# Head Trauma + MI



## SnowCal (Aug 19, 2013)

Call I ran in my internship and I'm still pretty confused about what was up and what I should've done or not done.

Dispatch elderly fall victim.  A quarter mile from scene we get an update that fire is doing CPR.  Ok...  Flip the lights on and walk in.  Pt is unconscious, has a fat hematoma on the forehead, fire is continuing CPR after their first shock.  Hook up our monitor showing a paced rhythm.  Pulse check shows a corresponding pulse.  Sweet.  Tell fire to stop CPR and get vitals, and keep c-spine which they were doing.  A quick assessment finds that big hematoma and a blown pupil.  Fire comes back with a BP of 260/140.  Crap.  Fire backboards, I drop a 14 in her EJ (easy, I coulda got oxygen tubing in that).  Hit the road.  Repeat vitals and assessment the same.  12-lead showing elevation, I forget where.  No tube due to clenched jaw.

This call wasn't especially smooth for me but I'm wondering if there were any things I did wrong.  I know I dropped the ball on getting lung sounds and doing the deer in headlights thing more than once.

And I'm still wondering what was up.  AMI causes dizziness leading to fall that causes headbleed.  Headbleed causes pt to brady but pacer catches the drop I'd hope.  Arrest would probably by AMI-related then.  That's my guess, but any of you have other reads?


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## Rialaigh (Aug 19, 2013)

Stroke (bleed) causes fall. PT has extensive cardiac history and chronic ST changes. AED didn't pick up paced rhythm and called for shock. 


That would be my random guess, a lot of different ways this thing could have gone. 

Transport and maintain airways, thats pretty much it...


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## SnowCal (Aug 19, 2013)

Rialaigh said:


> Stroke (bleed) causes fall. PT has extensive cardiac history and chronic ST changes. AED didn't pick up paced rhythm and called for shock.
> 
> 
> That would be my random guess, a lot of different ways this thing could have gone.
> ...



That makes sense.

A family member told us something about the pt having a seizure when she went out.  Being in ACLS mode I wrote that off as a VF seizure, but the bleed explains it too if no arrest actually happened.  I'd like to think that fire checked for pulse.  I know one of those guys is a medic.  Shoot, he pointed out that EJ when I was tourniqueting for an AC.


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## Rialaigh (Aug 19, 2013)

Seizure like activity prior to unresponsive with a BP like that and I would bet the stroke happened first. 


Nothing you can do in the field other than protect the airway, suspected bleed so you don't want to bring the BP down in the field (unless your transport time is ungodly long, and even then I would consult a physician first). 


If RSI in the protocols I think a tube is warranted, might be one of those situations where a little etomidate would have loosened the jaw enough to drop one but if you could ventilate adequately with a BVM then that works too.


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## SnowCal (Aug 19, 2013)

Rialaigh said:


> Seizure like activity prior to unresponsive with a BP like that and I would bet the stroke happened first.
> 
> Nothing you can do in the field other than protect the airway, suspected bleed so you don't want to bring the BP down in the field (unless your transport time is ungodly long, and even then I would consult a physician first).
> 
> If RSI in the protocols I think a tube is warranted, might be one of those situations where a little etomidate would have loosened the jaw enough to drop one but if you could ventilate adequately with a BVM then that works too.



I would've liked to RSI but California buddy.  The way this place works I think we're lucky that we can still give epi.


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## Aprz (Aug 19, 2013)

Ventricular paced is a STEMI-mimic. Like other STEMI-mimics, the T-waves and ST changes are usually discordant from the last deflection in the QRS complex.


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## VFlutter (Aug 19, 2013)

My guess is that the ST elevations were due to catecholamine surge, or "storm", secondary to markedly increased ICP.

TBIs are know to cause all kinds of crazy ST changes and "cerebral T waves"

Example: 12 lead of a patient with an acute bleed


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## Christopher (Aug 19, 2013)

SnowCal said:


> Call I ran in my internship and I'm still pretty confused about what was up and what I should've done or not done.
> 
> Dispatch elderly fall victim.  A quarter mile from scene we get an update that fire is doing CPR.  Ok...  Flip the lights on and walk in.  Pt is unconscious, has a fat hematoma on the forehead, fire is continuing CPR after their first shock.  Hook up our monitor showing a paced rhythm.  Pulse check shows a corresponding pulse.  Sweet.  Tell fire to stop CPR and get vitals, and keep c-spine which they were doing.  A quick assessment finds that big hematoma and a blown pupil.  Fire comes back with a BP of 260/140.  Crap.  Fire backboards, I drop a 14 in her EJ (easy, I coulda got oxygen tubing in that).  Hit the road.  Repeat vitals and assessment the same.  12-lead showing elevation, I forget where.  No tube due to clenched jaw.
> 
> ...



VF arrest with sz like activity with fall, hematoma secondary to same. The 12-Lead probably did not show a true STEMI if the post-arrest rhythm was V-paced.

I've worked a VF arrest with a sz and fall which resulted in a traumatic injury to the patient's eye and orbit; partial blindness being the patient's only sequelae after survival to discharge. Don't discount the fall as a cause of trauma, especially in the elderly.



Aprz said:


> Ventricular paced is a STEMI-mimic. Like other STEMI-mimics, the T-waves and ST changes are usually discordant from the last deflection in the QRS complex.



+1 to this.


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## Christopher (Aug 19, 2013)

Rialaigh said:


> AED didn't pick up paced rhythm and called for shock.



Pretty rare for an AED to shock a paced rhythm, usually what happens is the AED gets confused by both a shockable rhythm and pacemaker impulses and instead determines the rhythm to be non-shockable.


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## DesertMedic66 (Aug 19, 2013)

Chase said:


> My guess is that the ST elevations were due to catecholamine surge, or "storm", secondary to markedly increased ICP.
> 
> TBIs are know to cause all kinds of crazy ST changes and "cerebral T waves"
> 
> Example: 12 lead of a patient with an acute bleed



This is exactly what the 12-lead looked like on the patient I transported who had the brain bleed (84 y/o female with unknown history that the hospital accidentally gave tPA to)


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