# 68 y/o M chest pain and shortness of breath



## Psych (Apr 27, 2014)

Dispatched at 0845 to a private residence for chest pain/SOB. AOS TFA 68y/o obese M sitting on the floor AA+Ox0/1, in moderate respiratory distress (3 word sentences), skin pale, cool and diaphoretic, agitated. Pt c/c "it feels like I'm getting stabbed in the chest" (x3h, left hemithorax, worse on inspiration, rates at 7/10, denies radiation, describes pain as constant and stabbing/sharp). Per daughter on scene, she came to stay with him last night and found him in bed incontinent of urine, pt stated he had a fall earlier that day but denied any pain, only ℅ fatigue and went to sleep. Upon awaking at 0600, he developed ℅ back pain and then additional ℅ chest pain, shortness of breath and weakness ~20m PTA. She states she noted pt also developed hemoptysis at "some point during the night" and has some "small bruises" to the back. Pt has previously been recommended for catheter ablation, but did not want to undergo the procedure.

PMHx sig for HTN, paroxysmal AFib, CHF, HLD, COPD and tobacco Use 1 pack/day. Rx includes hctz, verapamil, bisoprolol, tiotropium, pradaxa, simvastatin and paxil (compliant c all, last doses 0800). Pt is allergic to NSAIDS and MSO4.

Initial assessment reveals GCS = 14 v/s = HR 106 irregular, weak, thready, delayed cap refill BP 88/60 high fowlers RR 28 shallow, labored SpO2 90% RA.

What would you like to know? How would you proceed?


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## Handsome Robb (Apr 27, 2014)

This fella sounds pretty sick. Lung sounds would be nice, also heart tones, might've missed them though. 12 lead ECG, O2 titrated to an spo2 of >92% BGL as well would be nice.  Any chance at waveform EtCO2?  

Where are we?? What are our hospital options? 

Recent illness? Med changes? Other recent trauma besides the fall? Recent hospitalizations? Any history of an abdominal or thoracic aneurysm? Pulse equal bilaterally in upper extremities? What about bilateral UE BPs? Is he normally altered? He's not profoundly hypoxic or hypotensive so the ALOC is kinda odd to me. When he fell did he hit his head on anything? Chest? What do the bruises on his back look like? Any bruising on his chest? Any crepitus in the thorax? Paradoxical movement? Subcutaneous emphysema? JVD? Any masses, pulsatile or non-pulsatile in his abdomen? Any guarding, bruising, rigidity? 

TAA/AAA or PE are my thoughts. Do need to consider MI as well as a COPD or CHF exacerbation although CHF doesn't really fit. Also pneumonia or a pneumothorax or pericardial tamponade. 

I'm tired so sorry that's so scattered, I'm interested though.

Treatment-wise I'm going to hold off until I'm not falling asleep and repeating myself but briefly O2, respiratory treatments if indicated, sidestream ETCO if we've got it, 12-lead, position of comfort, two lines titrate fluids to a MAP of 65-70mmHg but I'm going to be real careful giving him any sort of bolus, fentanyl for his pain and a ride to a hospital capable of cardiothoracic surgery if it's an option.


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## Psych (Apr 27, 2014)

Robb said:


> This fella sounds pretty sick. Lung sounds would be nice, also heart tones, might've missed them though. 12 lead ECG, O2 titrated to an spo2 of >92% BGL as well would be nice.  Any chance at waveform EtCO2?
> 
> Where are we?? What are our hospital options?
> 
> Recent illness? Med changes? Other recent trauma besides the fall? Recent hospitalizations? Any history of an abdominal or thoracic aneurysm? Pulse equal bilaterally in upper extremities? What about bilateral UE BPs? Is he normally altered? He's not profoundly hypoxic or hypotensive so the ALOC is kinda odd to me. When he fell did he hit his head on anything? Chest? What do the bruises on his back look like? Any bruising on his chest? Any crepitus in the thorax? Paradoxical movement? Subcutaneous emphysema? JVD? Any masses, pulsatile or non-pulsatile in his abdomen? Any guarding, bruising, rigidity?



Secondary physical assessment reveals two ~4-5cm hematomas around left intersection of sternal plane and posterior axillary line, jugular vein distension noted, decreased breath sounds left side, pitting edema of the lower extremities, palpable pain and tenderness of left hemithorax, crepitus noted around hematoma. No external hemorrhage, pupillary abnormalities, obvious neuro deficits or paradoxical chest motion noted at this time. Both patient and family deny any other trauma. ABD SNT s distension, PMS intact and equal at all distal extremities. 3-Lead EKG monitoring reveals afib with rapid ventricular response. EtCO2 is 26mmHg. I have no waveform nor a picture of the 12 lead for you right now, although it's not out of the question.

Your second set of vitals is a heart rate of 118, BP 80/60, RR 30 shallow labored, SpO2 91% on 15LPM.  

Code 3, you are 8-10 minutes out from a hospital normally capable of stabilization and diagnostics with very limited surgical/critical care capability and 18-20 minutes out from a level I trauma center (you're in the woods, it's rural, your scope of practice and receiving capabilities reflect this). No history of triple a, pradaxa was started about 3 weeks ago after the patient denied undergoing catheter ablation, the patient's daughter notes that he was non-compliant with the pradaxa last night because he went to sleep before she could give it to him but took his dose this morning.


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## Psych (Apr 27, 2014)

Oops, almost forgot the best part. It is 0910. While you are preparing to load, the daughter, upon asking about the catheter ablation/med changes, recalls the doctor said something about this medication making sure he "doesn't have a stroke cause of the clots in his legs". Yes this really happened. (Don't let it throw you off of what the rest of the assessment may suggest to you, however, also this pt had more than one thing going on and was probably the sickest person I've ever treated)


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## FLdoc2011 (Apr 27, 2014)

Yea he's sick.   He's on pradaxa so PE goes down the list in my mind, though w/ I guess a hx of recent DVT it's a possibly if it wasn't compliant.   

Was there a temp?


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## Psych (Apr 27, 2014)

We do not carry thermometers (I know right) but the temp at the hospital was 98.1F


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## Ewok Jerky (Apr 27, 2014)

Becks Triad: hypotension, JVD, muffled heart sounds. 

Fall last night, location of bruises, pradaxa, and shocky make me think he broke some ribs and is bleeding into pericardium.

Respiratory stuff on the left side could be hemothorax from broken ribs/trauma or maybe secondary to HF due to tamponade.

I want to see that EKG and hear that heart.
Any sign of broken ribs? Tenderness? Flail chest?

As for Tx I will say Robb hit it all. Code 3 to the level 1.

Great case!


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## mycrofft (Apr 27, 2014)

beano said:


> Becks Triad: hypotension, JVD, muffled heart sounds.
> 
> Fall last night, location of bruises, pradaxa, and shocky make me think he broke some ribs and is bleeding into pericardium.
> 
> ...



Sounds right.

No fan of new anticoags until they figure out a good monitoring system.


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## Angel (Apr 27, 2014)

great scenario!


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## Handsome Robb (Apr 27, 2014)

Pericardial Tamponade or Tension Penumothorax or Hemopneumothorax. What's his chest sound like with percussion? Also I asked about paradoxical movement but is his chest rising and falling equal bilaterally? I want to keep a close ear on those lung sounds to see if they're progressively diminishing, also i might've missed it but did we get heart tones on this gentleman?

If you can correct the problem and get his hemodynamic status a little better I want to go to the Level I but if we don't have the ability to do that we're going to the nearest facility.

With the posterior bruising it makes me think hemopneumo but then the location makes me think tamponade. 

Either way he's in obstructive shock and is going to go downhill fast if we don't correct these things.


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## Psych (Apr 27, 2014)

Robb said:


> Pericardial Tamponade or Tension Penumothorax or Hemopneumothorax. What's his chest sound like with percussion? Also I asked about paradoxical movement but is his chest rising and falling equal bilaterally? I want to keep a close ear on those lung sounds to see if they're progressively diminishing, also i might've missed it but did we get heart tones on this gentleman?
> 
> If you can correct the problem and get his hemodynamic status a little better I want to go to the Level I but if we don't have the ability to do that we're going to the nearest facility.
> 
> ...



My computer is pretty much deteriorating as fast as this patient was so forgive me if I miss anything. Becks Triad is present 100%, heart tones are "muffled". I didn't get percussion notes so I can't comment on that. The chest is rising and falling equally. Reassessment immediately prior to transport/while loaded reveal a change in mental status from cooperative but dazed to agitated, anxious, confused and combative. His O2 sat has not responded very well to the O2, never going above 91%. Vitals are becoming increasingly tachycardic and hypotensive, respirations have the same quality and hang around 28-32 per minute. You are going code 3 to the level 1 so you have some time with this guy, what can you do to make sure he doesn't die in the next 20 minutes?

(The interventions were the best part, for me at least. I still have to find out if it was medical control that thought it up or my partner or if it's actually in the literature somewhere but one of the treatments we did was totally out of the box and really interesting. He is in cardiogenic shock for sure but there is more to the picture.)


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## Psych (Apr 27, 2014)

I do have the 12 lead in front of me now, I cannot post it today but when I get a chance to go to the hospital and a) see if the patient is still alive / b) ask his permission if he is indeed alive and able to speak I will definitely post it. I still have to look at it a little more (back and forth from rapid ecg style) to really give an accurate description. The best I can do now is say there is the a fib rhythm with rvr with a QRS alternans pattern. There are some nonspecific ST segment changes and it meets the criteria for LVH. I did not pay much attention to the leads besides II enroute because his heart is pretty screwed up chronically and I disregarded my suspicion of thromboembolic event based on our med control conversation.


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## FLdoc2011 (Apr 27, 2014)

What are the QRS amplitudes?  

And I don't see the problem with posting it if it's properly de-identified.


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## Scott33 (Apr 27, 2014)

Sounds like a pulmonary contusion.


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## Psych (Apr 29, 2014)

FLdoc2011 said:


> What are the QRS amplitudes?
> 
> And I don't see the problem with posting it if it's properly de-identified.



We had an issue at our service with a privacy violation involving someone posting something to an online ems forum. It is now policy to both remove any identifying information as well as receive permission from the patient when posting things even as innocuous as a pic of a 12 lead. Unnecessary, I know, but the rules are the rules.

The patient's GCS dropped to 8 enrt. Although we were initially trying to avoid positive pressure ventilation due to the possibility of decreasing cardiac output/venous return, we ended up using a LTS-D because medical control wanted us to give him activated charcoal via an NG tube, their reasoning was that he was clearly losing a lot of blood and since he took the pradaxa less than 2 hours ago and they wanted to decrease the plasma levels of the drug as much as possible as there is no way to reverse the effects (plus the patient was non-compliant last night, so this actually may have done something...I don't know). We used ketamine, etomidate and succs in the process. We had vasopressors ready to go in case the sedation worsened the hypotension, but it did not.

We ran fluid via 2 16G IVs to a MAP of 60, we did not want to dilute his clotting factors any more than necessary. We ended up giving 1 liter of fluid total. We did not perform any respiratory treatments. They performed pericardiocentesis within a minute of us arriving into the trauma bay. He had severe pericardial effusion as well as hemothorax.

So are there any concerns for rate control in this patient? Now that you know the diagnosis would you have done anything differently?


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## mycrofft (Apr 29, 2014)

From now on, my own EKG's are going to be copyrighted so you guys can pay me a royalty it they're used.

Mine will have the special little T wave that looks like a happy face on it at the end..


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## Psych (Apr 29, 2014)

mycrofft said:


> From now on, my own EKG's are going to be copyrighted so you guys can pay me a royalty it they're used.
> 
> Mine will have the special little T wave that looks like a happy face on it at the end..



Ah, the have a nice day wave.


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