# Golden Carroll



## Medico (Mar 28, 2014)

You were having a 'slow' Sunday and the shift decided to fix an extravagant dinner. You just sat down to enjoy seared sea scallops and tones dropped for shoulder pain at the Golden Carroll. 

Its 1900, and dispatch notes "68yof in the delta corner of the restaurant is having left shoulder pain. Denies SOB and chest pain."

You arrive on scene to find a white, 68yof, who appears in moderate distress secondary to pain, and in no obvious resp distress. She is favoring her left shoulder and is grimacing in discomfort. The pt was alone, her family left 20minutes ago. She is well dressed and appears to take care of herself. 

During your assessment pt states her pain began two hours ago. She describes it as 'sharp' 10/10 radiating to her spine. Nothing makes the pain better or worse, no pain on palpation. Pt denied nausea/vomiting, SOB, chest pain, indigestion, abd pain, and headache. Hx of spinal stenosis, and HTN. NKDA. Pt had taken her Lisinopril. 

You ask her to stand and pivot onto the stretcher and notice she has a limp on the left side. She says that is normal, due to her stenosis. 

Initial set of vitals:

BP: 220/130
HR: 90 strong and regular
Skin: Warm and dry
RR: 20 non labored, clear and equal bilaterally
AOx4, GCS 15.

The Golden Carroll shares a parking lot with a free standing ED. You are 10m from a level II and 5m from a community hospital which is an accredited chest pain center.


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## mycrofft (Mar 28, 2014)

*Golden Corral*

Absent an EKG, she needs to be seen to r/o MI or other referred cardiac or visceral pain IF nothing else (like spinal palpation or abdominal palpation) causes more pain. 

Spinal includes neck. A stenosis causing a limp would not affect her shoulder, but a cervical insult could and she could probably tell you what instance started it.

Referred pain could be a few things. Her BP is worrisome. Meds? Allergies?


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## Carlos Danger (Mar 28, 2014)

Could be lots of things, some of them very bad. She needs an EKG and a CXR to start. 

I'd say she has an excellent chance of needing admission and the potential for needing emergent surgery or PCI, so I'd prefer to skip the free-standing ED, especially considering how close the hospitals are. It'd be her choice, though.

Get her on the stretcher, move her to the ambulance, put her on the monitor, start an IV and give her a whiff of fentanyl to start, take a nice easy ride to the hospital, get an EKG enroute.


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## Medico (Mar 28, 2014)

You perform a 12Lead and have the following. The pt is becoming increasingly anxious, and is now complaining of impending doom and indigestion. 

You establish two 18g IV in her R FA. 
NKDA, pt denies any additional meds other than her lisinopril.


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## teedubbyaw (Mar 28, 2014)

Hello STEMI. Let's start AMI treatment stat and to nearest cath lab.


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## Household6 (Mar 28, 2014)

That's a STEMI, I know that one.... I'd notify the cath lab of an incoming, give her a hug.

Old ladies love hugs.

Start the MI (MONA) treatment.


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## MrJones (Mar 28, 2014)

What _type_ STEMI?


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## teedubbyaw (Mar 28, 2014)

Inferior MI w/ possible RMI


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## MrJones (Mar 28, 2014)

teedubbyaw said:


> Inferior MI w/ possible RMI



What makes you suspicious of possible right side involvement? 

(Can you tell I enjoy ECG interpretation?)


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## NomadicMedic (Mar 28, 2014)

You mean, inferior with RVI. Get a v4r, give a fluid bolus and be cautious with NTG. She needs PCI. I'm a lot more cautious with bradycardic inferior MIs.


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## Handsome Robb (Mar 28, 2014)

MrJones said:


> What makes you suspicious of possible right side involvement?
> 
> (Can you tell I enjoy ECG interpretation?)



Without having seen that 12-lead I would've done a workup on this patient. Definitely wouldn't go BLS/ILS. 

Pick me! Pick me! 

No? OK I'll leave it alone. 

STEMI activation, v4R and potentially a posterior as well (usually do them at the same time), ASA, fluid bolus, NTG, O2 because I have to but I'm not gonna be stoked if she's got a good SpO2. Fentanyl if the pain is refractory to NTG. Draw some labs and jet her to the PCI capable facility. At 10 minutes out depending how fast the hospital spins their lab I might not go emergent just to sit and wait but if they're quick about it we'll be going emergent and prepping to bypass the ED.

She almost meets my criteria for metoprolol but I don't know how I feel about that one in the presence of RVI. With that said, I don't really know if I'm sold on RVI without the right-sided 12-lead with those vitals. Not saying it couldn't happen but it'd be a weird presentation. 

Our goal is <60 door-to-PCI and consistently do <30 minutes. The last one I had was 19 minutes from door-to-PCI.


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## teedubbyaw (Mar 28, 2014)

MrJones said:


> What makes you suspicious of possible right side involvement?
> 
> 
> 
> (Can you tell I enjoy ECG interpretation?)




You can't rule it out until you check for it. III > II. Probably won't have time to check with this patient.


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## MrJones (Mar 28, 2014)

teedubbyaw said:


> ...III > II....



Exact-a-mundo. And, even though I suspect right sided involvement (that I will ultimately confirm/rule out with V4R at least, and preferably a full 15 lead), with a BP like hers she'll be getting some nitro (as soon as I have a line in place, just in case) along with some aspirin and a whiff of O2.


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## Handsome Robb (Mar 28, 2014)

teedubbyaw said:


> You can't rule it out until you check for it. III > II. Probably won't have time to check with this patient.



Also, minor septal depression (v2 compared to v1) indicates the need for v4r.

I've heard high lateral depression can indicate RVI but it's reciprocal to an IWMI.


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## Medico (Mar 28, 2014)

Right sided is performed and the following is recorded. 

324mg PO ASA is administered.
NaCl is hung in case of rapid fluid resuscitation, and 0.4 SL Nitro administered.

5m post Nitro pt reports no ease to 10/10 pain.

Vitals are as followed:
BP: 150/96
HR: 98, strong and regular
Spo2: 99% 2LPM NC (pt was 99% RA)
RR: 20, non labored, clear bilaterally.

Pt continues to deny any changes or new discomforts. 

5mg Morphine is administered, relief to 8/10. 

STEMI alert is called and pt rapidly transported to ED. ED failed to activate cath lab and did not call the STEMI ALERT. Pt was delayed going to cath lab by an hour from time of arrival. Pt had total RCA occlusion, received a stent and was later discharged. 

A complaint was filed on staff for their inaction. 

This was an easier case, but I thought it was a good reminder of why 12 leads are so very important, and thorough assessments are necessary.

Please excuse my brevity. I am typing this on my flight from ATL to NO, and trying to complete prior to take off.


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## teedubbyaw (Mar 28, 2014)

Thanks for the scenario.

Were multiple 12 leads done? Any progression?


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## Medico (Mar 29, 2014)

There were. 12lead was done 5m post nitro and one additional prior to arrival at the ED. There was no progression and no changes to the pt.


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## NightShiftMedic (Apr 16, 2014)

It does actually appear that there are some subtle changes from the first ECG to the one with V4R.  V4R is slightly elevated, indicating to me probable RV involvement, and also it would appear to me that V2 and V3 show more ST depression, indicating more posterior involvement as well.

Just my .02

Good on you for filing a complaint regarding the inaction of the ED staff.  That had potential to be a disaster for the patient.


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