# 38yo Shortness of Breath



## Shishkabob (Oct 12, 2009)

You get dispatched to a shortness of breath call. Upon arrival you fine a 38yo male in obvious pain. 

Pt complains of Chest pain of a 9 out of 10, no related to respirations.  Vs p-140, rr 30 and shallow, bp 78/60, cool clammy skin   EKG shows sinus tach, 12-lead shows ST elevation of 3mm in leads V5 and V6. 






How's your treatment?


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## taporsnap44 (Oct 12, 2009)

Before a treatment plan a few more questions.... 

How long ago did the chest p/x start?
Did the pt. take any medications (ie. ASA or NTG) that helped the p/x?
What does the pain feel like and does the pain travel to any other parts of the body?
What medications is the pt. currently on?
Past medical history?
What happened prior to our arrival that caused the pain to come on? 

Lung sounds? and Is the pt. still SOB?
BGL?
Is the pain reproducible?


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## taporsnap44 (Oct 12, 2009)

Whoops, I meant to put my possible treatment. 

IV access, fluid bolus 40 ml/kg, and possibly dopamine if the fluid bolus cannot keep up cardiac output. With the ST elevation in V5 and V6 it may be a possible RVI so withholding NTG and Morphine may be the best bet right now.


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## MrBrown (Oct 12, 2009)

SAMPLE/PQRST 

How's my lung sounds, is he still SOB? 
SPO2?

Plan of treatment:  
- O2 4-6lpm on a simple fask mask 
- 324mg ASA unless allergic
- IV access
- If no crackles in the lungs would look at a small fluid bolus ~250ml
- Morphine say ... 2-3mg bearing in mind his crappy BP

On the stretcher and away we go ....


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## vquintessence (Oct 12, 2009)

What they said... only would opt for fentanyl instead.  Only additional input is what about any reciprocal ST depression leads II, III, aVL?  Any axis deviation (particularily right)? R-wave progression?


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## falcon-18 (Oct 12, 2009)

Linuss said:


> You get dispatched to a shortness of breath call. Upon arrival you fine a 38yo male in obvious pain.
> 
> Pt complains of Chest pain of a 9 out of 10, no related to respirations.  Vs p-140, rr 30 and shallow, bp 78/60, cool clammy skin   EKG shows sinus tach, 12-lead shows ST elevation of 3mm in leads V5 and V6.
> 
> ...




start with asbirin and high concentration O2 NRB do not giVe hime NTG or MS because he is in hypotension. 

then recheck for Bp  if it is stable give him it.


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## Shishkabob (Oct 12, 2009)

taporsnap44 said:


> How long ago did the chest p/x start?
> Did the pt. take any medications (ie. ASA or NTG) that helped the p/x?
> What does the pain feel like and does the pain travel to any other parts of the body?
> What medications is the pt. currently on?
> ...




20 minutes
No meds
Crushing, non-pinpoint
No current meds
Family history of HTN
"Just chillin' "

Lung sounds clear, equal bilat.  93% room air
88 bgl
No, constant.


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## Dwindlin (Oct 12, 2009)

While this looks like a text book MI, he is awful young unless he's trashed his heart with meth/coke/etc. Even with the crappiest lifestyle imaginable I think it would be odd to see a true AMI this young (again barring congentital defects/drug use).

However after saying that I would still go down the ACS road.  O2, get ASA on board.  I would try some fuild resus initially, but with the narrow pulse pressure I would be getting ready to hang some dopamine. Also even with the crappy pressure, need to get some pain control so I would go ahead initially with a low dose of MS.


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## Shishkabob (Oct 12, 2009)

Forgot to add, no st-depression in II, III, or aVf, so no reciprocal changes to the lateral elevation.


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## Melclin (Oct 13, 2009)

Pain relief is top of my list, regardless of cause. 

-IN fentanyl 200mcg, (repeat 5 minutely, 50mcg, up 400mcg; if he's greater than 60kg) (is anyone else using IN fentanyl?)
-Methoxyflurane (up too 6mls [barring hx of dialysis/tetracylcine antibiotics], if the fentanyl isn't enough; I'd really prefer not to give the guy morphine on account of the possibility of histamine release and tanking his already rubbish BP).

-ASA 300mg (no GTN [nitro] obviously with the BP)
-O2 8 lpm, simple face mask.
-250ml fluid bolus if the lungs are clear, and another 250 if they stay that way.

-Triage to PCI facility 

And/or ALS backup for: adrenaline infusion to improve perfusion, fibrinolytic therapy for long transports + better management of arrhythmias and peg-outery.


I reckon 38 is plenty old for an AMI, seen plenty of case studies with younger people than that who stop up a pipe or two. Also, how common is dopamine over in the states? It seems like a good option, esp for the rural guys.


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## MrBrown (Oct 13, 2009)

Dude WTF adrenaline, wouldn't that have an inotropic and chronotropic effect which would increase myocardial oxygen demand? :unsure:

We are getting fentanyl but I don't know if it will IN I'd rather use IV fent also methoxy is contraindicated for cardiac chest pain here


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## DrParasite (Oct 13, 2009)

from a BLS point of view, high flow oxygen via NRB, and rapid transport to an appropriate hospital with cardiac care capabilities

The one other "intervention" that I think needs to be mentioned is to notify the receiving hospital of what you are going in with.  maybe even activate the STEMI team, so you can have a ER team and cardiologist ready and waiting for when you arrive in the ER.


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## Melclin (Oct 13, 2009)

MrBrown said:


> *Dude WTF adrenaline, wouldn't that have an inotropic and chronotropic effect which would increase myocardial oxygen demand? :unsure:*
> 
> I would imagine so. The idea is peripheral vasoconstriction via a1 to shunt blood centrally obviously but I don't actually know that much about the modality because, as I said, its a MICA job. I assume its primarily for heart failure, but its simply listed as a guidelines for cardiogenic poor perfusion. There might be some sort of contraindication for cardiogenic shock due to STEMI, but its not listed in the guideline. I'll ask a MICA paramedic when next I see one. I suspect it might be a matter of balancing MvO2 and the crappy MAP and its only for poor output with crackles although I'm not entirely sure why.
> 
> ...



10char


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## Dwindlin (Oct 13, 2009)

Melclin said:


> I reckon 38 is plenty old for an AMI, seen plenty of case studies with younger people than that who stop up a pipe or two. Also, how common is dopamine over in the states? It seems like a good option, esp for the rural guys.



What do you mean by plenty?  Again assuming his only family contribution is HTN, and no drug use I would be very surprised for this to be a true AMI.  Not saying its not a possibility (obviously since the treatments I listed are for ACS), but even here in the states (the champions of crappy life style B) ) 38 is young for a lifestyle induced MI.


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## johnrsemt (Oct 13, 2009)

my old area we had Fentanyl for 3 years,  IN for 2008  (left in June);  it was great,  just give it slow, because I have had complaints that it tastes bad.    but works in about 15 seconds,  which is great for first dose,  then get the IV when the patient is more cooperative.

   here we just got Fentanyl this year,  and we just got the IN devices last month.    and with how busy we are,  it may be next year before I get to use it.


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## Smash (Oct 13, 2009)

Clinically he appears to have an evolving lateral left ventricular infarction occuring, complicated by cardiogenic shock.  I'm a little surprised that he doesn't have more widespread changes, but we'll deal with what we have.

ASA as per protocol, O2 because he appears to have perfusion issues.  No nitrates for the same reason.  Large bore bilateral IV access.  Cautious use of fluids to attempt to improve perfusion: 2 x 250ml boluses of crystalloids, keeping close eye on lung sounds (eye on sounds?  You know what I mean)

If no effective with fluid, start epinepherine infusion, 5mcgs/min, adjust as required.  If chest stays clear continue with cautious administration of fluid.

Contact cath lab, transport expediently.

With regards to the epi and the apparent STEMI, we are unfortunately left in a rather precarious predicament.  We need to correct the perfusion abnormalities that are present or they myocardium will not be well perfused and the patient will not do well.  However we are aware that epi may increase myocardial O2 demand and thus extend the infarct and the patient will not do well.

Thus it is a very delicate balancing act.

Cardiogenic shock complicating AMI has a very high mortality rate.  No prehospital treatments (beyond aspirin and the likes) has really shown to improve outcome.  Inotropes of any type have also not been shown to improve outcome.  In fact, any inotrope is associated with worse outcomes, however they are a temporizing measure to get someone to PCI alive.

There is much debate as to which is the best one to use, however at the end of the day, none of them really help more than the others, and all are  precursors to epi anyway, so whatever other effects you get along the way, you still get epi in the mix.

Epi therefore has at least some advantages, in that it is well understood by paramedics, reduces the different drugs (and drug calcs) that are needed, is cheap and there is no evidence to suggest that it is any less effective or more deleterious that any other.

MelClin, how is it that you can gain IV access, give fluids to cardiogenic shock, bypass hospital for cathlab, yet have to give IN or inhaled analgesia?  That's wierd!


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## skivail (Oct 13, 2009)

Sorry, but what does "IN" stand for? Thats a new one to me.


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## Smash (Oct 13, 2009)

Sorry I didn't mean to use acronyms. It's very annoying because everyone uses different ones and we have people from all over the world contributing so things can get confusing quickly. 

IN stands for intranasal. Some medications can be atomized up the nose to provide very quick and effective actions without the need for needles. Narcan, midazolam and fentanyl are the most popular drugs given the way.


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## Epi-do (Oct 13, 2009)

skivail said:


> Sorry, but what does "IN" stand for? Thats a new one to me.



IN = Indiana  or, in this case, it means Intra Nasal.


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## skivail (Oct 13, 2009)

Thanks. That is what I had guessed but wanted to be sure.


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## redcrossemt (Oct 13, 2009)

Linuss said:


> ST elevation of 3mm in leads V5 and V6.



Would also want to look at the posterior leads...


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## MrBrown (Oct 14, 2009)

Smash said:


> MelClin, how is it that you can gain IV access, give fluids to cardiogenic shock, bypass hospital for cathlab, yet have to give IN or inhaled analgesia?  That's wierd!



Because IV analgesia may not be in the base level scope of practice in Victoria


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## Melclin (Oct 14, 2009)

atkinsje said:


> What do you mean by plenty? ...



I just skimmed over that and took its to mean he was _too_ young for it to be an AMI. My mistake. I agree with you, its young, and you would be interested in factors that had accelerated the process.



Smash said:


> MelClin, how is it that you can gain IV access, give fluids to cardiogenic shock, bypass hospital for cathlab, yet have to give IN or inhaled analgesia?  That's wierd!





MrBrown said:


> Because IV analgesia may not be in the base level scope of practice in Victoria



We can give IV analgesia in the form of morphine (as I said, I really didn't want to give the guy morphine because of the BP). We just are not supposed to give fentanyl via the IV route. I'm sure you could call the clinician and explain your problem and if you sounded like you had things under control then you'd be allowed too. 

Its just that some of the older basic level paramedics are still around from the days when our basics weren't that different from your American basics. So every time they throw something new into the mix for basics, despite the fact that the majority of us are university educated and very competent, they still have to consider how the worst of us might stuff things up. A very frustrating fact indeed. It will be nice when we can say, "You really don't have to worry about giving us new drug X, we all did pharmacology at uni, we all had drug calcs as a massive part of our curriculum - drug X will be fine, most of us know lots about it anyway, because a lot of recent research has called for its use in the pre-hospital setting - and naturally we're all up to date on recent research". *Sigh* ...one day.


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## Smash (Oct 14, 2009)

Ah, ok that makes sense.

It's funny though, as I was fairly sure that according to CPG A0407, page 63 of Ambulance Victoria CPGs version 4, last updated 11/01/05 that IV fluid for cardiogenic shock was an Intensive Scare skill 

Mind you, that is the problem with printed protocol they go out of date (fashion?) fairly easily, necessitating local variances which my sources may not have informed me about.  h34r:


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## Melclin (Oct 14, 2009)

You're quite possibly right. Our book learnin' at uni is not specific to Victorian protocols so we tend to learn a lot more than we might necessarily be allowed to practice. I'll read the new guidelines see what the new word is on the matter (the ones on the internet are fairly old if those are the ones you're refering too).

EDIT: the guideline lists it as a MICA skill, specific to cardiogenic shock. However, we'd simply have to 'suspect' that a pt was volume depleted so administer fluids. Which reminds me of how a lot of APO pts are 'asked if they have chest pain *winking*' because we can't give morphine to calm an APO pt down for CPAP (thats a MICA skill) but we can give it for most kinds of pain so..... I wonder if a certain RRT lass will turn up to rip me a new one about this.


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## Smash (Oct 14, 2009)

Maybe, one never knows... 

The CRUSADE trial looked at morphine in chest pain patients and concluded that thos who recieved morphine and conlcuded that they were more likely to die.  It was however a retrospective registry examination, and it certainly raised more questions than it necessarily answered.  Obviously the biggest question is:  Did they recieve morphine because they were more unwell, therefore more likely to die anyway, or did the morphine cause them to die?  It;s a big question.

Nonetheless respiratory depression is something to be avoided obviously in these patients, so I would at least be cautious with morphine.

Then again, I'm just a 'B' with no letters after my name, so heck, I don't know. 

Quote for the day:

"The spread of secondary and latterly of tertiary education has produced a large population of people, often with well developed literary and scholarly tastes, who have been educated far beyond their capacity to undertake analytical thought."  - Peter Medawar


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## MrBrown (Oct 14, 2009)

Smash said:


> The CRUSADE trial looked at morphine in chest pain patients and concluded that thos who recieved morphine and conlcuded that they were more likely to die.  It was however a retrospective registry examination, and it certainly raised more questions than it necessarily answered.  Obviously the biggest question is:  Did they recieve morphine because they were more unwell, therefore more likely to die anyway, or did the morphine cause them to die?  It;s a big question.



That study was mentioned in our latest clinical newsletter; problem is that methodology is pretty backwards and open to lots of interpretation; I forget the name but we learnt in research methods that you can have a situation just like this and say "well morphine caused them to die" because you have a) they got morph and b) they died, when in fact the two may be unrelated.

I wonder how many people who don't realise the methodology is flawed will read [about] it and change thier practice, consider changing it or hit up thier medical directors for it to be changed.


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## Smash (Oct 14, 2009)

MrBrown said:


> That study was mentioned in our latest clinical newsletter; problem is that methodology is pretty backwards and open to lots of interpretation; I forget the name but we learnt in research methods that you can have a situation just like this and say "well morphine caused them to die" because you have a) they got morph and b) they died, when in fact the two may be unrelated.
> 
> I wonder how many people who don't realise the methodology is flawed will read [about] it and change thier practice, consider changing it or hit up thier medical directors for it to be changed.



Far be it from me to discuss methodolgy of research papers, I'll only get a few strawmen built and thrown my way along with a fair old smattering of lies and abuse.  Nonetheless, us brave few should soldier on, so once more into the breach dear friends, once more / or close the wall up with our English dead...

You've hit the nail on the head; there is no way demonstrate a causative link between the two from the CRUSADE trial.  At very best it raises the possibility that more research may need to be conducted into the effects of morphine in patients with chest pain (and cardigenic shock).  

However I would still be careful with morphine in the cardiogenic shock patient.  I would probably tend towards fentanyl anyway as there is a lesser likelihood of causing further hypotension with it.


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## MrBrown (Oct 14, 2009)

Probably one of the reasons we are getting fent


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## Melclin (Oct 14, 2009)

I like that quote; its familiar, which makes sense given the person who said it (describes some of my lecturers pretty well). Taken in combination with your signature, I think we may have much in common.

On the topic of morphine, it would make sense that a drug that can cause  adverse haemodynamic changes might cause troubles in the ACS context. I'll add that to the list of reasons why I love fent. In any case I'm off to bed, 50mg of promethazine is getting the better of me.


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## MrBrown (Oct 14, 2009)

Bloody hell mate, 25mg IV (which stings something FIERCE) and wow my GCS was what ... like 8 or 9? ... seriously I was pretty smashed they said the other patients were asking what I was on, and that they wanted some ...  hell if I remember 

Mind you your 50mg was probably PO


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## usalsfyre (Oct 14, 2009)

MAP is 66, so I'm going to hesitate jumping on pressors right away. ASA, O2, IV, fentanyl for pain control due to the labile pressure, and small/careful fluid boluses (100-200ml at a time)  until the lungs get wet or B/P gets to a comfortable level. Posterior 12 lead, and consider transdermal/IV NTG depending on outcome of further 12 lead and/or fluid boluses.


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## Melclin (Oct 14, 2009)

MrBrown said:


> Mind you your 50mg was probably PO



Yep.

Probably a fact more suited to the promethazine thred, but its also a local anesthetic. A fact that I discovered first when I accidentally bit down on a tablet once and my entire mouth burnt for a moment then went completely numb for about 30 mins .


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