# Chest Pain Fall



## AMF (Nov 5, 2013)

So 67 yo male falls off a ladder, 12' or so, somewhat witnessed by wife.  He's got wicked cp (10/10) and sob which he says originated before the fall.  Chest pain radiates to his lower jaw.  He reports drinking, denies drugs, meds, allergies.  Reports family history of cardiac problems, dad was murdered, mom died from sepsis after a car accident, reports solumedrol allergy.  He's got a golf ball-sized bump on his squamosal suture, about half way back on his right lateral side.  He's free of otto/rhinorrhagia/rrhea and is otherwise normocephalic.  Pupils are normal in size, equal, and a little slow to respond. No nystagmus and conjugate gaze is present.  JVD goes up past his clavicle.  He's tripoding, has a normal i:e ratio and a normal anteriorosterior ratio.  Skin is pretty sweaty.  CSMs are x4 (I think his right pulse is weaker than his left, partner disagrees)  BP 100/p HR 152 RR 22 SpO2 86%.  ALS transports.

My question is, with a head injury, are you still going to give aspirin?


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## NomadicMedic (Nov 5, 2013)

I'd want to see his 12 lead, but yeah, at first look ...I'd consult with the doc and tell him I'd like to hold the aspirin. Medical->trauma is such a chicken/egg exercise. Obviously, you fix the life threats, then you've got to wait until you've got access to more diagnostics.


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## EMT B (Nov 5, 2013)

I would consult a physician..That is what they are there for. Assuming the pt was transported to Maine Med? When my mom got into a bike accident she had a really bad concussion and lost consciousness etc. First thing the doc did in the trauma bay was hang heparin to prevent DVT/PE. I was extremely surprised they did this BEFORE the CT scan, however the doc said the benefits way outweigh the risks. If they are willing to do heparin without a CT scan, I don't think they would be too concerned with 324mg of ASA. Just speculating though so feel free to slam me for being a moron.


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## AMF (Nov 5, 2013)

Nice to see another Mainer.  Patient was transported to cmmc, due to proximity.  That's an interesting anecdote.  We probably should have called medical control.  

Regarding the EKG, I think the patient was definitely having a heart attack.  What would the EKG have told you re: management of this patient?

Also, the egg totally came first.  What about dinosaur eggs?


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## VFlutter (Nov 5, 2013)

EMT B said:


> First thing the doc did in the trauma bay was hang heparin to prevent DVT/PE. I was extremely surprised they did this BEFORE the CT scan, however the doc said the benefits way outweigh the risks. If they are willing to do heparin without a CT scan, I don't think they would be too concerned with 324mg of ASA. Just speculating though so feel free to slam me for being a moron.



Uhhh about that...IMHO a heparin drip is totally inappropriate. DVT prophylaxis is usually subQ heparin or lovenox q12hrs. Heparin drips are not used for prophylaxis but rather for known or highly suspected acute clots (DVT/PE/ACS). Regardless we do not really worry about acquired DVTs until after 24hours of admission. They are not going to develop a DVT in a day. And even if there was high suspicion for DVT/PE I do not think that it out weights a potential traumatic hemorrhage. 

I would give the ASA. 



AMF said:


> Regarding the EKG, I think the patient was definitely having a heart attack.  What would the EKG have told you re: management of this patient?



What makes you sure he was having a MI? If a true MI then transfer to nearest PCI capable facility. I doubt they will get Lytics.


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## teedubbyaw (Nov 5, 2013)

All that cute medical terminology and you ask about ASA. 

What did the 12 lead show? Was he working to breath or was it a sensation? Lung sounds? Could keep going on with this, but to answer your question, I would likely hold ASA pending 12 lead findings and pt presentation.


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## EMT B (Nov 5, 2013)

I do not think he has access to the ekg. basics in maine are not permitted to perform 12 lead ekg


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## mycrofft (Nov 6, 2013)

Warfarin, Aspirin, Natasha Richardson...head bleeds don't fare well if you add NSAIDS or anticoags. Not that Ms R was given any, but she c/o HA and wound up deceased from a bleeding CVA related to head trauma, and sort of rhymes with the two drugs.....

1. Length of time between fall  and eval would help dictate if neuro signs of intracranial bleed are apparent short of CT scan etc. Stuff like leaking cerebrospinal fluid, periorbital ecchymoses and Battle signs don't just appear all at once, unless you're really mashed. Or it has occurred previously and/or recurrently.

2. Severity of EKG might be weighed against likelihood (as judged on scene from subtle clues and patient exam) of bleeding closed head injury*  before deciding, _per protoco_l. Or whether ASA is indicated at all, _per protocol_.

3. Transport time to receiving facility would help dictate whether it was better to transport promptly, smoothly and securely, versus dithering with Rx which could conceivably kill the pt.

*Or bleeding paraspinal vascular injury, as our former member Veneficus might point out.


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## HandsInTheER (Nov 11, 2013)

I'm re-reading the scenario and ruling out AMI not so subtly hidden under a CHI. Am I worried about the CHI? Oh yeah. Could his HPI, vitals and presentation reflect both cardiac and traumatic neurological pathologies? Oh yeah.

Cardiac family hx, hypoxia, and tachycardia are worrisome when the CP preceded the fall. The decreased BP could be related to brain contusion (would be nice to see a diastolic pressure to calculate a mean), but I would still give ASA for cardiac protection; nitro trial is out due to BP. The OP states no current meds for the patient, so I am not as worried about ICH than if he was on coumadin/warfarin or took a daily ASA.

Plan of Care: Rapid trauma assessment; C-collar only (if your agency permits it); pt position of comfort w/head elevated; 12-lead EKG if possible, O2; ASA, assume AMI unless evidence otherwise; assume CHI and keep BP under control;  transport l/s to nearest PCI hospital for cardiac eval and head CT.


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