rhan101277
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We get a call about a 47 y/o female with a syncopal episode whom has a heart history. She has a 4cm hole in her septal wall.
We arrive to find her lying on the floor and her husband saying she got dizzy on the couch and tried to get up and walk and then decided to lie on the ground.
She is AAOx3 and states she had some chest pain about 2 hours ago and it went away. The pt is currently having some left shoulder pain and pain located behind her left scapula. She appears in no serious distress.
The patient is put on the monitor and afib with RVR is noted at 147 rate.
Blood pressure is 76/42
12 lead shows ST elevation in V1 and aVL. Marked ST depression in II,III,avF, V3-V6. A right sided 12 lead is done and shows no elevation or depression. No time to do a posterior.
Patient is administered 324mg ASA, NTG is not given due to BP. An IV could not be established after 4 attempts. The patient remained AAO in route to ER, blood pressure dropped as low as 54 systolic but patient is still responding and doesn't have further complaints.
I activate a STEMI alert and show doc the 12 lead when we arrive. STEMI is activated and she goes right to a room. Later STEMI is cancelled, it takes nurses 10 attempts to get IV. Doc orders cardizem to slow rate. It is later found her troponin was 1.47 and eventually went up to 8. I talked to doctor a few days later who said she was thankful I activated and it wasn't a "classic" activation and she had a NSTEMI MI.
My question is:
I was concerned about cardioverting her since it was possible this rate problem was due to ischemia or problems with low perfusion that existing in the SA/AV nodes.
If she would have been unresponsive I would have done it, but she was talking and I thought it could do more harm than good with her history.
I realize they administered cardizem to slow the rate but they seems like a risk/reward scenario. CCB's will diminish cardiac contractile force and hamper the bodies ability to raise blood pressure. They did have some fluids running concomitantly, but something needed to be done.
What are your thoughts? What would you have done?
We arrive to find her lying on the floor and her husband saying she got dizzy on the couch and tried to get up and walk and then decided to lie on the ground.
She is AAOx3 and states she had some chest pain about 2 hours ago and it went away. The pt is currently having some left shoulder pain and pain located behind her left scapula. She appears in no serious distress.
The patient is put on the monitor and afib with RVR is noted at 147 rate.
Blood pressure is 76/42
12 lead shows ST elevation in V1 and aVL. Marked ST depression in II,III,avF, V3-V6. A right sided 12 lead is done and shows no elevation or depression. No time to do a posterior.
Patient is administered 324mg ASA, NTG is not given due to BP. An IV could not be established after 4 attempts. The patient remained AAO in route to ER, blood pressure dropped as low as 54 systolic but patient is still responding and doesn't have further complaints.
I activate a STEMI alert and show doc the 12 lead when we arrive. STEMI is activated and she goes right to a room. Later STEMI is cancelled, it takes nurses 10 attempts to get IV. Doc orders cardizem to slow rate. It is later found her troponin was 1.47 and eventually went up to 8. I talked to doctor a few days later who said she was thankful I activated and it wasn't a "classic" activation and she had a NSTEMI MI.
My question is:
I was concerned about cardioverting her since it was possible this rate problem was due to ischemia or problems with low perfusion that existing in the SA/AV nodes.
If she would have been unresponsive I would have done it, but she was talking and I thought it could do more harm than good with her history.
I realize they administered cardizem to slow the rate but they seems like a risk/reward scenario. CCB's will diminish cardiac contractile force and hamper the bodies ability to raise blood pressure. They did have some fluids running concomitantly, but something needed to be done.
What are your thoughts? What would you have done?
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