# Recent Learning Experience



## Luno (Aug 11, 2022)

Here's one for you guys, 
Report of 46 y/o Male c/o chest tightness and muscular feeling pain between shoulder blades, sudden onset.  Pt reports "feels like heart is racing," and has been for approximately 45 minutes since they climbed 20 stairs up from their garage.  BLS observes non-obese patient in tripod position, breathing at approximately 20/min, SpO2 at 98%, HR at 104 BPM, Glucose 108, no visible retractions, skin warm/pink/dry, bp of 170/110 R, 178/118 L.  ALS arrives, 12 lead EKG is unremarkable other than slightly tachycardic.  Patient meds are oxycontin and acetaminophen for pain from motorcycle accident 6 months prior.  Medical history is motorcycle accident with pelvic fracture and internal stabilization 6 months prior, and removal of pelvic fixation device 3 weeks prior.  No cardiac history or any other pertinent medical history.  Patient has no family cardiac history, does have family history of type II diabetes.  Patient is able to self ambulate, and states that they are in physical therapy and does has been increasing their movement post surgery, to approximately 6k steps per day.  This one was close to a miss, but I'll post a picture up later that will make more sense...


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## NomadicMedic (Aug 11, 2022)

PE or other emboli after the removal of the fixation device?


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## Chris EMT J (Aug 11, 2022)

Very interesting! What are the breath sounds? Patient is ambulating so not too sure about DVT to PE especially with a normal O2. They went up some stairs and got chest tightness and shoulder blade pain so maybe resolving unstable angina? If he doesn't have a history of hypertension then I am going to note this and check again before drop off. Maybe administer a NSAID during transport.


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## Luno (Aug 12, 2022)

ChrisEMTA said:


> Very interesting! What are the breath sounds? Patient is ambulating so not too sure about DVT to PE especially with a normal O2. They went up some stairs and got chest tightness and shoulder blade pain so maybe resolving unstable angina? If he doesn't have a history of hypertension then I am going to note this and check again before drop off. Maybe administer a NSAID during transport.


Breath sounds were unremarkable... All clear.


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## Comfort Care (Aug 13, 2022)

Sounds like PE, given the recent pelvic injury and ORIF. Who knows how long we was immobile, if at all. He'll get CT Angiogram to rule out PE in the ED. Pulmonary embolism can present different especially when they get into the submissive, massive size.


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## johnrsemt (Aug 13, 2022)

I would lean to PE also,  mainly because I have 6 of them right now; which did not present "normally" per 2 ED doctors.
So I am a little leary or them


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## E tank (Aug 13, 2022)

PE v. pericardial dz v. pleuritic process v. ACS v. ascending aortic dissection v. hyperventilation syndrome v. costochondritis v. GERD v.....


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## Luno (Aug 17, 2022)

For your consideration... Post thrombectomy


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## NomadicMedic (Aug 18, 2022)

Curious, what was his ETCO2? (I noticed you didn’t list that in the initial scenario)


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## Chris EMT J (Aug 18, 2022)

Luno said:


> For your consideration... Post thrombectomy


Interesting. A normal O2 and a pulmonary embolism. Don't see that very often


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## E tank (Aug 18, 2022)

Gonna guess that was an evolving PE, showering emboli progressively as time went on. Probably not that extensive on first contact with EMS.


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## Luno (Aug 18, 2022)

NomadicMedic said:


> Curious, what was his ETCO2? (I noticed you didn’t list that in the initial scenario)


Not checked


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## Luno (Aug 18, 2022)

ChrisEMTA said:


> Interesting. A normal O2 and a pulmonary embolism. Don't see that very often


Caught early, SPO2 started heading down about 2 hours later and there was an increase in Troponin I. Interesting was the early onset of chest band tightness and "muscular discomfort" between shoulder blades that could be changed with movement/resp.


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## johnrsemt (Aug 30, 2022)

My PE's presented with 98% on room air (usually I walk around at 92-93% due to my asthma) and lower right chest/rib pain  I went to the ED thinking I had a broken rib or 2 from coughing hard from a major asthma attack 2 days earlier (that a duoneb treatment cured).  Didn't have any other breathing issues in between.
Rib x-rays were clean;  D-Dimer was 1750


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