# "I'm Having A Heart Attack"



## Tigger (Apr 26, 2016)

Your ALS ambulance is dispatched on an unknown medical sometime after midnight to a private residence located approximately 20 minutes away. Enroute you are advised that the patient is being exceptionally impatient with the call taker but says he is having the chest pains. BLS Fire is also responding with a similar ETA to you. If you elect to transport, you have a six bed ED with no specialty services 30 minutes away and several full service medical centers 70 minutes away. The helicopter will not be flying.

You arrive on scene to find a less then well kept single-wide. Fortunately for you, as you exit the ambulance the patient comes running towards you, clutching his chest and yelling that he is dying of a heart attack. The patient wastes no time hopping in the side door and plopping himself down onto the cot, where he then promptly vomits. The patient is 58 and will not stop carrying on about his imminent demise. 

What do you want and what do you do?


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## zzyzx (Apr 26, 2016)

We can start by giving him a vomit bag.


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## PotatoMedic (Apr 26, 2016)

So the pt is not answering questions?  If they do answer questions onset, anything make it worse or better, describe the pain/discomfort, med history, allergies, medications.  

What does their skin look like?  Lung sounds.

Have my partner start working in a 12 lead.
Start an IV and give zofran.  

And what does the vomit look like.

Vitals?

We'll start there.


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## Akulahawk (Apr 26, 2016)

Tigger said:


> Your ALS ambulance is dispatched on an unknown medical sometime after midnight to a private residence located approximately 20 minutes away. Enroute you are advised that the patient is being exceptionally impatient with the call taker but says he is having the chest pains. BLS Fire is also responding with a similar ETA to you. If you elect to transport, you have a six bed ED with no specialty services 30 minutes away and several full service medical centers 70 minutes away. The helicopter will not be flying.
> 
> You arrive on scene to find a less then well kept single-wide. Fortunately for you, as you exit the ambulance the patient comes running towards you, clutching his chest and yelling that he is dying of a heart attack. The patient wastes no time hopping in the side door and plopping himself down onto the cot, where he then promptly vomits. The patient is 58 and will not stop carrying on about his imminent demise.
> 
> What do you want and *what do you do?*


The same thing we do every night, Pinky - try to take over the world!

Give him a vomit bag and believe him until proven otherwise. Then get on with things and assess the guy. Could he be experiencing a heart attack? Sure. Could it be a panic attack? Sure. Could he simply be insane? I'm already there.... but enough about me.  Could it be that he needs to clear datum? Yes... 

Bottom line is that we do what we always are supposed to do and begin assessing the guy for a possible cardiac problem and go from there as the data we develop suggests.


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## DesertMedic66 (Apr 26, 2016)

Start off with a standard assessment.
Medical Hx
Medications
Location of pain
Onset of pain
Anything make it better or worse
Baseline vitals
12-lead
Had this pain before?
SOB? Lightheadedness?
I'll wait for results before I start jumping into possible treatments.


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## Old Tracker (Apr 26, 2016)

DesertMedic66 said:


> Start off with a standard assessment.
> Medical Hx
> Medications
> Location of pain
> ...



Besides all of the above, I'd be trying to calm him down. Whatever anxiety he is showing, if indeed he is having a heart attack, is not helping him in the least. I have next to no experience with potential heart patients, but the ones I have dealt with, haven't been feeling well enough to run anywhere.


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## Underoath87 (Apr 27, 2016)

Yep, never seen anybody with actual ischemic chest pain running around and agitated.  They're generally on the lethargic end.


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## Tigger (Apr 27, 2016)

You are able to calm the patient down enough to get a 12 lead which is attached. Thankfully, now that you have provided the patient a vomit bag, he stops (the vomit was unremarkable). 

You elicit the following: the patient has had a previous MI, of which he says this feels similar. The pain started at rest and has been going on for "days," but it suddenly worsened for no reason. He won't describe the pain for you, just "it feels real bad and I'm dying!" When asked about his previous medical history, the patient states "I've been sick for years." Eventually you get out that he has hypertension, diabetes, and hepatitis C. He takes a hypertension med and oral diabetic control med. He has no allergies. 

Vital signs: 254/110. Radial Pulse at 30. Respirations at 24. BGL 109. SpO2: 94%.


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## Alan L Serve (Apr 27, 2016)

Radial of 30 vs monitor at 85. Super high BP with + hx of MI, DM, and HCV. Put on O2 NRB 15lpm, start IV tko, continue monitoring, place PT in position of comfort. Need to get that pressure down so might consider a beta blocker or SL nitro. I imagine his PVCs are due to his kidneys having failed from DM and severe HTN causing his K to skyrocket. Therefore I would start nebulized albuterol. Does this ambulance carry any insulin?

He's too sick for the doc in a box.


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## Carlos Danger (Apr 27, 2016)

I wouldn't give a beta blocker to someone with a pulse of 30.

I'd give him a ntg or two and see what happens.

NC and IV, of course.


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## Alan L Serve (Apr 27, 2016)

Remi said:


> I wouldn't give a beta blocker to someone with a pulse of 30.
> 
> I'd give him a ntg or two and see what happens.
> 
> NC and IV, of course.


That is concerning but I have a feeling his radial pulse is an abnormality. Do we have any ACE-I or ARBs?


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## Carlos Danger (Apr 27, 2016)

Alan L Serve said:


> That is concerning but I have a feeling his radial pulse is an abnormality. Do we have any ACE-I or ARBs?


Anytime the pulse and monitor differ, it is the monitor that is the abnormality.

Even if we were going with the monitor over the pulse......a HR of 85 isn't an indication for a beta blocker.


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## Alan L Serve (Apr 27, 2016)

Remi said:


> Anytime the pulse and monitor differ, it is the monitor that is the abnormality.
> 
> Even if we were going with the monitor over the pulse......a HR of 85 isn't an indication for a beta blocker.


I agree with the monitor vs pulse, but if his pulse is in fact that high we can use a beta blocker to help in quickly reducing his pressure which is so high he's likely to burst somewhere and soon.


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## Alan L Serve (Apr 27, 2016)

Forgot to add I'd give PO ASA for suspected ACS.


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## Tigger (Apr 27, 2016)

I suppose I should add that the rhythm strip above the 12 lead is continuous, we didn't have to catch this. He was in that upon placing the four lead and did not spontaneously stop.


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## Carlos Danger (Apr 27, 2016)

Alan L Serve said:


> I agree with the monitor vs pulse, *but if his pulse is in fact that high *we can use a beta blocker to help in quickly reducing his pressure which is so high he's likely to burst somewhere and soon.



Well that's just it; the pulse is NOT in fact that high. It was only 30.

You give a beta blocker to a patient with a new onset BBB and a pulse rate of 30, and you may very well kill them. 

Again, even if their pulse rate was 85 as indicated on the monitor, that is still not an indication for beta blockade. The HR is not the cause pf the HTN.

A pulse rate of 85 may reasonably be treated with metoprolol only AFTER the BP has normalized and and chest pain has stabilized.


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## Alan L Serve (Apr 27, 2016)

Remi said:


> Well that's just it; the pulse is NOT in fact that high. It was only 30.
> 
> You give a beta blocker to a patient with a new onset BBB and a pulse rate of 30, and you may very well kill them.
> 
> ...



True, tho I suspect the radial pulse might be that low and I would use also get an apical pulse and compare the two. If indeed it was that very bradycardic then certainly no beta blocker should be used. 

Any idea on the availability of insulin, furosemide, or an ACE-I/ARB?


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## nater (Apr 27, 2016)

I would want a potassium level as well.The chest pain, nausea, bradycardia, 12 lead with peaked T waves  suggest hyperkalmia. It looks like a sine wave might be forming which would raise concern that this patient is close to arrest.I would go to the closest 6 bed facility.  D50, insulin, Calcium, bicarb and albuterol can help him, dialysis will also be needed.


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## ERDoc (Apr 28, 2016)

There is no indication for beta blockers.  Your pulse is what matters, not what the monitor says or what you hear apically.  Your pulse is what perfuses and right now you are only perfusing at 30.  I also think we are jumping the gun on hyperK.  There aren't any peaked t waves.  When someone who has had a heart attack before tells you they are having a heart, trust them.  They know what it feels like.  I'm not saying that is what this case is but it is something that should raise your suspicions.


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## Tigger (Apr 28, 2016)

You are on a "mostly standard" ALS ambulance. No lab values, insulin, beta blockers or an ACE-I. We do have IV nitro, but aside from that it's a pretty standard formulary. Furosemide if you want.

What are everyone's rhythm and 12 lead interpretations? I feel like mine is very different than many here, or maybe not?


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## jaksasquatch (Apr 28, 2016)

Looking at that 12 lead in conjunction with the patient's symptoms I'm seeing a Sinus rhythm with a RBBB with PVC's, there are (as of now) no signs of infarct, to call those T waves symmetrica/hyperacute and evidence of LAD occlusion is tempting but considering the Hx they are more than likely Hyper K. If I was on a truck at this moment I would really want an SpO2 pleth so that I could see if every PVC is really getting through, I've been confused by the radial pulse one too many times. If the rate is indeed 35 (which I don't believe) with a blood pressure that high being of a different source (chronic medical conditions) I would lower the pressure and continue monitoring cardiac (12 lead every 5 min). Paying attention to signs of stroke I would also like to confirm this pressure manually. SL Nitro would be necessary at this time. BB's would be contraindicated. ASA given prior.


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## Tigger (Apr 28, 2016)

The pulse rate is confirmed with a good pleth wave, I did not print that. The blood pressures were all taken manually. The patient is neurologically intact.


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## zzyzx (Apr 30, 2016)

This is really a great scenario, Tigger! It's quite complicated, and to be honest I'm not entirely sure what to do.

First of all, one strip shows bigeminy, but the other does not. Was he continually in bigeminy? This is important as it would determine how I would treat him. I would also make sure that I'm getting accurate BP's.

If he is continually in bigeminy and his PVC's are not creating a pulse, then this bradycardia needs to be addressed. Is the bradycardia due to ischemia from a developing MI? I don't see any ST elevation, but I won't rule that out. Or, is the bradycardia due to the extreme high blood pressure that his not-so-healthy heart has to pump against? Is the hypertension a response to the bradycardia, or is it a stress response? It's a couple of chicken-or-egg questions!

In a nutshell, I want to both bring up his heart rate and bring down his BP. This is what makes the patient complicated.

So, two things have to be corrected--the bradycardia and the hypertension. Certainly giving him some benzos would be a good place to start. My first thought is to start pacing him. If the hypertension is due to the bradycardia, and the chest pain and probably ischemia due to the hypertension, then by pacing him we could get him to a normal rate and thereby bring down his blood pressure. If it was a very short transport to a cath lab, then I would not do this, but considering the distance given in this scenario, I would not want to transport someone with underlying heart disease this far while he having massive chest pain and a massively high BP. Pacing this already very anxious guy is obviously not going to be easy, and again, I would be liberal with benzos and pain control. 

Atropine is a consideration, and it would be easier on him that pacing, but once we give it we can't just turn it off again due to its long half life.

Aspirin and a spray of nitro would be okay. But, I don't think treating the BP with nitro would be appropriate, nor would giving anything else that only addressed his BP without also bringing up his heart rate.

This is definitely a time where I would consult with a doc at the receiving hospital. I look forward to seeing how you guys would treat this patient. Again, great scenario!


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## SpecialK (Apr 30, 2016)

Everything about this guy screams "recommend immediate referral to a heart attack centre and take him there by ambulance".

I would give him aspirin and try one spray of GTN, gain IV access and give him pain relief if he wants it.  I'd start with entonox (or methoxyflurane if entonox is contraindicated) and give him some IV morphine if that didn't work

As for his bradycardia, if it is not symptomatic I am not overly concerned about it to be honest.  

BP of 260 is a bit worrying, but he does have PMHx of HTN so for him that might be normal, does he know what his BP usually is? 

Bottom line from me is treat as above, take to a PCI-capable hospital and if he gets significantly worse, seek clinical advice.


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## Underoath87 (Apr 30, 2016)

SpecialK said:


> BP of 260 is a bit worrying, but he does have PMHx of HTN so for him that might be normal, does he know what his BP usually is?



I don't think it's possible for anyone's "normal" BP to be well into hemorrhagic stroke territory...


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## SpecialK (May 1, 2016)

Underoath87 said:


> I don't think it's possible for anyone's "normal" BP to be well into hemorrhagic stroke territory...



It would be unusual yes, but anything is possible in medicine.  I have seen a normal hypertensive BP of 220.


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## Alan L Serve (May 1, 2016)

SpecialK said:


> It would be unusual yes, but anything is possible in medicine.  I have seen a normal hypertensive BP of 220.


Maybe but this guy is clearly symptomatic with a very abnormal EKG. It's not normal for him.


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## Tigger (May 1, 2016)

zzyzx said:


> This is really a great scenario, Tigger! It's quite complicated, and to be honest I'm not entirely sure what to do.
> 
> First of all, one strip shows bigeminy, but the other does not. Was he continually in bigeminy? This is important as it would determine how I would treat him. I would also make sure that I'm getting accurate BP's.


Indeed, that 12 lead was the only time he was not in continued bigeminy. 

We (my partner really, I thought ALS was magic at the time) elected to treat the bigeminy with a lidocaine, he converted following a 1mg/kg bolus. A 2mg/min lido drip was started, and this kept the bigeminy at a bay for a while though eventually it was turned up to three to keep a sinus rhythm. His BP came down to the 190s and the patient became entirely asymptomatic. He received aspirin and subsequent 12 leads were unremarkable. No NTG as the patient no longer had chest pain and this system does not like it for anything but that.


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## SpecialK (May 1, 2016)

Alan L Serve said:


> Maybe but this guy is clearly symptomatic with a very abnormal EKG. It's not normal for him.



It's likely not normal for him no but the only thing I have to reduce his blood pressure is sublingual GTN and I'm not very keen on using for a purpose I know absolutely nothing about.

If the hospital want to do it then they can go for it like a skinned cat.


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## zzyzx (May 6, 2016)

Tigger said:


> Indeed, that 12 lead was the only time he was not in continued bigeminy.
> 
> We (my partner really, I thought ALS was magic at the time) elected to treat the bigeminy with a lidocaine, he converted following a 1mg/kg bolus. A 2mg/min lido drip was started, and this kept the bigeminy at a bay for a while though eventually it was turned up to three to keep a sinus rhythm. His BP came down to the 190s and the patient became entirely asymptomatic. He received aspirin and subsequent 12 leads were unremarkable. No NTG as the patient no longer had chest pain and this system does not like it for anything but that.



Huh? Your partner treated a bigeminy with an underlying sinus bradycardia in the 30s with lidocaine? That's a big contraindication, for obvious reasons.


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## Tigger (May 6, 2016)

zzyzx said:


> Huh? Your partner treated a bigeminy with an underlying sinus bradycardia in the 30s with lidocaine? That's a big contraindication, for obvious reasons.


Not so obvious to me I guess. It was a case presented in class as well. These do not appear to be escape beats and this isn't a heart block. The patient is having 60 PVCs a minute and is symptomatic, it would appear that lidocaine should be considered, as could atropine.


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## zzyzx (May 6, 2016)

Sounds like your partner was really old school. 
Treating PVC's with anti-dysrhythmics is no longer recommended, though I don't doubt you'll find some old ER docs that will do it. 
However, it is a clear contraindication to treat bigeminy with lidocaine when the underlying rhythm is 30.

This is a complicated case, and I'm looking forward to see how other providers would have treated this guy.


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## Tigger (May 6, 2016)

zzyzx said:


> Sounds like your partner was really old school.
> Treating PVC's with anti-dysrhythmics is no longer recommended, though I don't doubt you'll find some old ER docs that will do it.
> However, it is a clear contraindication to treat bigeminy with lidocaine when the underlying rhythm is 30.
> 
> This is a complicated case, and I'm looking forward to see how other providers would have treated this guy.


At least here, treating non-symptomatic PVCs is not recommended. If the patient is symptomatic the expectation is that they will be managed, or so says our QI. I guess I am still unclear on how it's a contraindication. If it was a rate of 30 in the context of a block or escape rhythm, absolutely.


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## hosejockey (May 11, 2016)

if it's 30 apical, I'm going to opt for I.V 18 g left AC if possible, with a lock..

I'd give atropine 0.5mg, I'd give morphine for discomfort(going for >60 palpable, since the pvc's are interfering with the monitor) continue monitoring all the way in, document.


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## hosejockey (May 11, 2016)

hosejockey said:


> if it's 30 apical, I'm going to opt for I.V 18 g left AC if possible, with a lock..
> 
> I'd give atropine 0.5mg, I'd give morphine for discomfort(going for >60 palpable, since the pvc's are interfering with the monitor) continue monitoring all the way in, document.


I ran out of time to edit... Anyways, it's hard. My concern is 30 isn't life sustaining. It feels like there's a lot of ways to look at this. I'm glad I came across this.


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## gotbeerz001 (May 11, 2016)

So, what's the answer?
I just had this pt and had a WTF moment...
54 yom, pacemaker placed last week, currently in bigeminy with a rate of 45 and BP of 190/90. Chest "soreness" from the implant last week; says he cannot differentiate whether he has CP (as we mean it) with mild nausea and mild SOB when asked specifically about these symptoms. Pt has some numbness to extremities (unsolicited). 

Treat the brady despite high BP? Treat the bigeminy though there is a low underlying pulse rate? Get an IV and ready to prepare for him to crash while hoping he makes it for the ride?? Also, preferred hospital is 40+ minutes by ground (probably 60 mins with traffic). 


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## gotbeerz001 (May 11, 2016)

Also, said pt was very concerned that we let his dogs out and make sure to leave a cell phone in a certain spot on the counter...




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## Tigger (May 12, 2016)

gotshirtz001 said:


> So, what's the answer?
> I just had this pt and had a WTF moment...
> 54 yom, pacemaker placed last week, currently in bigeminy with a rate of 45 and BP of 190/90. Chest "soreness" from the implant last week; says he cannot differentiate whether he has CP (as we mean it) with mild nausea and mild SOB when asked specifically about these symptoms. Pt has some numbness to extremities (unsolicited).
> 
> ...


I don't know. She elected to treat the PVCs as malignant considering the chest pain and it was effective, and when it was brought up in class that was said to be fine, though not much elaboration. I've found some places that support this practice (http://www.aafp.org/afp/2002/0615/p2491.html, this anesthesia text) or at least say consider it. I'm still not sure why it's so contraindicated in this situation as @zzyzx suggests.


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## gotbeerz001 (May 12, 2016)

We run Lidocaine and I have come across warnings that administration for PVCs with underlying bradycardia could potentially cause arrest. Others that I have spoken to state you should generally treat the bradycardia over the PVCs and deal with them if still present once the rate has improved. I was working the engine that day but with so many different issues going on concurrently, I would probably make a base call if I were the transporting medic and the hospital were any further than around the corner.  


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## Tigger (May 12, 2016)

gotshirtz001 said:


> We run Lidocaine and I have come across warnings that administration for PVCs with underlying bradycardia could potentially cause arrest. Others that I have spoken to state you should generally treat the bradycardia over the PVCs and deal with them if still present once the rate has improved. I was working the engine that day but with so many different issues going on concurrently, I would probably make a base call if I were the transporting medic and the hospital were any further than around the corner.
> 
> 
> Sent from my iPhone using Tapatalk


Apparently a decrease in contractility can occur at toxic dosing levels. No part of our protocols have that kinda warning, they could of course be lacking.


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## ERDoc (May 19, 2016)

I would not treat with Lidocaine in this case.  Yeah, it's bigeminy and he is bradycardic but he is stable.  The normal beats don't look concerning.  I would sit on him and see if something else evolves.


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## NYBLS (Jun 4, 2016)

Alan L Serve said:


> Radial of 30 vs monitor at 85. Super high BP with + hx of MI, DM, and HCV. Put on O2 NRB 15lpm, start IV tko, continue monitoring, place PT in position of comfort. Need to get that pressure down so might consider a beta blocker or SL nitro. I imagine his PVCs are due to his kidneys having failed from DM and severe HTN causing his K to skyrocket. Therefore I would start nebulized albuterol. Does this ambulance carry any insulin?
> 
> He's too sick for the doc in a box.




Why the oxygen? It doesn't appear hypoxia is the cause for it and it can cause more damage... 



hosejockey said:


> if it's 30 apical, I'm going to opt for I.V 18 g left AC if possible, with a lock..
> 
> I'd give atropine 0.5mg, I'd give morphine for discomfort(going for >60 palpable, since the pvc's are interfering with the monitor) continue monitoring all the way in, document.




Why an 18g? I think Fentanyl would also be a better choice. More hemodynamically stable, might calm him down a little and bring down his pressure.

Treatment?
ASA, 12 lead q5 minutes (or whenever he complains about something new), couple big boy IVs, zofran, Fentanyl


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## zzyzx (Jun 6, 2016)

ERDoc said:


> I would not treat with Lidocaine in this case.  Yeah, it's bigeminy and he is bradycardic but he is stable.  The normal beats don't look concerning.  I would sit on him and see if something else evolves.



Is he stable? He's good a cardiac history, having excruciating chest pain, and is really hypertensive.


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## ERDoc (Jun 8, 2016)

I haven't looked back through the thread but I thought the pain went away at some point.  If he is bradycardic but mentating and non-hypotensive then I would say he is relatively stable.  Sometimes not doing anything is the best thing to do, waiting can be therapeutic.


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## Rialaigh (Jun 9, 2016)

Interesting 4 lead and 12 lead. I'm thinking liberal with some benzo's and maybe some narcotics. ASA, IV, Monitor.

I'm not sure I'm opposed to a moderate fluid bolus to see if it does anything for frequency of PVC's or Heart Rate or blood pressure, especially given the possibility of vomiting that has been going on longer than the last couple minutes, if he's been feeling bad for days its very likely hes at least a teeny weeny bit dehydrated. 

And I think I jump straight to pacing in the event that we lose hemodynamic stability, but if that occurs its very likely I get very aggressive with this patient given a 45-60 minute transport in my area.


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## zzyzx (Jun 17, 2016)

Actually, I think what this guy really needs is a transvenous pacer. His circulation has clamped down to compensate for his severely compromised heart rate, and now his tired old heart is having to pump against a massive systemic vascular resistance, the SVR being the only thing in the equation (BP=cardiac out x SVR) that is sustaining his blood pressure. I said earlier that I would consider externally pacing him, but I was never sure of that since it would be painful and just add to his stress and anxiety. Again, I think atropine is potentially a bad idea because you can't turn it off due to its long half life. So, I'll say that the best action for EMS is to hold off on pacing or atropine and just get him to the ER so a transvenous pacer can be placed. Once his heart rate is restored to a more normal rate, his cardiac output will be increased, and hopefully the SVR will relax, thus reducing the workload on his heart.


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## systemet (Jul 10, 2016)

Underoath87 said:


> Yep, never seen anybody with actual ischemic chest pain running around and agitated.  They're generally on the lethargic end.



I realise this is an older thread, but I have very much seen this presentation several times with acute MI.  Including a guy with a massive anterior who arrested in triage.

This guys presentation with hypertension and chest pain is concerning.  Some considerations:

* Are there risk factors or physical exam findings suggesting thoracic dissection? Do we have equal radial pulses / bilateral BPs.
* Any neuro symptoms?
* Any degree of heart failure?
* Recent sympathomimetic ingestion?
* Prior hx neuro deficitis / unexplained syncope?
* Recent sentinel blood pressure events or changes in med?

I don't see a lot pointing to acute renal failure.  The most reasonable course seems to be to given some ASA, considerate an anxiolytic, we could trial NTG, but we don't know what is driving the BP up right now, so we don't want to reduce the MAP too rapidly.

This is someone who needs some imaging.  Then we can decide what we're going to do with the blood pressure.

Not overly worried by the bigeminy.  If it progresses to something more sinister we can address it then.


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