# Chest Pain



## VFlutter (Jan 29, 2019)

You respond to a patient with complaints of chest pain and syncope. Upon arrival patient is ashen, diaphoretic, and responsive to voice but drowsy and slow to respond. A&Ox3. No medical history.

Vitals:

HR: 50s with occasional drops to low 40s
RR: 14 non labored
Sp02: 94%
BP: 84/40

EKG as below....What is your treatment plan? What is likely the primary cause of the hypotension? Do you treat the bradycardia? 












Right Sided EKG.....


----------



## Peak (Jan 29, 2019)

Proximal RCA occlusion. Hypotension is the result of right atrial/ventricular dysfunction resulting in decreased pulmonary blood flow and therefore decreased blood flow to the left side the heart. 

Without prior EKGs or further H&P there is certainly a large amount of speculation, but as there is some lengthening to the PR interval I suspect a rather large amount of sinoatrial node ischemia. You could trial atropine but I highly doubt it would do anything. I would be hesitant to consider epi as the increased oxygen demand probably isn't worth in inotropic or pressor effects. At this point I don't think that pacing is of good value, if the patient consistently bradies below 40, enters a escape rhythm, becomes persistently unconscious, or has a more unstable pressure then I would certainly consider it. Overall I wouldn't be that concerned about the bradycardia at this point, although this patient will certainly earn at least pacer wires in the cath lab, and there is a good change he will get an implanted pacer before leaving the hospital.

Hypotension can be supported by giving fluids to support preload. As the patient's poor pressure is likely cardiac in nature and not peripheral I wouldn't strongly consider epi, levo, neo, or vaso unless the patient enters entremis, but even then they are temporizing measures that are going to cost as much heart tissue as time is borrowed. I wouldn't consider dobutamine or even milrinone due to the patient's hypotension, although if absolutely necessary I would certainly favor the latter. Dopamine may be of benefit but to me would be a lower priority to almost any other treatment. 

Rapid transport to the nearest appropriate cath lab. Cardiac activation. Large bore IV access x2. Fluids to support preload. ASA/clopidogrel, consider heparin if available. Pacer/defib pads are mandatory, radiolucent if your service has them. Titrate oxygen as appropriate. Serial EKGs and trop, not that it makes any difference in this patient's disposition. Consider fentanyl, although to be honest I'd be a hesitant given his presentation.


----------



## E tank (Jan 29, 2019)

.02 -.03 epi, fluid and narcotic. ASA.


----------



## SpecialK (Feb 1, 2019)

Oh deary me this patient is crook AF.

He is having a nasty inferior STEMI which is likely to have taken out his right ventricle.  The pressure gradient through the RV is very small (from memory it's about 10 mmHg at most) and because it can now no longer pump effectively that is causing his hypotension. I would suspect his lungs sound bad to listen to.

He needs aspirin, intravenous fluids, pain relief, and to go to a catheter lab super quick.


----------



## johnrsemt (Feb 5, 2019)

For me;  all of the above, and fly them cause our closest cath lab of any decency is 85 miles away (except the last 2 days with 70 + mph winds) so it is a long drive).
ASA, Fluid, Fentanyl (low BP, no morphine) Atropine if fluid doesn't help; try pacing call medical control.   Call EMS in next valley to pick up medical crew from the helicopter in their valley and meet us on the highway for extra help.


----------



## RocketMedic (Feb 28, 2019)




----------



## MSDeltaFlt (Mar 21, 2019)

RCA/Cx inferior/posterior AMI.  Right side ECG superfluous.  O2, ASA, Fluids, Dopamine, pain management.  Cath lab now if this patient is still within the window.  If not, local ER for thrombolytics.


----------



## Gurby (Mar 21, 2019)

MSDeltaFlt said:


> RCA/Cx inferior/posterior AMI.  Right side ECG superfluous.  O2, ASA, Fluids, Dopamine, pain management.  Cath lab now if this patient is still within the window.  If not, local ER for thrombolytics.



I'm not aware of a window period for STEMI's like there is for strokes?  

I thought the "90-minute window" is more of a guideline for the ED -- If PCI can't be done within 90 minutes of presentation, they are supposed to start fibrinolytics.  It's not like you just don't do a cath in this patient who clearly still has active infarct seen on the EKG.


----------



## VFlutter (Mar 22, 2019)

Gurby said:


> I'm not aware of a window period for STEMI's like there is for strokes?
> 
> I thought the "90-minute window" is more of a guideline for the ED -- If PCI can't be done within 90 minutes of presentation, they are supposed to start fibrinolytics.  It's not like you just don't do a cath in this patient who clearly still has active infarct seen on the EKG.




There are some recommendations that if they patient has a STEMI in a rural hospital, and can not be transported to a PCI center within 3-4hrs, than Fibrinolytics can be considered over PCI. Unfortunately delays PCI for 24hrs


----------

