# Daisys Dilema



## MrBrown (Jan 2, 2011)

It's a very hot day and you are called to an elderly lady who has had a "spell" while tending to her flowers.  She was removing some weeds and her husband took them down to the mulch pile on the tractor, when he came back she was collapsed on the ground.  They are on a country property about an hour by road to the nearest hospital.

The patient relates she felt dizzy then had back, jaw and neck pain then crushing heavy chest pain; she does not remember what happened after that and woke up on the ground.  When her husband found her he was not sure if she was breathing and said it looked like she was dead.  She has no cardiac or medical history apart from taking oral antihypocglycaemics for diabetes.  

BP 80 systolic
HR 48
RR 8, shallow and laboured
SPO2 97% on 10lpm
BGL 5mmol (about 85 mg/dl)
GCS 13 (3/4/6)
Appears very pale/grey and shut down
Pain described as heavy, central chest pain 7/10
Anterioseptal infarct on 12 lead with ST elevation in V1-4
Underlying ECG is a sinus rhythm 

Intensive Care (ALS) are coming towards you and will locate in approx 15 minutes, HEMS are avaliable but will take about 20 minutes to land at a local sportsground and its an hour (in good traffic) up the interstate to hospital.

1) How do you manage this patient, and
2) What is wrong with them?


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## usafmedic45 (Jan 2, 2011)

What meds is she taking specifically?  What's the weather like?  What was she specifically doing with her flowers when this all started?

I'd give her some glucose for starters to correct the BGL being a little low.  I'd probably drop her back to a nasal cannula as well if she maintains her sat.   What is out exact capabilities here since you mention we're not an ALS unit but you're giving us info that up here we would have to be an ALS unit to obtain (BGL, 12-lead)


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## Outbac1 (Jan 2, 2011)

If HEMS will fly medical cases from scene ask for them. They can deliver to the cath lab quicker. BGL is OK. Pt is on O2. Apply pacing pads. Start IV, load pt in ambulance(you know one of those old fashioned ground mobile thingys). Get onroute to LZ (if Brown coming), or cath lab (if only an hour that would be my 2nd choice) Bolus pt with 500cc ns. If b/p doesn't come up give 0.5mg atropine. If no HEMS or cannot get to cath lab in under 3 hours from onset head to nearest hosp that can thrombolyse or initiate field thrombolysis. 
 She is having a good oldfashioned MI. She is symptomatic and although one could go straight to pacing I would try the bolus/atropine first. One could also consider dopamine or another pressor, also nitro if her b/p comes up sufficently. 

 Thats my 2cents.


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## lightsandsirens5 (Jan 2, 2011)

usafmedic45 said:


> but you're giving us info that up here we would have to be an ALS unit to obtain (BGL, 12-lead)



Not here. 

Anyhow, so we are an hour by road from the nearest hospital? Hmmmmm......prolly not a cath lab, right? I am guessing it is a small rural hospital. Ie. Level IV Trauma center, nearest cath lab is an hour from them. :huh:

So, I would defiantly be calling for a bird as this gal appears to be needing quite a bit of care with as much quickliness as can be mustered. I am guessing we are looking at a fully evolved anterioseptal MI.

As for treatment, 314 mg of ASA, no NTG at this time due to B/P. I'd start a line, keep a close eye on that 12 lead. Small fluid bolus (500ml?) to to try to bring that B/P up a little. That is about as far I as an intermediate can go. If I was ALS though. I'd have pacing/defib pads on, atropine if the B/P doesn't come up with the bolus. Prolly try some sort of pressor maybe.

Start rolling and hopefully meet up with the bird pretty soon.


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## Scott33 (Jan 2, 2011)

MrBrown said:


> HR 48...
> Underlying ECG is a sinus rhythm



So what is the rate showing on the monitor?



> Anterioseptal infarct on 12 lead



Have you ruled out any possible STEMI mimickers? Any reciprocal changes noted?


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## MrBrown (Jan 2, 2011)

Here is what each level can do

*Paramedic*
Oxygen, OPA, NPA, LMA, manual defibrillation, synchronised cardioversion, 12 lead ECG interpretation, IV fluid administration, combat application tourniquet, entonox, methoxyflurane, aspirin, GTN, salbutamol nebules, glucagon, 10% glucose, ondansetron, adrenaline, morphine, paracetamol

*Intensive Care Paramedic*
All of the above plus intubation, cricothyrotomy, intraosseous needle access, pacing, atropine, frusemide, ketamine, midazolam, rapid sequence intubation (select Officers only)

A BGL of between 4 and 11 mmol (75-198mg/dl) is considered normal here so personally Brown would not give her any glucose.

Aspirin and one litre of fluid are administered

New vital signs 
BP 90 systolic
HR 70
Pain is still heay 7/10

No reciprocal changes on the 12 lead and no, this is not an MI do you think Brown would post something that easy?


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## usafmedic45 (Jan 2, 2011)

Was she using any chemicals on her flowers?  It sounds like organophosphate or carbamate toxicity.  What are her breath sounds?


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## lightsandsirens5 (Jan 2, 2011)

usafmedic45 said:


> Was she using any chemicals on her flowers?  It sounds like organophosphate or carbamate toxicity.  What are her breath sounds?



Oh! Good one! Didn't even think of that. :blush:

Now, I also might venture to say that it was a heart attack caused by her finding out that her husband was putting the weeds in the mulch pile. Cause I would have a heart attack if someone put weeds in my mulch pile. That is supposed to be weed-free. Weeds go in the burn pile. :angry:


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## usafmedic45 (Jan 2, 2011)

> Weeds go in the burn pile.



You know what they call a burn pile in Australia?   Victoria. 



*waits patiently as he's going to have to explain a Black Saturday joke to all the non-Aussies on the forums*


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## mycrofft (Jan 2, 2011)

*Victoria? Ouch!!*

And as far as nerve agents, drooling, constricted pupils, asphyxia, and other signs of acetocholine overload would be evident. Think of the oppposite of atropine and you get typical organophosphate intoxication. Another danged mnemonic from eMed:
"Mnemonic devices used to remember the muscarinic effects of organophosphates are SLUDGE (salivation, lacrimation, urination, diarrhea, GI upset, emesis) and DUMBELS (diaphoresis and diarrhea; urination; miosis; bradycardia, bronchospasm, bronchorrhea; emesis; excess lacrimation; and salivation)".  

Let's see...if subjective sensations mimic a heart attack, maybe we are talking about a thoracic event affecting the same sensory pathways as the heart, oesophagus, trachea, and mediastinum, or arising from the mid thoracic spinal nerve roots, even if that effect _per se_ is not the cause of primary concern. Sure as heck sounds like MI or something else that swatted her down, then let her recover enough to give a hx....??


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## usafmedic45 (Jan 2, 2011)

> drooling, constricted pupils, asphyxia, and other signs of acetocholine overload would be evident.



You're thinking the "faucets on" syndrome:  lacrimation, salivation, diarrhea, nausea/vomiting, diaphoresis.  That's the classical syndrome for organophosphate toxicity, but let me remind you that you don't always have classic presentation.  How many head trauma patients have Cushing's triad?  How many patients with tamponade have all three signs of Beck's triad?  

Copious secretions are often a late sign and not always present with all chemicals in those classes.  Also, you're not always going to get constricted and non-reactive pupils until you reach a certain threshold. Pulmonary edema, bradycardia and altered mental status are going to be much more prominent in early or mild exposure, particularly to the carbamates.  Remember that most of the "asphyxia" is related to the obstruction of the airway from secretions.  Only in either massive exposure or exposure to weapons grade agents are you going to get sustained asphyxia in a true sense.

I'm not 100% certain that this is a toxic exposure but it sounds a lot like a case I worked where the lady had mixed up the agent in a glass and took a sip of it, mistaking it for her lemonade after being distracted by a phone call.


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## MrBrown (Jan 3, 2011)

Brown LOL'd at Victoria .... anyway 

Breath sounds are OK and not using any chemicals on the flowers.

What else would you like to know


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## usafmedic45 (Jan 3, 2011)

MrBrown said:


> Brown LOL'd at Victoria .... anyway
> 
> Breath sounds are OK and not using any chemicals on the flowers.
> 
> What else would you like to know



She wasn't eating her precious foxglove was she?  LOL

Any other pertinent findings?


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## MrBrown (Jan 3, 2011)

The patient states she has a heavy, crushing pain in her chest and feels tired.  Pain is centralised and also radiates inferior 7/10, did have pain her jaw and back but they have gone.

Very pale and shut down, does have a radial pulse and while palpable is weak and irregular.  Was bradycardiac, remains hypotensive.

The ST elevation on the 12 lead remains.

Husband thinks he remembers the patient taking a voltaren tablet (diclofenac) this am for an inflamed knee she saw the doctor about yesterday.


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## usafmedic45 (Jan 3, 2011)

The diclofenac would put her at a slightly increased risk of an MI and there's a couple of case reports of it being associated with renal failure which resulted in hyperkalemia and bradycardia.  

BTW What's her temp?


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## ClarkKent (Jan 3, 2011)

From Mr. Browns first posting about this scenario



MrBrown said:


> 2) What is wrong with *them*?



From what I have read from all of Mr. Browns scenarios, he likes to hint at things.  Is this just a misspelling , or are we missing something??  I know that I am not the best speller in the world, but just a thought?


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## MrBrown (Jan 3, 2011)

It is an oversight on Browns part, its just the one patient.


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## ClarkKent (Jan 3, 2011)

When it come to your scenarios Mr. Brown, I try and not look over anything.  But almost 99.9999% of the time it is over my head since I have not able to find work in the EMS field and I am trying to keep my education and training up to speed.


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## Veneficus (Jan 3, 2011)

*all these experts*

This time Brown has a textbook scenario, but you have to know your textbook real well to get it.

The devil is in the details and everything needed is in the OP


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## Aidey (Jan 3, 2011)

Room SpO2? Capnography?  What does that leg look like on exam, any redness or swelling? 

It could be a PE...

Alternative route. What is her temp? Heat stroke?


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## vquintessence (Jan 3, 2011)

Just a little stream of consciousness but...

Regarding the 12 lead:  Any abnormalities in the PRI (ex: prolonged, elevated or depressed)?  What is the amplitude of the QRS's in the precordial leads (ex: evidence of LVH?).  Is there any manifestation of a bundle blockage (ex: rSr leads v1 w/ S wave lead I?).  Any indications of electrolyte derangement (ex: peaked t-waves, widened qrs, etc)?  Sorry, I'm just trying to get a more specific description than anteroseptal STE to rule in&out the mimics.

Well, barring any profound neurological presentations, denial of presence of toxins and an unremarkable physical exam...

Letting my cart lead the donkey, I'd like to meekly suggest Brugadas syndrome?  I know an elderly female doesn't exactly fit the demographic norm... but what we do know is:

Nana was working in the heat, which possibly triggered the event/syndrome (a run of VT making the pt feel the described general thoracic discomfort); the run then self terminated, resulting in her syncope and "looking dead" to her husband temporarily.  The ECG findings could arguably help strengthen this train of thought?

It is a shot in the dark, but I also like to run with the scissors pointed outwards and nothing else is coming to mind.


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## Sam Adams (Jan 3, 2011)

= radials? / brachials? / femorals?


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## zzyzx (Jan 3, 2011)

I didn't know zebras lived in New Zealand.

A thoracic aneurysm could irritate the vagal nerve and cause the bradycardia. But is that too easy as well?:wacko:


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## Smash (Jan 3, 2011)

Spontaneous coronary artery dissection? I seem to recall that a certain Dr Smith having such a beast. Mostly happens in women although not necessarily this demographic. She may have increased shear forces bending over her flowers, precipitating dissection, giving her the sickness of muchness. 
Or it may be that I had 4 hours ofsleep and shouldn't be allowed near a keyboard, much less a patient.


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## jjesusfreak01 (Jan 3, 2011)

ParathinkIam Brad (thats my name) thinks she vagaled out when pulling weeks, causing depressed breathing which strangely led to cardiac ischemia (angina like effects). Recommend oxygen therapy (probably a nasal canula will be fine) and a quick trip to see a person with MD written after their name on a door somewhere. If arterial dissection can be reasonably ruled out, ASA and GTN might be on the menu.


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## Outbac1 (Jan 3, 2011)

MrBrown said:


> Aspirin and one litre of fluid are administered
> 
> New vital signs
> BP 90 systolic
> ...



Not really but the initial presentation leads one this way.  My initial tx started with a bolus. Now that she has had one her HR is up but B/P is not up a lot.  It was a hot day and she was working outside. Dehydration is a possibility leading to electrolyte imbalance. The voltarn (not familiar with this so googled it) can add K . So what did her Ts look like? Peaked? How about dehydration signs? Turgor? Furry tongue? Any hx of renal failure?
 An aneurysm could also explain the fluid loss, pain presentation, and lack of increased B/P after 1 liter as well. Perhaps she has both? 
 If dehydrated and peaked Ts more fluid is needed. But she shouldn't be overloaded on just ns. It is just adding Na. methinks a more balanced solution would be better (ringers/hartmans). Potassium toxicity would call for 0.5 - 1.0 g of calcium chloride. 
 Continued transport to Dr. Brown and comrades is still in order.


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## MrBrown (Jan 3, 2011)

Sam Adams said:


> = radials? / brachials? / femorals?



Radial and brachial are palpable and irregular, no femoral pulse is palpable but given her blood pressure is it a suprise?



zzyzx said:


> I didn't know zebras lived in New Zealand.
> 
> A thoracic aneurysm could irritate the vagal nerve and cause the bradycardia. But is that too easy as well?:wacko:



No but we have a healthy heard of Browns.  An aneurysm should not be ruled out at this stage.



Smash said:


> Spontaneous coronary artery dissection?
> 
> Or it may be that I had 4 hours ofsleep and shouldn't be allowed near a keyboard, much less a patient.



Nah its not that.  Now, bend over so Brown can stick this ketofol in your bum and you can get some sleep.



jjesusfreak01 said:


> ParathinkIam Brad (thats my name) thinks she vagaled out when pulling weeks, causing depressed breathing which strangely led to cardiac ischemia (angina like effects).



At least you admit being a Parathinktheyare, thats the first step mate 

At this stage no morphine or GTN because of her blood pressure if we can get it a bit higher maybe one tab of nitro but then again GTN really has no role in STEMI or so Brown thinks.  Brown thinks perhaps we could try maybe a mg or two of morphine if her pressure stays where it is.



Outbac1 said:


> So what did her Ts look like? Peaked? How about dehydration signs? Turgor? Furry tongue? Any hx of renal failure?
> An aneurysm could also explain the fluid loss, pain presentation, and lack of increased B/P after 1 liter as well. Perhaps she has both?
> 
> Continued transport to Dr. Brown and comrades is still in order.



No signs of hyperkalemia and the patient does not appear to be dehydrated.


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## usafmedic45 (Jan 3, 2011)

> no femoral pulse is palpable but given her blood pressure is it a suprise?



Actually, yeah, that would be a big one in my book since you're probably going to lose your radials and brachials first before you lose your femoral pulses.  Given that bit of information, I'm guessing this is an aortic dissection with compression of the coronary arteries.  What's her diastolic pressure?  If she's sporting a narrowed pulse pressure, I would be concerned for cardiac tamponade as well.


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## CAOX3 (Jan 3, 2011)

Oh that little bugger the Katipo got her.

Im guessing myocarditis is causing the ST elevation and not an MI.

Now I want a case of FOUR LOKO as my prize.


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## usafmedic45 (Jan 4, 2011)

You could see those EKG changes with pericarditis, but I would not expect someone to drop their pressure so dramatically from it (not to mention that the pain is often relieved to a great extent by positioning and it's not normally a "crushing" pain but rather pleuritic in nature) unless they had a very large effusion with it and even then you don't normally go from no real symptoms to death door without warning.  

In myocarditis, usually you have a stabbing or tearing chest pain.  The EKG changes are also generally fairly characteristic and are often described as "saddle-shaped" as they are in pericarditis as well.  The lack of T wave inversion in the non-elevated leads also makes me think this is not myocarditis.  The only thing that makes me even put myocarditis on the DDx list is the history of recent joint pain which might suggest a recent viral infection.


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## CAOX3 (Jan 4, 2011)

usafmedic45 said:


> You could see those EKG changes with pericarditis, but I would not expect someone to drop their pressure so dramatically from it (not to mention that the pain is often relieved to a great extent by positioning and it's not normally a "crushing" pain but rather pleuritic in nature) unless they had a very large effusion with it and even then you don't normally go from no real symptoms to death door without warning.
> 
> In myocarditis, usually you have a stabbing or tearing chest pain.  The EKG changes are also generally fairly characteristic and are often described as "saddle-shaped" as they are in pericarditis as well.  The lack of T wave inversion in the non-elevated leads also makes me think this is not myocarditis.  The only thing that makes me even put myocarditis on the DDx list is the history of recent joint pain which might suggest a recent viral infection.




I was basing it on the joint pain and complete system shut down, I was going with snake bite but I remembered from sleeping on my Zoology book every M, W, F for three months that New Zealand has no native poisonous snakes.

It was a stertch but can I still get my prize.


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## Veneficus (Jan 4, 2011)

*11 complications of an MI*

1. Contractile dysfunction
2. Arrhythmia
*3. Myocardial rupture* Not often seen, but usually seen in females, over 60, with no prior history of MI, history of hypertension, and no evidence of left ventricular hypertrophy.(mitral or aortic murmers) Most often seen in Anterior transmural infarcts. (STEMI) 90% to the free wall, 10% to the ventricular septum.
4. Pericarditis
5. Septal dysfunction
6. Infarct extension
7. Infarct expansion
8. Mural thrombus
9. Ventricular aneurysm
10. Papilary muscle dysfunction
11. Progressive late heart failure

Why oh why do they spend so much time on cardiology in paramedic education?


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## MrBrown (Jan 4, 2011)

All prizes have been curtailed due to the neeed for Brown to increase financial resillance.  Diapers and baby food are expensive!


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## usafmedic45 (Jan 4, 2011)

MrBrown said:


> All prizes have been curtailed due to the neeed for Brown to increase financial resillance.  Diapers and baby food are expensive!


I'll settle for you catching me one of those Kiwi birds you all have down there and overnighting it.


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## MrBrown (Jan 4, 2011)

usafmedic45 said:


> I'll settle for you catching me one of those Kiwi birds you all have down there and overnighting it.



The Department of Conseration and Ministry of Agriculture & Fisheries might have a problem with that.  Brown will get you a T shirt.


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## usafmedic45 (Jan 4, 2011)

MrBrown said:


> The Department of Conseration and Ministry of Agriculture & Fisheries might have a problem with that.  Brown will get you a T shirt.


I'll accept a t-shirt.  If you make it two (one for me and one for the fiancee) we can reciprocate and send you two back.  Sort of like cultural t-shirt exchange.  LOL


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## CAOX3 (Jan 4, 2011)

Veneficus said:


> 1. Contractile dysfunction
> 2. Arrhythmia
> *3. Myocardial rupture* Not often seen, but usually seen in females, over 60, with no prior history of MI, history of hypertension, and no evidence of left ventricular hypertrophy.(mitral or aortic murmers) Most often seen in Anterior transmural infarcts. (STEMI) 90% to the free wall, 10% to the ventricular septum.
> 4. Pericarditis
> ...



Listen rupture is so boring compared to the story of that little buggie thing taken a chunk out of youin the woods.

But from now on all almost doctors are disqualified, stop collecting all the the dam prizes, show off. Insert smiley face but I couldn't because my phone sucks

And I'm going back to verizon to get stupid phone in the bag like magnum pi had, screw this technology.

Congratulations on the baby Brown.


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## Aidey (Jan 4, 2011)

MrBrown said:


> No reciprocal changes on the 12 lead and *no, this is not an MI* do you think Brown would post something that easy?





Veneficus said:


> 1. Contractile dysfunction
> 2. Arrhythmia
> *3. Myocardial rupture* Not often seen, but usually seen in females, over 60, with no prior history of MI, history of hypertension, and no evidence of left ventricular hypertrophy.(mitral or aortic murmers) Most often seen in Anterior transmural infarcts. (STEMI) 90% to the free wall, 10% to the ventricular septum.
> etc......



I'm calling foul. It can't be a complication of an MI when you said it wasn't an MI, unless it is a spontaneous rupture not associated with an MI.


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## Veneficus (Jan 4, 2011)

CAOX3 said:


> Listen rupture is so boring compared to the story of that little buggie thing taken a chunk out of youin the woods.
> 
> But from now on all almost doctors are disqualified, stop collecting all the the dam prizes, show off. Insert smiley face but I couldn't because my phone sucks
> 
> ...



I don't want the prize, I tried to toss you guys some clues a few pages back and have been kind enogh to answer several scenarios in PM so others could have a chance. 

But you guys were getting farther and farther away. 

I find it very disheartening that so much time in paramedic class is dedicated to cardiology instead of something much more complicated like trauma. 

I know that the complications of MI are very rarely ever even mentioned, much less tested in paramedic school despite EMS using their ability to make a difference in MIs as the centerpiece of ALS value.


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## Veneficus (Jan 4, 2011)

Aidey said:


> I'm calling foul. It can't be a complication of an MI when you said it wasn't an MI, unless it is a spontaneous rupture not associated with an MI.



It is secondary to the MI.

like DIC can be secondary to sepsis.

(I keep trying to tell you guys that you need thicker physio and patho books, it is not sufficently covered all in the paramedic texts.)

What happens when you start filling this patient up with fluid and giving her ASA?


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## Aidey (Jan 4, 2011)

Right, I get it was secondary to an MI. I just take issue with the semantics of it. 

As for what will happen, she will develop a tamponade eventually.


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## Veneficus (Jan 4, 2011)

Aidey said:


> Right, I get it was secondary to an MI. I just take issue with the semantics of it.
> 
> As for what will happen, she will develop a tamponade eventually.



Faster still when you add water and antiplatelet aggregates to the mix.


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## zzyzx (Jan 4, 2011)

Doesn't myocardial rupture occur a long time (days?) after an MI; due to the rupture of scar tissue that has formed after an MI has damaged a portion of the myocaridum? Why then are we still seeing ST elevation? 

Correct me if I'm wrong; I've never researched this.


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## Veneficus (Jan 4, 2011)

zzyzx said:


> Doesn't myocardial rupture occur a long time (days?) after an MI; due to the rupture of scar tissue that has formed after an MI has damaged a portion of the myocaridum? Why then are we still seeing ST elevation?
> 
> Correct me if I'm wrong; I've never researched this.



The normal occurance is usually 1-10 days with the average of 4 for the reasons you described, but there can be an acute rupture usually when the conditions listed above are met.


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## Outbac1 (Jan 4, 2011)

Hmmmm, interesting. This still appears to me to be an MI and needs appropriate treatment. There is no indication of chest trauma. The vitals given do not include a diastolic value so no map, narrowing pressures etc can be infered. I'm not a fan of blindly dumping in copious quantities of fluid into people. Few need it. In this case she received a liter with some improvement. But it indicates a leak somewhere. Be it a myocardiac rupture or a disecting AAA isn't going to change field tx. She still needs some fluids and transport. A field pericardiocentesis isn't going to happen nor is a CT or echocardiogram. 
 Treat what you can and transport to the Docs and fancy epuipment. 
 Always good to think deeper than what you see, even if you can't treat it.


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## Veneficus (Jan 4, 2011)

Outbac1 said:


> Hmmmm, interesting. This still appears to me to be an MI and needs appropriate treatment. There is no indication of chest trauma. The vitals given do not include a diastolic value so no map, narrowing pressures etc can be infered. I'm not a fan of blindly dumping in copious quantities of fluid into people. Few need it. In this case she received a liter with some improvement. But it indicates a leak somewhere. Be it a myocardiac rupture or a disecting AAA isn't going to change field tx. She still needs some fluids and transport. A field pericardiocentesis isn't going to happen nor is a CT or echocardiogram.
> Treat what you can and transport to the Docs and fancy epuipment.
> Always good to think deeper than what you see, even if you can't treat it.



I think the important thing to consider is not to start initiating any therapy that would increase bleeding.

In order for this lady to survive I would be willing to bet she is going to need cardio surgery. PCI might take a bit too long.

By understanding the pathology and deeper understanding, it should definately help your treatment decisions in the field. 

Strictly going by ACS protocol this lady might find herself getting all manner of iatrogenic treatment trying to follow an algorythm or normalizing numbers.


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## Outbac1 (Jan 4, 2011)

Certainly something to consider, but difficult to dx in the field. So to broaden mine and others knowledge on this, how many times have you run across this in the field? In this scenario what was it that tipped you off? How would you have TX this pt if you suspected this myocardium rupture?

Thanks


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## usafmedic45 (Jan 4, 2011)

> How would you have tx this pt if you suspected this myocardium rupture?



As quickly as possible to somewhere with CT surgery capability.


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## Veneficus (Jan 5, 2011)

Outbac1 said:


> Certainly something to consider, but difficult to dx in the field. So to broaden mine and others knowledge on this, how many times have you run across this in the field?



In the field, never that I knew. But probably not because it didn't happen, but because I wasn't born with my current level of knowledge. If somebody might have mentioned this kind of stuff earlier in my career, I would have been better prepared.

I have seen it a handful of times in the hospital.



Outbac1 said:


> In this scenario what was it that tipped you off? How would you have TX this pt if you suspected this myocardium rupture?



I discussed the scenario with the author prior but I will do a walk through.


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## Veneficus (Jan 5, 2011)

The most important aspect of finding a dx or complications is knowing what they might be. Earlier in the discussion I posted the 11 complications of an MI. If you never covered them, your educators have failed you.

I have a very significant interest in physical diagnosis, I wish more people outside of Europe shared such a passion. Especially EMS providers who don't have all kinds of data gathering technology. (which often is not required anyway)




MrBrown said:


> It's a very hot day and you are called to an elderly lady who has had a "spell" while tending to her flowers.



Elderly, involved in physical activity in a strenuous environment. This is very ripe for a cardiac event or a ruptured aneurysm



MrBrown said:


> She was removing some weeds and her husband took them down to the mulch pile on the tractor, when he came back she was collapsed on the ground.  They are on a country property about an hour by road to the nearest hospital.
> 
> The patient relates she felt dizzy then had back, jaw and neck pain then crushing heavy chest pain;



In both aortic aneurysm and myocardial aneurysm or rupture, the initial pain is worse than the constant pain, in this case probably great enough to make her pass out, but either way the loss of circulation acute enough to cause neuro deficit. So the blood is either blocked, not transferring oxygen, or leaking.



MrBrown said:


> When her husband found her he was not sure if she was breathing and said it looked like she was dead.



Obvious shock state, the only question is what kind? (accepting 1 or more can be present together)



MrBrown said:


> She has no cardiac or medical history apart from taking oral antihypocglycaemics for diabetes.



"3. Myocardial rupture Not often seen, but usually seen in *females, over 60, with no prior history of MI,* history of hypertension, and *no evidence of left ventricular hypertrophy.(mitral or aortic murmers)* Most often seen in *Anterior transmural infarcts. (STEMI) 90%* to the free wall, 10% to the ventricular septum."

this is the textbook example of the risk factors for acute myocardial rupture. If you don't know your pathology though, how would you know to look for it?



MrBrown said:


> BP 80 systolic
> HR 48



This could point to aneurysm, cardiogenic shock, right sided MI, CVA, hypoglycemia, PE, or cardiac rupture with what we have so far. The BP is still high for typical right sided MI.



MrBrown said:


> RR 8, shallow and laboured
> SPO2 97% on 10lpm



Late shock state, doesn't help with differential



MrBrown said:


> BGL 5mmol (about 85 mg/dl)
> GCS 13 (3/4/6)



Diabetic emergency ruled out, still inadequate cerebral perfusion of profound shock.




MrBrown said:


> Pain described as *heavy, central chest pain 7/10
> Anterioseptal infarct on 12 lead with ST elevation in V1-4*
> Underlying ECG is a sinus rhythm



Doesn't get more typical for an Anterior MI.

Pt meets qualifications for MI and complication of myocardial rupture.

Underlying Sinus further excludes the possibility of right sided MI with lack of compromise of sinus node. 

Gray appearance, lack of perfusion to brain, suggestive of hypovolemic shock. Consider places for blood loss. Assess heart tones.

No murmers, rubs, or gallops mentioned, tamponade happens over time, consider baseline volume and reasess in a few minutes.

Consider QRS amplitude, diminished amplitude sensitive, but not specific for tamponade. But many other things point to MI with textbook complication. Significant clinical probability has been established. This complication is also the most life threatening. So if you are going to make a bet prehospital, most lethal and most evidence for. Can't be faulted for that.   



MrBrown said:


> Intensive Care (ALS) are coming towards you and will locate in approx 15 minutes, HEMS are avaliable but will take about 20 minutes to land at a local sportsground and its an hour (in good traffic) up the interstate to hospital.



If you had a bullet hole in your heart, you'd be looking for a surgeon. Mechanism of the hole insignificant. ALS rendezvous insignificant. ASA is out, fluid out, pressors not useful, survival will be determined by fixing the hole, not by respiratory support or correcting blood pressure numbers. Anyone not bringing blood to the party isn't contributing.



MrBrown said:


> 1) How do you manage this patient, and



No ASA, no fluid, no waiting, call helo, advise them of likely Dx. Start some IVs TKO, support ventilation.



MrBrown said:


> 2) What is wrong with them?



they have a hole in their heart.

If it looks like a duck, walks like a duck, and quacks like a duck, until proven otherwise, it is a duck.


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## zzyzx (Jan 5, 2011)

Veneficus wrote "If it looks like a duck, walks like a duck, and quacks like a duck, until proven otherwise, it is a duck."

Weren't we talking about zebras? I very much admire your assessment skills, but you'd have to be awfully sure of your abilities to make this diagnosis based on just a history and exam.

All the same, thanks for a very interesting and education scenario!


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## Veneficus (Jan 5, 2011)

zzyzx said:


> Veneficus wrote "If it looks like a duck, walks like a duck, and quacks like a duck, until proven otherwise, it is a duck."
> 
> Weren't we talking about zebras? I very much admire your assessment skills, but you'd have to be awfully sure of your abilities to make this diagnosis based on just a history and exam.
> 
> All the same, thanks for a very interesting and education scenario!



I am not bad at my exam skills 

Really though, the education here places a premium on it, students here don't make it out of the 4th year if they cannot dx where in the brain an acute stroke is from history and physical as an example.


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## MrBrown (Jan 5, 2011)

Veneficus said:


> ...students here don't make it out of the 4th year if they cannot dx where in the brain an acute stroke is from history and physical as an example.



A CT scan is part of a physical exam right? 

*Brown and Oz stand by the helicopter with a CT machine next to it and scratch thier head

Dang it Oz, don't think this thing will fit, lets try it one more time! .....


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## zzyzx (Jan 5, 2011)

Here's what Brown and Vene dream of when they go to sleep...

http://fineartamerica.com/featured/unicorn-zebra-marjorie-peterson.html


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## Veneficus (Jan 5, 2011)

MrBrown said:


> A CT scan is part of a physical exam right? .....



Only in the US.

Everywhere else it is an adjunct to the physical exam. 

A junc t?

A junk?


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## Outbac1 (Jan 6, 2011)

*Thanks*

Mr. Brown & Veneficus thanks for a good scenario with detailed explanations. That was a good reminder to look beyond the obvious for other problems/complications. Too often we just treat what is initially presenting without digging deeper like we should.

Thanks


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## mycrofft (Jan 6, 2011)

*"Paraneoplasticsyndrome"*

Brown, auscultation of thorax and abdomen, preferably fore and aft please.  (Et tu, Bruit?).

PS: USAF, I was only taught about being drenched with carbamates. Where's that pesky Atropen and 2-PAM autoinjector when you need them?


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## mycrofft (Jan 16, 2011)

*disregard*

anomaly in posting. Sorry for late reply above. Press on.


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