# 41y/M CP



## FLMedic311 (Apr 10, 2017)

SO you are dispatched to a 41y M pt and on arrival of a fairly clean appearing home you find the pt just past the front door, sitting on the floor half in the jacket/shoe closet.  He is clearly pale cool and diaphoretic.  He is a/o x4 and complains of chest and side pain.  The pt sts that 4 days ago he got home from surgery where half of one of his kidneys was removed.  As to why his best explanation is that it was damaged.  Initial vitals are P-102 irregular, R-38 and shallow, SPO2- 91%RA, BP-90/48 BGL-112..  Feel free to ask for any additional info and of course here is your first 12 lead..


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## captaindepth (Apr 10, 2017)

So the obvious to begin with.... search for any prescribed medications in the house and what are they? Is the pt on home oxygen? what is the pts diagnosed medical history? How long has the pt had chest/side pain? any other associated symptoms (i.e. dizziness, L.O.C. , extremity pain/swelling, or N/V)? Ge the pt on the stretcher w/O2 and into the ambulance. Once in the ambulance grab a 12 lead  - which appears to show sinus tach around 100 bpm with frequent PVCs and other ectopy, significant ST depression throughout the anterior/lateral leads and elevation in the septal/ R sided leads.... shoot a V4R as well as posterior leads V7-V9. At this point i'm good with O2, ASA 324mg PO, ETCO2, starting a line w/ fluids running, and completing a secondary physical exam. Any significant findings on exam (lung sounds, subcutaneous air, positional discomfort,  extremity edema.... etc)?

With recent surgery, chest pain, and hypoxia, P.E. is high on the list... also considering M.I. and pericarditis.


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## Eden (Apr 11, 2017)

In addition to what he ^ said, the ecg is very worrying. Imma jump the gun and say it seems like a significant lmca lesion.


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## SpecialK (Apr 11, 2017)

Oh dear, this bloke looks very sick.  He needs to go to STEMI centre quickly and let the experts determine what the cause of his ticker badness is.


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## VFlutter (Apr 11, 2017)

Takotsubo Cardiomyopathy. Boom


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## StCEMT (Apr 11, 2017)

On top of what Captain asked, take a quick peek at the surgical site before strapping him in. While looking, get v7-9 back there then move to v4r. 324mg asa. Bilateral 18's and hang some fluid. Nasal cannula 2L. Go from there based on the history, physical exam, and rest of the EKGs.


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## EpiEMS (Apr 11, 2017)

Chase said:


> Takotsubo Cardiomyopathy. Boom


Could you walk us through this?


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## VentMonkey (Apr 11, 2017)

Chase said:


> Takotsubo Cardiomyopathy. Boom





EpiEMS said:


> Could you walk us through this?


Lol, I'm pretty sure he was being facetious, but maybe not...
http://www.health.harvard.edu/heart-health/takotsubo-cardiomyopathy-broken-heart-syndrome


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## StCEMT (Apr 11, 2017)

VentMonkey said:


> Lol, I'm pretty sure he was being facetious, but maybe not...
> http://www.health.harvard.edu/heart-health/takotsubo-cardiomyopathy-broken-heart-syndrome


Oh that heart is broken....just maybe not takotsubo broken.


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## EpiEMS (Apr 11, 2017)

VentMonkey said:


> Lol, I'm pretty sure he was being facetious, but maybe not...
> http://www.health.harvard.edu/heart-health/takotsubo-cardiomyopathy-broken-heart-syndrome



I wasn't sure whether he was joking or not - figured I'd check  Thanks for the link! I was mainly curious as to whether there were specific ECG changes indicative of Takotsubo (other than the ST-elevation that...I think?...we see here)

To the OP's original point - I see squigglies that look bad, 'mkay


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## VFlutter (Apr 11, 2017)

I was mostly joking since it would be rare, but not unheard of, in a younger male patient but possible with recent surgery/stress and possibility of adrenal issues presenting with what sounds like acute cardiogenic shock and global ST changes. Either that or a coronary vasospasm.


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## medichopeful (Apr 11, 2017)

What's the surgical site look like?  Bruised?  Hot?  Tender/swollen?  I'm a bit concerned about re-bleeding and don't necessarily want to just give this guy ASA until we dive further into this, even with the chest pain.

Left-sided EKG?


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## jaeems (Apr 11, 2017)

What's his LOC? Any known allergies as well? Seizure history? 

Good scenario, though. Is he in pain, maybe an NSAIDS.


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## StCEMT (Apr 11, 2017)

Unrelated and ultimately doesn't change my treatment, buuuut...Interpretation of wenkeback yet it recorded a PRI? Que?


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## FLdoc2011 (Apr 11, 2017)

medichopeful said:


> What's the surgical site look like?  Bruised?  Hot?  Tender/swollen?  I'm a bit concerned about re-bleeding and don't necessarily want to just give this guy ASA until we dive further into this, even with the chest pain.



I agree,  good pickup about possible bleeding.   Post-op patient who appears in some short of shock state,  bleeding always high on list.  

Kidneys are retroperitoneal structures so bleeding there could cause a significant RP bleed and would certainly focus some of my exam on that area.


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## FLMedic311 (Apr 11, 2017)

Hey all! Sorry for the late reply!  Some great stuff so far.  I am going to open up the door on this case now for a bit more discussion.  So after further investigation you find the pt's surgical site appears to be healing appropriately, no obvious signs of infection, and the pain does not localize to the area  Further PMHx includes HTN, Hyperlipid, Aortic stenosis (Not repaired), NIDDM, Hypothyroid.  NKDA, medications are appropriate for Hx ( I don't have them available, and honestly don't think it is pertinent to the DDx)  The pt is afebrile A/O x4 GCS-15 but as earlier stated significantly pale and diaphoretic.  Further head to toe assessment does reveals JVD and lung sounds with basilar rales bilaterally.  No pedal edema and good PMS.  The CP is substernal non-radiating, and also sts that he feels extremely weak, and that exertion has made it worse which is why he says you found him on the floor, he says he nearly passed out.  Further BP is 82/P and repeat 12 lead is as follows...  Further thoughts?  What do you think is going on? if I didn't clarify something well or just have additional questions fire away!!


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## FLMedic311 (Apr 11, 2017)

The pt is also noted to be breathing rapid and shallow and sts that the pain is increased upon deep inspiration.


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## E tank (Apr 11, 2017)

My DD....evolving perioperative MI v. PE v. delayed post op bleed v. ascending aortic dissection v. post op pneumonia. All of which can be ruled out by  CT and cath if necessary.


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## StCEMT (Apr 11, 2017)

I think Eden was on the right track with LMCA occlusion. I had to go dig up the other signs besides AVR elevation and that ekg is hitting them all.


Widespread horizontal ST depression, most prominent in leads I, II and V4-6
ST elevation in aVR ≥ 1mm
ST elevation in aVR ≥ V1


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## Eden (Apr 12, 2017)

FLMedic311 said:


> Hey all! Sorry for the late reply!  Some great stuff so far.  I am going to open up the door on this case now for a bit more discussion.  So after further investigation you find the pt's surgical site appears to be healing appropriately, no obvious signs of infection, and the pain does not localize to the area  Further PMHx includes HTN, Hyperlipid, Aortic stenosis (Not repaired), NIDDM, Hypothyroid.  NKDA, medications are appropriate for Hx ( I don't have them available, and honestly don't think it is pertinent to the DDx)  The pt is afebrile A/O x4 GCS-15 but as earlier stated significantly pale and diaphoretic.  Further head to toe assessment does reveals JVD and lung sounds with basilar rales bilaterally.  No pedal edema and good PMS.  The CP is substernal non-radiating, and also sts that he feels extremely weak, and that exertion has made it worse which is why he says you found him on the floor, he says he nearly passed out.  Further BP is 82/P and repeat 12 lead is as follows...  Further thoughts?  What do you think is going on? if I didn't clarify something well or just have additional questions fire away!!


 Okay so now im more confident in my inital diagonsis. This guy is in cardiogenic shock due to lmca lesion.
What i would do
Asa o2 heparin put the pads on him and hang a pressor (in my case dopamine ). full throttle to closest stemi center

Bleeding,  ascending aortic dissection and such can also cause these kind of changes in the ecg. But with the patient symptoms and this specific ecg, which is very imperssive and like stcemt said it nails every point for lmca lesion, It seems to me that this is the most probable dx.


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## E tank (Apr 12, 2017)

Eden said:


> Okay so now im more confident in my inital diagonsis. This guy is in cardiogenic shock due to lmca lesion.
> What i would do
> Asa o2 heparin put the pads on him and hang a pressor (in my case dopamine ). full throttle to closest stemi center
> 
> Bleeding,  ascending aortic dissection and such can also cause these kind of changes in the ecg. But with the patient symptoms and this specific ecg, which is very imperssive and like stcemt said it nails every point for lmca lesion, It seems to me that this is the most probable dx.



OK...food for thought...if his ascending aorta were dissecting, it could very well involve the root vessels. So your diagnosis of a left main lesion would be correct, but the treatment would be significantly different. A 41 year old having such severe left main disease would more than likely have a very strong family history (like his dad dying from the same thing at about the same age) and I'd want to tease that out as best as I could.


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## EpiEMS (Apr 12, 2017)

@E tank if we have the potential for an ascending aortic dissection...then we ought to be really cautious about doing anything on the coagulation inhibition spectrum, right? So is it conceivable that we might elect to do nothing other than O2, ECG, pain management, and a fluid bolus?


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## Eden (Apr 12, 2017)

E tank said:


> OK...food for thought...if his ascending aorta were dissecting, it could very well involve the root vessels. So your diagnosis of a left main lesion would be correct, but the treatment would be significantly different. A 41 year old having such severe left main disease would more than likely have a very strong family history (like his dad dying from the same thing at about the same age) and I'd want to tease that out as best as I could.


Yes I agree,  I would expect him to have relevant family history. But he does have the rest relevant risk factors.

Had an aortic dissection present itself as rca occlusion. These are definitely tricky.
I would measure bp on both hands too.
Minimal intervention approach to this case might not be wrong too.


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## E tank (Apr 12, 2017)

EpiEMS said:


> @E tank if we have the potential for an ascending aortic dissection...then we ought to be really cautious about doing anything on the coagulation inhibition spectrum, right? So is it conceivable that we might elect to do nothing other than O2, ECG, pain management, and a fluid bolus?



So, at the risk of chasing zebras, if we are including an ascending dissection that is involving the coronaries, the only difference in treatment here would be where you brought the patient. That said, you wouldn't pass a hospital with a cath lab and drive 30 minutes to the heart center either. 

Good thought about the anticoagulation therapy. Functionally speaking, an aspirin won't hurt someone like this. Even heparin would not be the end of the world. What really complicates surgical repair is when someone gives the patient something like Plavix. That is a real hassle when it comes to intraoperative bleeding. 

I'd be very tolerant of a MAP of about 65 with a guy like this and hold off on inotropic support unless it fell below 60. I'd give fluid if I could instead.


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## StCEMT (Apr 12, 2017)

I was actually about to ask you @E tank  about the risk of with holding in this case. It seems like asa has more benefit if it is a LMCA occlusion vs harm if this was an aortic dissection. That answers my question.


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## EpiEMS (Apr 12, 2017)

@E tank, thanks! That makes sense. (Interestingly enough, we don't carry anything beyond aspirin - even on our ALS units - as far as I can tell, for anticoagulation).


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## FLdoc2011 (Apr 12, 2017)

A 41yr old with aortic stenosis?   That should set off some bells as to a specific valvular pathology and an associated condition....


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## E tank (Apr 12, 2017)

FLdoc2011 said:


> A 41yr old with aortic stenosis?   That should set off some bells as to a specific valvular pathology and an associated condition....



Well, don't GIVE it away....


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## FLMedic311 (Apr 12, 2017)

FLdoc2011 said:


> A 41yr old with aortic stenosis?   That should set off some bells as to a specific valvular pathology and an associated condition....


So this was indeed a pt with severe cardiac ischemia secondary to untreated aortic stenosis.  The pt was found to have clean coronary arteries and a PAWP of 42mmHg.  The aortic valve was stented open by balloon valvuloplasty and is scheduled to have a valve replacement in the coming days.  Hope you all enjoyed, loved seeing the comments and thought process, a lot of great ideas and considerations.  As far as what this Pt's pre-hospital Tx actually consisted of was treated and transported to the closest hospital with Cath capabilities and en route received O2 15LPM NRB, 2x IV with 150mL of LR for BP.  ASA was with held due to concerns of the surgery and delivered to the receiving hospital without further complications.


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## StCEMT (Apr 12, 2017)

This was a good one. Guess I have to go look up the pathology FLdoc was talking about now.


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## VFlutter (Apr 12, 2017)

Good case and patho. This is the type of patient you start vaspressors on then arrest... afterload kills.


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## E tank (Apr 12, 2017)

Chase said:


> Good case and patho. This is the type of patient you start vaspressors on then arrest... afterload kills.



You would really think that, but it's counter intuitive...something like phenylephrine or vasopressin would actually help this guy. If you think about it, his afterload is already off the chart as it is because of the stenotic valve. This causes a wide pressure gradient between the left ventricle and the aortic root where the coronary arteries come off.

 Basically, all of the pressure stays in the ventricle and there is little left over to push blood down the RCA and LMCA. When you add a pressor, you increase the pressure in the aortic root from the other side of the heart and restore pressure head to the coronaries.

What is a killer for a guy like this is a faster heart rate, so epinephrine is not a good choice for hemodynamic management at all.

The absolute quickest way to kill this guy? Nitroglycerin.


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## VFlutter (Apr 12, 2017)

I get rate control and optimizing filling time but does normalizing the gradient really gain that much forward flow? You still likely have a poorly functioning LV that can't overcome Increased SVR.


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## EpiEMS (Apr 13, 2017)

E tank said:


> The absolute quickest way to kill this guy? Nitroglycerin.



In some places, EMTs and AEMTs who don't have ECG monitoring capabilities may administer EMS nitro (not patient carried nitro). This patient likely wouldn't be a candidate (as far as I can tell), given his hypotensive state, but if he were normotensive...how would we know not to administer nitroglycerin? Does it have something to do with reducing afterload through vasodilation?

(Probably a dumb question, just want to make sure I'm following here.)


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## E tank (Apr 13, 2017)

Chase said:


> I get rate control and optimizing filling time but does normalizing the gradient really gain that much forward flow? You still likely have a poorly functioning LV that can't overcome Increased SVR.



You won't increase the SVR any more than his stenotic valve does. There is no net increased work put on the LV. In fact the LV function should improve with the greater coronary artery flow.


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## E tank (Apr 13, 2017)

EpiEMS said:


> In some places, EMTs and AEMTs who don't have ECG monitoring capabilities may administer EMS nitro (not patient carried nitro). This patient likely wouldn't be a candidate (as far as I can tell), given his hypotensive state, but if he were normotensive...how would we know not to administer nitroglycerin? Does it have something to do with reducing afterload through vasodilation?
> 
> (Probably a dumb question, just want to make sure I'm following here.)



Obviously, I'm not familiar with local protocol, but if someone gives a history of aortic stenosis that you would say is a candidate for NTG, I'd recommend running that by someone first. 

The problem is that the NTG will unload the right heart by increasing venous capacitance at the periphery.  That just causes the amount of blood ending up in the LV (read: the coronary arteries) to fall.  With severe AS, existing impaired coronary flow falls even more.  That causes the vicious cycle of pump failure causing more pump failure.


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## EpiEMS (Apr 13, 2017)

@E tank 
Thanks for the explanation - appreciate it!


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## RocketMedic (Apr 22, 2017)

In this case, I'd hold the aspirin and nitro (as E tank explained) and go with fluid, O2 and a pressor PRN. Although we do carry heparin, this guy's recent kidney surgery would keep me away from it; the last thing he needs is to blow any clots we might need.


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## MikeC (Apr 27, 2017)

FLMedic311 said:


> SO you are dispatched to a 41y M pt and on arrival of a fairly clean appearing home you find the pt just past the front door, sitting on the floor half in the jacket/shoe closet.  He is clearly pale cool and diaphoretic.  He is a/o x4 and complains of chest and side pain.  The pt sts that 4 days ago he got home from surgery where half of one of his kidneys was removed.  As to why his best explanation is that it was damaged.  Initial vitals are P-102 irregular, R-38 and shallow, SPO2- 91%RA, BP-90/48 BGL-112..  Feel free to ask for any additional info and of course here is your first 12 lead..


 
I think recent surgery with s/s of cardiac chest pain w/ high resp rate and Pulmonary Embolism comes to mind. Load and go to facility that has thrombolytic therapy.

Looks like possible ST depression?

Either way, it doesn't look good. Give O2 via CPAP, place in a semi-fowler position if tolerated with feet raised. Be prepared for CPR and chest compressions.


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