with a 2.0 x 15 Apex over-the-wire balloon was performed
and repeat angiography was performed. Posterolateral branch did not appear to
be an extremely large branch. However, there was now a large posterior
descending artery.
At this point the patient's blood pressure dropped further. He had continued
ectopy. His systolic blood pressure was in the 40-60 range. He had altered
levels of consciousness. Thus, we called anesthesia emergently for support of
intubation, and Dr. immediately arrived to help control the airway. The
patient had significant nausea and vomiting and was suctioned. The patient did
have ventricular fibrillation cardiac arrest requiring 200 joules of shock with
reestablishment of sinus rhythm. The patient awoke at that time. However, due
to the complexity, the hypotension, and the shock, as well as his nausea and
vomiting, I felt that to control his airway was more prudent. Thus, Dr. Buese
sedated the patient and intubated per standard protocol without complication.
At this point the patient remained in cardiogenic shock. Thus, I used
lidocaine to the left common femoral area and put in a 6-French sheath. This
6-French sheath was then exchanged, per standard protocol, for an intraaortic
balloon pump, and this was placed under fluoroscopic guidance to the descending
thoracic aorta and hooked to 1:1. At this point the patient's blood pressure
only minimally improved with augmentation. He was on full IV fluids as well as
dopamine of 15.
At this point there were discussions regarding the need for emergent coronary
artery bypass grafting due to 3 vessel disease. We attempted to cali
cardiothoracic surgery. However, there was going to be a delay in care. Thus,
I felt more prudent at this time to stabilize the right coronary artery in this
distal segment and perform stenting with a 3.5 x 18 Integrity non-drug-eluting
stent. Status post stenting there was TIMI-3 flow and 0% residual stenosis.
There was now a large PDA which is widely patent with grade 2 collaterals,
filling a chronic total occlusion of the LAD. Multiple-view angiography was
performed. Wire and catheter were removed.
Next, at this point the patient remained in cardiogenic shock and was
hypotensive. I was worried about the high dose of dopamine, and the
intraaortic balloon pump was not supporting the patient. Thus, through the
right common femoral area we did angiography. This was followed by insertion
of the Impella device which was placed into the LV under fluoroscopic guidance
and prepped in standard protocol and reestablished adequate pressure. Then,
through the left common femoral artery we placed a wire through the intraaortic
balloon pump. The intraaortic balloon pump was removed and we placed a
9-French sheath to the left common femoral area. The patient was
hemodynamically stable. We were able to reduce dopamine. At this time he is
intubated and airway is controlled. He is in critical condition.