# I don't feel good



## ERDoc (Mar 12, 2016)

You are called to the residence of a 78y/o female how says about an hour before she called she had a sudden onset of feeling light headed, like she was going to pass out.  She says she can't stand because it makes her feel worse.  She also has a substernal tightness and shortness of breath.

On exam, she is noted to be wearing her normal glasses and then dark glasses over them.  She is holding her head and moaning.  Your partner gets a set of vitals:  HR 32  BP 70/32  RR 22  Sat 96%RA.


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## luke_31 (Mar 12, 2016)

To start I'd hook her up to the monitor, get pacing pads, and start pacing. She is definitely in a symptomatic bradycardia and that heart rate needs to go up. If I could I'd want a 12-lead to see what's going on with the heart. What kind of medical history does she have?  Does she have a pacemaker?  If so it doesn't look like its functioning.


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## MonkeyArrow (Mar 12, 2016)

First thing that popped into my head is meningitis. The headahe and photophobia are classic signs. The nausea and vertigo are also potential signs of meningitis. Would want to check to see if there is any neck motion stiffness/restriction. At the hospital, spinal tap.

But then, the vitals are also concening. Is she perfusing well? Cap refill? AMS?


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## ERDoc (Mar 12, 2016)

She has a h/o htn, CAD with stents 5 years ago, elevated cholesterol, diabetes, and diverticular disease.  No pacemaker.  Skin is cool to the touch with sligtly delayed cap refill.  As long as her head is not elevated more than 30 degrees she is mentating fine, above that and she starts to get real dizzy.


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## SpecialK (Mar 12, 2016)

This lady is very sick.  My diagnosis is complete heart block.  I was initially going to say junctional bradycardia but I see some P waves. I do not see STEMI.

I would initiate pacing at a rate of 70/min.  If she didn't like it to the point of needing analgesia I'd go with fentanyl, and ketamine ontop if required.  Both are good and wouldn't be overly deleterious to her blood pressure, well, not the ketamine anyway.  

She needs to go to a hospital with interventional cardiology who can put in a temporary pacemaker.  Early hospital call to get them alerted


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## cprted (Mar 12, 2016)

What is she on for meds?  Is she compliant? Could she have taken an overdose of a Beta or Ca channel blocker?

Other history?  Has she been well lately? Any clue to kidney function? Fluid/food intake? Vomiting/diarrhea?


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## ERDoc (Mar 13, 2016)

Her meds include aspirin, simvastatin, metformin, metoprolol.  She is compliant and this episode started about an hour after taking her meds.  She was admitted to the hospital about a month ago for a similar episode.  She was told it was due to one of her meds but she doesn't know which one.  She just started taking it again about a week ago.  Her son (who is not present) sets up her meds for her so she doesn't know which one.  Until today she has otherwise been in her typical state of health.  She has no history of kidney problems and they didn't say there were any problems when she was in the hospital last month.  She has been eating and drinking normally until this episode started but now she feels to nauseous for oral intake.  No diarrhea.


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## k9Dog (Mar 13, 2016)

Fluid challenge, positioning, oxygen would be first. If no result, I'd try atropine 0.5mg IV. If no improvement I'd medicate for pain and begin pacing. Consider glucagon.

Likely due to her beta blocker (metoprolol) based upon he history stated.  It appears to be a junctional rhythm with a prolonged Q-T interval. It's possible that it's a complete heart block but doesn't look to be as obvious. The p wave doesn't appear to completely wander. Atropine is typically not effective with high degree heart blocks, but I would prefer the least invasive and painful approach first. There is no STEMI so I wouldn't be as concerned with the atropine worsening her condition. 

If you wanted to get crazy and start going out of protocol you could consider a beta agonist to reverse the beta blockade, like Epi or IV Glucagon. But it's best to avoid being a cowboy as it ends you up in supervisors office


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## Akulahawk (Mar 14, 2016)

I'd look at starting an IV, consider doing 0.5 ma Atropine, but I doubt it'll work. I'd do that just to say I tried it per protocol... so that I could go on to asking for an order to try glucagon because the patient is taking a beta blocker and has a history of this happening before with the same medications she's on now. I would also set up for pacing just in case I'm told to do that instead. Yes, the patient is diabetic... The ED or inpatient folks can deal with any hyperglycemia that may result from the glucagon. My concern about the pacing is that she might need a higher mA than usual to get good capture and that could become somewhat painful. Also, if the glucagon doesn't work, I'd be all set to premedicate for pain/discomfort and pace if I go that route.


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## johnrsemt (Mar 14, 2016)

Along as her mental status is good (even with the low BP) I would try fluid challenge and Atropine first,  with the IV you can sedate if you need to pace her;  but she needs a bolus of diesel, (load and go).


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## cprted (Mar 14, 2016)

You guys must carry a lot more Glucagon than I do.  I usually have 1mg in the kit and another 1mg in the car. My understanding of glucagon in the setting of B Blocker OD is that the initial dose is 5mg IV followed by a 5mg/hour infusion. I doubt I have that much sitting in the stock room.

For my own treatment plan, IV access and a small bolus of saline. Electrical therapy pads can go on, but if the patient is borderline asymptomatic in the supine position I don't feel the need start TCP at the moment (also negates the need to give sedation as well).  Like others, I'd give 0.6mg Atropine, probably repeated once. Depending on pt presentation, I'd consider starting an epi infusion at a couple of mcg/min to effect.

We should probably check a sugar at some too.


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## ERDoc (Mar 15, 2016)

You give 2 0.5mg Atropine with no improvement.  You give her a liter of NS and her lungs start to sound wet but there is no change.  As long as she stays with her head below 30 degrees she is asymptomatic.


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## cprted (Mar 15, 2016)

ERDoc said:


> You give 2 0.5mg Atropine with no improvement.  You give her a liter of NS and her lungs start to sound wet but there is no change.  As long as she stays with her head below 30 degrees she is asymptomatic.


A litre? Jeez Doc, I was thinking along the lines of 250ml.

Zero change with atropine and patient remains asymptomatic supine/near supine? I'm inclined to leave well enough alone. Pads are on in case that things deteriorate. Probably have an epi infusion mixed. OPAs sized and nearby, have a BVM out of the package just in case things really go sideways. Call ahead and transport to the nearest appropriate hospital.


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## Carlos Danger (Mar 15, 2016)

This is an interesting one. Sounds like a clear cut case of a beta-antagonist OD, but who knows. 

I would give 25mg of ephedrine or 1 ml of 1:100:00 epi and follow that up with an epi infusion if it worked. If that doesn't help, I would probably pace her.


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## NomadicMedic (Mar 15, 2016)

She doesn't take Digoxin, right? 

I think I'd be going straight to pacing. Nothing I have, aside from Epi or Dopamine, is indicated and she seems unstable to me. Perhaps after TCP her pressure will improve enough to add some sedation. 

**Eh, maybe 5-10 mcg/kg/min of Dop would be my next step. I'd certainly call the med control doc and say "uh, you're gonna see me in 30 minutes. What do you want me to do?"


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## Summit (Mar 15, 2016)

DEmedic said:


> She doesn't take Digoxin, right?
> 
> I think I'd be going straight to pacing. Nothing I have, aside from Epi or Dopamine, is indicated and she seems unstable to me. Perhaps after TCP her pressure will improve enough to add some sedation.
> 
> **Eh, maybe 5-10 mcg/kg/min of Dop would be my next step. I'd certainly call the med control doc and say "uh, you're gonna see me in 30 minutes. What do you want me to do?"


I like this more... I think she is symptomatic and even if she isn't dizzy when lying down, I doubt her kidneys appreciate the hypoperfusion.


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## RScott (Mar 15, 2016)

I'm concerned about an allergic reaction to the metoprolol.  Any itching, hives, difficulty breathing?


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## SpecialK (Mar 16, 2016)

I wouldn't bother with atropine or glucagon.

As for sedation for pacing, I'd use ketamine (say 0.5 mg/kg) and 1-2 mg of midazolam.  I wouldn't bother with any fentanyl.


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## NUEMT (Mar 16, 2016)

Well I will start off by saying that I wont delay transport thinking on the finer points of Dig OD or other pharma considerations in this case.  I want a good history and repeat B/P in both arms.  Dexi as well. Rapid mini neuro and rule out fall.  Don't think I see complete heart block.

ERdoc states a liter has gone in with no change and pt is positional. I would still have gone to the atropine, my protocols state up to 3mg and pacing with 2.5 versed for sedation.  Keep a TKO drip and call for the dope if the time would indicate it.

Apply Diesel bolus with my crash supplies in place.

Onset after medication is suspicious and will be relayed as per norm.  I have had pts like this actually repeat their doses thinking it was their first time today.  Fluids up, dexi to normal and supportive O2 via nc.  Meds coming with us.  

You folks with longer transport actually have a lot more depth with your algorithms, we are 10 mins from 6 level ones.  PRos and cons.  Cons usually for our practice.


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## ERDoc (Mar 17, 2016)

So this lady had a sensitivity to metoprolol, meaning that it worked too good for her.  I'm not sure why they restarted it after the first hospitaliztion.  After the atropine didn't work, a dopamine drip was started which worked well getting her BP up to 120/60 and HR to 55 at 15 mcgs.  She was readmitted and d/cd the next day after the metoprolol wore off and she could be weaned off the dopa.


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## NomadicMedic (Mar 17, 2016)

Good scenario. Thanks Doc.


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