# Shortness of breath



## StCEMT (Dec 2, 2017)

So got thrown for a loop with equipment today. Give me your top guesses without 12 lead since it didn't work til later in the call and I will add it later as it happened for me.

63 y/o m complaining of shortness of breath. Sitting upright, not pale or diaphoretic, good lung sounds in all fields although slightly tachypneic. Says he became short of breath in the shower about 30 minutes ago. He is an immigrant, so clear history is hard to get, but you get that he had a leaky valve. Pulse was weak and rapid, hard to track it well enough to get an exact number, but definitely tachycardic. BP was 120/70's, SpO2 was 78%. Holding nitro and said he took two and they made his breathing feel better, no pedal edema or wet lungs though. 12 lead says lead fault, you gotta check it, so until it works, what are your first few differentials?


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## Carlos Danger (Dec 2, 2017)

"Leaky valve" = mitral regurgitation. MR + weak and rapid pulse = rapid a-fib. 

Management is to de-stress the heart. Keep HR up but reduce wall tension.


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## VFlutter (Dec 2, 2017)

I doubt many people have aggressive afterload reduction in their protocols but it may be worth a call to med control for some hydralazine.


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## Akulahawk (Dec 3, 2017)

Chase said:


> I doubt many people have aggressive afterload reduction in their protocols but it may be worth a call to med control for some *hydralazine*.


Assuming your system's units carry it in the first place...


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## VFlutter (Dec 3, 2017)

Akulahawk said:


> Assuming your system's units carry it in the first place...



Minor details....


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## E tank (Dec 3, 2017)

Had a leaky valve or has a leaky valve? Surgery (scar)? Blood thinners? I'd be concerned with the language barrier and just what "leaky" means. Just as likely to be a stenotic aortic valve with/without insufficiency as anything else, IMHO. Here's where heart sounds are pretty important before you go mucking with vasomotor tone/venous capacitance. I'm not sure I'd do anything given the givens beside some O2 and diesel. 

The echo could be surprising...


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## StCEMT (Dec 3, 2017)

Nice to see where y'all thoughts go. I'll post the 12 once I get home from this shift. And yes he had a surgical scar on his chest. No thinners that I recall


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## RocketMedic (Dec 8, 2017)

Food for thought, if your leads are not functioning, you can usually still grab a quick look by placing defib pads and using that connection instead (it'll be Lead 2 equivalent). This is because the pads cable is a separate connection and bypasses broken wires, missed contacts, etc. Its not a substitute, but a workaround for emergency use.


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## Carlos Danger (Dec 8, 2017)

E tank said:


> Had a leaky valve or has a leaky valve? Surgery (scar)? Blood thinners? I'd be concerned with the language barrier and just what "leaky" means. *Just as likely to be a stenotic aortic valve with/without insufficiency as anything else, IMHO.* Here's where heart sounds are pretty important before you go mucking with vasomotor tone/venous capacitance. I'm not sure I'd do anything given the givens beside some O2 and diesel.



Yeah, perhaps. IME MR is by far the most common thing that people would refer to in that way, and with the pulse rate the way he describes I would presume a-fib but of course without a monitor and a better history or an echo, there's no way to be sure enough what is going on to treat anything.

If the nitro is making him feel better, then I'd probably keep cautiously feeding him those and some O2, IV, and get him to an ED for a 12-lead and echo.   




RocketMedic said:


> Food for thought, if your leads are not functioning, you can usually still grab a quick look by placing defib pads and using that connection instead (it'll be Lead 2 equivalent). This is because the pads cable is a separate connection and bypasses broken wires, missed contacts, etc. Its not a substitute, but a workaround for emergency use.



Yep, good point. Surprised I didn't think of that. Back in the day that dinosaurs roamed the earth and 12-leads were not yet common prehospital, defibs had paddles instead of patches and a "quick look" with the paddles was exactly how we assessed unresponsive folks, or even conscious folks in extremis (though that tended to freak people out).

No need to put the leads on at all during the early phases of a resuscitation. Put the paddles on at the same time that you are assessing breathing and pulse and if they were in a shockable rhythm, charge the defib and shock. If no shockable rhythm but pulseless, start compressions and airway management and do another quick look in a minute or two. Eventually you'd put the leads on of course but it wasn't uncommon to run a whole code without doing so.


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## Chimpie (Dec 8, 2017)

@StCEMT So what happened with the 12 lead?


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## ThadeusJ (Dec 8, 2017)

Embolism?  Did the HR on the SpO2 match the palpated pulse (just tossing things out there)?


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## E tank (Dec 8, 2017)

RocketMedic said:


> Food for thought, if your leads are not functioning, you can usually still grab a quick look by placing defib pads and using that connection instead (it'll be Lead 2 equivalent). This is because the pads cable is a separate connection and bypasses broken wires, missed contacts, etc. Its not a substitute, but a workaround for emergency use.



Good thought. The other thing that could shed some light is the pulse ox pleth. Lots it wouldn't tell you but it would tell you if it were a pulsus alternans kind of deal  with a regular rhythm. That would tell me not to unload the heart any further anyway.


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## StCEMT (Dec 8, 2017)

Sorry about the delay...vacationing, no wifi, etc. Here is the 12.


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## Colt45 (Dec 9, 2017)

Well the 12 lead picture explains why he isn't perfusing very well. Seems like he was relatively haemodynamically stable when you were assesing him. Time to go down that algorithm. I'm curious how this ended up. I would predict that you either arrived at the hospital before doing any cardioversion due to the trouble with the 12-lead, you ended up cardioverting, or this dude was circling the drain or coding by the time you got to the hospital. Thanks for the pictures StCEMT.


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## Aprz (Dec 21, 2017)

For the record, that's a pretty nice looking ventricular tachycardia.

When you see a wide complex tachycardia, you should always assume ventricular tachycardia (VT) until proven otherwise. This is especially true when the patient is older (63 year old male) and has cardiac history (he took nitroglycerin, has a scar on his chest). The things that strike me as VT on this 12-lead was the fact that

a) It has extreme right axis deviation (lead I and aVF are BOTH negative). Extreme right axis deviation is not sensitive for VT (it's not always present even though the patient is having VT). However, it is very specific for VT (if it's present, it's probably VT).

b) This has an atypical RBBB-like pattern because lead V1 is mostly positive. It's not the typical qR or rsR' wave that we see in lead V1. Also usually RBBB is not associated with axis change, so it would have a Rs "slurred s" wave in lead I and V6. In here, lead I and V6 are both negative. V6 being entirely negative is also another specific finding for VT.

I'm not sure what the deal-o is with the 6th beat in lead III. Potentially looks like a fusion beat to me, but not necessary to make the diagnosis.

I don't have much experience with Zoll. On the LifePack and Philips, I would override it and print anyways. Although it is preferable to have ALL the leads, I would at least want most of them. Like others mentioned, paddles/pads would've been good. What a Hell of the time to have ECG problems.

My question for patient treatment is why were you considering giving nitroglycerin? For me, I wouldn't want to give it to somebody who is extremely tachycardic. They didn't mention chest pain. You also noted that you didn't appreciate pulmonary edema. At the same time, I wouldn't find that if the patient give to themselves, that it should not be continued to be given, especially after the patient said they felt better after the two does they gave themselves. Nitroglycerin has a very short half life so it isn't really an issue if the patient self administered it prior to arrival.


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## StCEMT (Dec 21, 2017)

I wasn't considering it. He was physically holding the tiny bottle.


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## Aprz (Dec 22, 2017)

StCEMT said:


> I wasn't considering it. He was physically holding the tiny bottle.


I totally misread that.


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## StCEMT (Dec 22, 2017)

Oh and you wouldn't be able to override. Initially, not a single lead was reading out of 12.


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## Medic27 (Dec 27, 2017)

Did you ever figure out a diagnosis for the ED or nah?


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## StCEMT (Dec 28, 2017)

It was VT


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