Car crash and acute MI

[ken158]

The PT is a 70 year old male in a severe car crash, found in his seat. He has signs of an acute MI (nontraumatic chest pain, shortness of breath, all the classic signs). He is A&O X3.

What will you do?

 

[bahnrokt]

Does he have any trauma injuries? Does he need to be boarded? Vitals? How long to extricate? How long is the ride to the nearest appropriate hospital? Is he the worst pt in the crash? HX?

 

[ken158]

Yes, suspect spinal. Possible femur fracture. It will take some time to apply the KED. He's the only pt in the crash, history of angina pectoris. He has nitroglycerin with him (DICE is clear).

 

[Handsome Robb]

How can you call his pain "non traumatic" after being in a "severe car crash"? Did the pain start before or after the accident? Did the accident cause the pain or did the pain cause the accident? You didn't specify.

Treat him appropriately and transport... I don't understand your question. Work him up for the trauma and chest pain...Vitals, c-spine if appropriate, 12-lead if you're really going down the ACS route, NTG if you're still stuck on the ACS route but I'd be careful with a multisystems trauma patient and NTG, especially if he's hypovolemic. I'd shy away from aspirin on the chance that he has internal bleeding from the accident (edit: you said femur fx - no ASA then), IV, O2 if indicated, analgesia and transport. Activate your STEMI protocol if the 12-lead shows a STEMI, and drive faster...

Lots of people have SOB and chest pain after car accidents, especially with airbag deployment if they have a history of reactive airway diseases.

 

[sirengirl]

What interests me is why he crashed. Did he black out from hypotension? Possibly caused by cardiac arrhythmias? Does he have a hx if syncope in this at all? If so i'm 12leading the shoot outta him before that KED goes on. Agree no ASA and would consider NTG after initial BP and a look at my limb leads to check for right side. If BP is good and RR sustained, also consider morphine (depending on protocol in the area in regards to what is obviously a trauma alert)

 

[Aidey]

What do the limb leads have to do with the right side?

 

[JPINFV]

What do the limb leads have to do with the right side?

II, III, AvF are all limb leads and the leads that an inferior/left side EKG would have ST elevation.

 

[sirengirl]

II, III, AvF are all limb leads and the leads that an inferior/left side EKG would have ST elevation.

And AMI on the right side is well known for dumping the preload to the right side of the heart, making them hypotensive or highly susceptible to become hypotensive if you give NTG or morphine because both dump the preload.

 

[Aidey]

II, III, AvF are all limb leads and the leads that an inferior/left side EKG would have ST elevation.

I misunderstood when I read it. My brain inserted "move" into that sentence so the way I read it was that she would move the limb leads to look at the right side.

And AMI on the right side is well known for dumping the preload to the right side of the heart, making them hypotensive or highly susceptible to become hypotensive if you give NTG or morphine because both dump the preload.

Just FYI that OMS-3 under his name stands for osteopathic medical school year 3.

 

[sirengirl]

Just FYI that OMS-3 under his name stands for osteopathic medical school year 3.

Didn't mean my reply to sound insulting or belittling, was explaining my thought process

 

[JPINFV]

Just FYI that OMS-3 under his name stands for osteopathic medical school year 3.

Um.. ok... I think she was completing the thought of the issues with right side STEMIs...

 

[Veneficus]

Who cares?

I think it is important to remember to see the forest from the trees.

Tree #1: acute trauma patient

Tree #2: potential MI

Forest: you can't do anything to accurately diagnose and treat these things in combination. Rapidly extricate and drive safely to the place that can.

Let's keep this in perspective.

high speed crash.
restrained
70 years old
long bone fracture

How do you call that a traumatic chest pain?

Even if by some miracle, the patient describes crushing substernal chest pain radiating to the arm and jaw with nausea prior to crashing, how do you rule out a cardiac contusion, pulmonary contusion, early tamponade, or aortic tear with just the information given?

These pathologies can occur in this case even if the patient also had an MI.

Let's talk about this MI. Could EKG changes be caused by trauma?
Could this be a non STEMI MI?

Ruling out angina with nitro in this case is also problematic.

First, if there is bleeding somewhere, nitro is going to decrease venous return to the heart, which is exactly the main life threatening problem in hemorrhage.

Second, endogenous opioid, endorphines, are shown to cause subendocardial capilary constriction. (appearing as a Qwave infarct on EKG sometimes) so his "nontraumatic chest pain" might not even be responsive to anything you have. Decreasin venous retun may actually make the problem worse.

In a controlled environment, playing with ASA in a bleeding patient is reasonable when you have a more accurate Dx.

But you have to be rather sure, especially in an elderly trauma patient. Forget bleeding in to the closed compartment of his distal extremity, how did you determine he didn't rupture bridging veins in his sub arachnoid space?

Giving ASA to that would be a far more serious problem than some blood in his leg.

From the stanpoint of protocol, you will probably be required to suspect a spinal injury. Which in an elderly person in a high speed accident is probably a good idea. The actual method of (supposed)immobilization might be a factor. This person may have other issues that preclude a longboard with head blocks and a bunch of straps.

Despite what is taught in trauma in EMS, it is in my not always humble opinion one of, if not the most complex disease in humans. It involves every system in the body, from skin to endocrine. Trauma has multiple phases. It also requires a combination of surgery and medicine in order to treat. (Incidentally the only other medical specialty that shares these characteristics is OB/Gyn)

Once this patient gets to a trauma center, many very tough decisions are going to have to be made. Like what is treated first, what is neglected, minimally invasive, maximumly (is that even a word?) aggresive with potentially multiple maybe simultaneous surgeries. Perhaps sequential. Not to mention the details of things like anesthesia, surgical techniques, etc.

Complex patients like this require an ivory tower, multispecialty trauma center.

If you delay that, especially monkeying around with community facilities, the only thing that will happen is delaying the patient the care they need.

If this was a scenario given in class, the only thing your instructor should require of you is: "this patient may be beyond EMS, let's just go."

Discretion is sometimes the better part of valor. Don't play games when you are in over your head.

 

[OzAmbo]

What Veneficus said

 

[AnthonyTheEmt]

The PT is a 70 year old male in a severe car crash, found in his seat. He has signs of an acute MI (nontraumatic chest pain, shortness of breath, all the classic signs). He is A&O X3.

What will you do?

Can you provide some details about this guy? Did you have any injuries after the severe car crash? How does he present? Need more details before making any decisions on this guy.

 

[VFlutter]

Can you provide some details about this guy? Did you have any injuries after the severe car crash? How does he present? Need more details before making any decisions on this guy.

I don't think this is real, It sounds like the typical classroom scenario to make you think critically and to prioritize.

 

[NomadicMedic]

I don't think this is real, It sounds like the typical classroom scenario to make you think critically and to prioritize.

Well, there was recently an MVA here where the 70ish year old driver was en route to the ED for his chest pain, lost control of his vehicle, struck another vehicle and sustained extensive multi system trauma, along with his MI.

Obviously, he was treated for trauma, not chest pain.

So, "real or not", it's certainly a scenario worth investigating.

 

[Tigger]

I don't think this is real, It sounds like the typical classroom scenario to make you think critically and to prioritize.

One of the first EMS calls I ever ran was single vehicle MVA into a tree. Elderly driver suffered an MI and lightly hit a fire hydrant. Happily it was right next to the cath lab and the agency set the current time to balloon record.

 

[Maine iac]

http://hqmeded-ecg.blogspot.com/2012/08/gunshot-wound-to-chest-with-st-elevation.html

http://hqmeded-ecg.blogspot.com/2012/07/right-bundle-branch-block-after-blunt.html

Dr. Smith highlights two cases where there are EKG findings not associated with ACS.


This guy you are talking about will get the full trauma work up and from what you are alluding to in your scenario will be going lights and sirens to a TRAUMA center. If my transport time is long enough and I have done everything else on my list he might get a 12 lead done. If I notice any EKG changes they'll be passed along to the Drs waiting for my arrival.

 

[Milla3P]

Possible femur fracture. It will take some time to apply the KED.

Then why do it? This seems like more of a rapid extrication situation. There are faster ways to take someone out of a vehicle.

 

[Handsome Robb]

Then why do it? This seems like more of a rapid extrication situation. There are faster ways to take someone out of a vehicle.

Just because someone has a femur fracture doesn't mean they are automatically bleeding into that space...

If his vitals are "stable" I'd be keen to take a little bit of time with this guy to make sure he's comfortable. Unless the pain started before the accident I'm not really thinking MI in this scenario. Even then, I see multiple people a day complaining of "crushing chest pain radiating into my arm" that aren't having STEMIs or NSTEMIs for that matter. Not saying it isn't possible but with a traumatic mechanism I'd be looking more at that than a cardiogenic issue. That's just me and my very inexperienced self's personal opinion.

With that said, elderly bring out a whole new can of worms? He may have a "normal" rate and still be bleeding because the medications he's on don't allow his HR to increase to compensate.... Just one example.

I was talking to my FTO about this today actually. Like Vene pointed out trauma could very well cause ECG changes. To what extent, I regret to say that I'm not sure but it's one thing to add to my long list of things to study.

Without further information we are all just taking shots in the dark about this scenario. There is no cut and dry way to do things that fits every patient, as you all know.