19F Chest pain - confused me

[Melclin]

Had a standard patient at uni today present like this. I was playing the role of driver, so I was involved and treating but only at the direction of the "jockey" who was being assessed.

11:34 - CODE 1: Chest pain, 19yrs Female.

O/A: The patient looks relieved to see the crew and states, “I feel like my heart is about to leap out of my chest, I think I’m having a panic attack”.

Event hx: Arrived at uni for an exam. While walking pts heart starts racing and the pt assumed she was nervous about the exam. It then got worse, with the new onset of chest tightness. Pt has had panic attacks before and it feels pretty similar.

The sensation in her the middle of her chest is described as a tightness. Her heart started racing 30 minutes prior followed by chest tightness beginning 10 mins ago. She also complains of mild SOB and dizziness. Nil N&V. The discomfort is rated on a pain scale as 3/10.

Whilst taking vitals the pt has many questions, is talking quickly and becomes quite upset about the idea of cannulation. Denies ETOH or drugs and seems quite honest.

Vitals
Pulse: 170 (Regular & strong)
BP: 125/85
RR: 26 (No excessive effort or accessory muscle use).
GCS: 15
Temp: 36.8
Spo2 on RA: 97
Medications: prn xanax, but she does not have it with her and has not taken any today.

Med Hx: Suffers from “panic attacks” and is under the care of her GP.
Recent stressors are all uni related. She is currently in the middle of an exam period, and she was up all night studying and drinking energy drinks.
She lives at home with her brother and her parents in a pretty standard upper middleclass house and reports no abnormally stressful life events other than university where she studies a double degree in arts and business.

Family Hx: Brother has mild down syndrome. Isn't aware of any of her parents medical problems, but nothing obvious to her.

Physical: No change to feeling of discomfort on movement, palpation and inspiration. Pt’s skin is warm, clammy and pale. You note nothing else unusual on the physical exam.

I'm sorry about the ECG but I couldn't get a good picture on my iPhone. Its lead II. The ECG's actual rate in the pic is 183 for some reason, but take it to be 170.

This job caused me some concern when we debriefed with the sessional afterward, I'll talk about why after people have a bit of a play with it.

 

[SanDiegoEmt7]

Caffeine overdose from consumption of numerous strong energy drinks. Would account for tachycardia, rapid speech and thoughts, etc. Couple that with her nervousness for her exam and her predisposition to panic.

How many beverages did she consume and over what period of time?

As for the EKG, I'm teaching myself cardiology right now so I can't definitively say. ST elevation?

Maybe she truly is having a MI, or Prinzmetal's angina/ cardiac syndrome X.

Did she get nitro? If yes, was there any relief of CP following its administration?

Is she taking birth control (estrogen containing), is she overweight, does she smoke?

Also DDx for Pulmonary embolism: Increased pain on inspiration? Any cough?

 

[Melclin]

I think it was three cans (about 200mls each I suppose) and it was in the early hours of the morning. Its now about 11:45am.


I can't see any ST-elevation.

No nitro was given.

No birth control. Patient weighs maybe 60kgs. Non-smoker.

No change in pain on inspiration. No cough.


For any lurkers, jump in. This isn't a quiz, I actually want people to answer some of my own questions, but I don't want anybody's suggested management to be biased by me asking those questions straight off the bat.

 

[clibb]

SVT which people will get from coffee. Will also explain SOB and dizziness. With the amount of caffeine people consume without any snacks or food, it doesn't surprise me she's in SVT.

 

[46Young]

Did you try to get her to vagal down enough to see if it was sinus tach or not?

 

[46Young]

As for the EKG, I'm teaching myself cardiology right now so I can't definitively say. ST elevation?

An ECG can be read in either monitor or diagnostic mode. Elevations and such can only be definitively read in diagnostic mode. The next time you go to work, hook yourself up and see the difference in the two modes. Also check out the rhythm generator as well. I've seen obvious ST evelations in the inferior leads on the pt in monitor mode and then see nothing whatsoever on the diagnostic mode. Hope this helps.

 

[medic417]

Did you run a 12 lead?

Any response to vagal?

Is she compliant with medications?

Were the beverages just soda pop or were they the mega caffeine energy drinks?

Had she had any arguments with family/friends prior to the events?

 

[EMS49393]

Did you get a 12-lead? This looks like SVT, but a 12-lead is necessary for a truly diagnostic look. This a strip in monitoring mode.

Caffeine and even smoking can cause SVT in otherwise healthy young people. So can cocaine, amphetamines, and extreme panic.

A 12-lead is important to help rule-out any aberrancy conduction issues that rear their ugly heads in the age group this young lady falls in. WPW usually starts appearing in the older teenager, early 20's year old person. Certain anti-arrhythmics are contraindicated with these aberrancy conduction problems so it's generally a good idea to have some idea of what you are really looking at should it come to a need for conversion of the otherwise alert and conscious patient that would really mind electricity.

In this patients instance, the text book will tell you she is unstable secondary to chest pain and shortness of breath. Given your information, I would deem her stable at this interval because her blood pressure is holding, her SPO2 is holding (how are her lung sounds?), she is not altered, and appears to be compensating on her own pretty well. Once you start throwing drugs at patients, you run the risk of shutting down their own compensatory mechanisms.

I would get a 12-lead, have a nice sized, fairly proximal IV in place, continue to monitor, have O2 at the ready, and have her attempt to vagal. If you feel this to be truly SVT and not WPW or LGL syndrome, and she does not convert with vagal maneuvers, you may elect based on her condition to assist in her conversion, either electrically or pharmacologically. In her case, I'd probably start with drugs, specifically adenosine. I'm super cautious with adenosine, even with it's extremely short half-life, and I have a lot of things in place before I administer the drug. I have my initial 12-lead, and I will print a strip from the point that I administer the drug until they convert. I understand that a cardiologist can actually see quite a bit when that conversion process is documented via a nice long strip. I also like to have the combo-pads in place before I administer the drug, just in case something goes awry. If they convert for you, you're likely looking at a PSVT situation. The other symptoms should resolve after the heart rate is under control.

If you elect to treat with electricity and your patient would greatly mind the electricity, I would hope you would be kind to them and pre-medicate them with something that would render them relatively care-free and pain-free. I like a little versed (if the BP is high enough) and some fentanyl.

This is all based on the limited information presented in your case, and would be subject to change should I actually be able to assess this patient for myself.

Before the inquisition begins, I readily admit that I am an overly cautious paramedic and tend to really overkill on precautions when I do things to patients. Some people are more comfortable just throwing things at patients with little forethought or caution. My overly analytical brain will not let me work that way.

 

[johnrsemt]

You can DX SVT without a 12 lead; as long as it is regular. Irregular is A-fib

Our Med Director used to teach not to go with a set rate, but it was 220 - age: so a 20 year old would be in SVT with a HR of 200.
Use Adenocard to DX it, when it slows down, you can see if it was SVT (regular rhythm) or A-Fib. just don't document that you used the Adenocard to Diagnose it. (his wording not mine).

 

[gicts]

Looks like SVT due to stress, sleep deprivation, and caffeine (on an empty stomach too?) . I'd try to reassure her, try vagals, and place a line in en route. No need to push drugs unless she worsens.

Because it sounds like perhaps it was (or could have been) something else, I'd ask about dehydration or allergies. Was an abdominal assessment done?

Caffeine overdose from consumption of numerous strong energy drinks. Would account for tachycardia, rapid speech and thoughts, etc. Couple that with her nervousness for her exam and her predisposition to panic.

How many beverages did she consume and over what period of time?

As for the EKG, I'm teaching myself cardiology right now so I can't definitively say. ST elevation?

Maybe she truly is having a MI, or Prinzmetal's angina/ cardiac syndrome X.

Did she get nitro? If yes, was there any relief of CP following its administration?

Is she taking birth control (estrogen containing), is she overweight, does she smoke?

Also DDx for Pulmonary embolism: Increased pain on inspiration? Any cough?

By ST elevation do you mean enlarged T wave? Also, why the nitro? Good question about the BC.

 

[FLEMTP]

I have a better idea before ya'll jump into using medications like adenosine.

how about some calming reassurance and some good ol' normal saline? if her rate comes down, it was anxiety, and dehydration.

She said she takes xanax every day.. but did not take it today.. seems pretty simple to me.

Why is it that most people are just so ready to jump into pushing drugs?

I had a patient the other day that was in a sinus tach... on the 4 lead it looked MARGINALLY wide... but it did not have the typical morphology of v-tach. My partner, who is a Paramedic by licensure working as an EMT in our system, saw it and was like.. "um.. monitor! look at the monitor! Do you want the amiodarone?" I glanced over, saw it was sinus tach with what was probably a mild Bundle branch block, and said, nah, just a 12 lead is cool.

The patient had a complaint of mild epigastric pain after eating meat he thought was possibly rancid, but he cooked it to kill whatever. He was smoking a cigarette upon our arrival and ambulated to the truck.

Not exactly something requiring a drug, or panic, but there are quite a few paramedics that seem to jump right into both..

i'll never understand it.

 

[Veneficus]

I have a better idea before ya'll jump into using medications like adenosine.

how about some calming reassurance and some good ol' normal saline? if her rate comes down, it was anxiety, and dehydration.

She said she takes xanax every day.. but did not take it today.. seems pretty simple to me.

Why is it that most people are just so ready to jump into pushing drugs?

I had a patient the other day that was in a sinus tach... on the 4 lead it looked MARGINALLY wide... but it did not have the typical morphology of v-tach. My partner, who is a Paramedic by licensure working as an EMT in our system, saw it and was like.. "um.. monitor! look at the monitor! Do you want the amiodarone?" I glanced over, saw it was sinus tach with what was probably a mild Bundle branch block, and said, nah, just a 12 lead is cool.

The patient had a complaint of mild epigastric pain after eating meat he thought was possibly rancid, but he cooked it to kill whatever. He was smoking a cigarette upon our arrival and ambulated to the truck.

Not exactly something requiring a drug, or panic, but there are quite a few paramedics that seem to jump right into both..

i'll never understand it.

I understand it, but it doesn't make it any less stupid.

Because a large portion of those providing paramedic education/service present it in an almost military style of "You will do this when you see... or you are wrong, and the patient is going to die, the protocol will be breached you will lose your license, and get sued for an amount of money you will never earn in your life..."

Thinking is not on the menu, reacting is.

You also have to remember you work for one of the best services anywhere. A large population of systems in the US don't want paramedics to actually think. Few actually provide their employees with professional educational opportunities or try to constantly increase the capabilities an thereby value of their employees. I bet we could name >95% of them just from reputation.

We both see it all the time I am sure, it is still madness. You even see it here on the ACLS threads and the like. "because the protocol says..." "Because my instructor said..." "Because there are solicitors waiting around every corner, reviewing every run report waiting to catch a paramedic in anyway deviating from cookbook so they can litigate for all the poor :censored::censored::censored::censored::censored::censored::censored:'s worldly possessions."

 

[EMS49393]

I have a better idea before ya'll jump into using medications like adenosine.

how about some calming reassurance and some good ol' normal saline? if her rate comes down, it was anxiety, and dehydration.

She said she takes xanax every day.. but did not take it today.. seems pretty simple to me.

Why is it that most people are just so ready to jump into pushing drugs?

I had a patient the other day that was in a sinus tach... on the 4 lead it looked MARGINALLY wide... but it did not have the typical morphology of v-tach. My partner, who is a Paramedic by licensure working as an EMT in our system, saw it and was like.. "um.. monitor! look at the monitor! Do you want the amiodarone?" I glanced over, saw it was sinus tach with what was probably a mild Bundle branch block, and said, nah, just a 12 lead is cool.

The patient had a complaint of mild epigastric pain after eating meat he thought was possibly rancid, but he cooked it to kill whatever. He was smoking a cigarette upon our arrival and ambulated to the truck.

Not exactly something requiring a drug, or panic, but there are quite a few paramedics that seem to jump right into both..

i'll never understand it.

I'm sure this was directed at me, which is fine, however you failed to read my post in its entirety or you simply found the fault you wanted to find and are now tearing it apart.

I do not advocate pushing drugs if a patient is compensating on their own, which judging by the very limited information given, she clearly was. I do advocate making certain you take every precaution if you feel you have to administer a medication, including taking the time to run a 12-lead ECG in this instance.

I think she's nervous, period. I think they over prescribe drugs like Xanax. I also think it's an interesting scenario given the patients age and presentation. She may not be nervous, she may have a genuine cardiac issue that presents in her age group. She may have a PE or even a partial spontaneous pneumo. There's a multitude of things that could be wrong with this girl and I do not think it's a bad thing to consider every possibility and not just go with "she's some chick that didn't take her daily Xanax."

It's about discussion and learning. Or it's about egos. Wait, it's EMS, it must be about the egos. How silly for me to forget.

 

[FLEMTP]

I understand it, but it doesn't make it any less stupid.

Because a large portion of those providing paramedic education/service present it in an almost military style of "You will do this when you see... or you are wrong, and the patient is going to die, the protocol will be breached you will lose your license, and get sued for an amount of money you will never earn in your life..."

Thinking is not on the menu, reacting is.

You also have to remember you work for one of the best services anywhere. A large population of systems in the US don't want paramedics to actually think. Few actually provide their employees with professional educational opportunities or try to constantly increase the capabilities an thereby value of their employees. I bet we could name >95% of them just from reputation.

We both see it all the time I am sure, it is still madness. You even see it here on the ACLS threads and the like. "because the protocol says..." "Because my instructor said..." "Because there are solicitors waiting around every corner, reviewing every run report waiting to catch a paramedic in anyway deviating from cookbook so they can litigate for all the poor :censored::censored::censored::censored::censored::censored::censored:'s worldly possessions."

Well.. i'll say you are right. I just couldn't imagine working some where that i wasn't allowed to think for myself, examine the patient, and treat the patient based on my exam, irregardless of what the "protocols" say.

I feel like my hands are tied as it is ... being a paramedic. Id love to be able to obtain lab values, radiological exams, and have the ability to treat a patient on a longer term basis than 20 or so minutes.

I guess im going to have to suck it up and go to PA school.In the meantime im going to keep working at trying to get Paramedic Practitioners brought into EMS.

 

[MrBrown]

She's just a bit upset nothing to worry about, transport not required.

What exactly about this job is bothering you mate?

 

[Veneficus]

I think they over prescribe drugs like Xanax.

Could I respectfully inquire how you came to that decision, and given the current state of western society what alternative treatment you would advocate?

(I do agree, and have some ideas, but I am interested in your thoughts)

She may not be nervous, she may have a genuine cardiac issue that presents in her age group.

Fair enough. (with no prior cardiac hx but a prior psych hx and her current med, I don't think anyone could fault you for entertaining this thought, but I also don't think it likely.)

She may have a PE or even a partial spontaneous pneumo.

I think these are getting a little out in left field.

There's a multitude of things that could be wrong with this girl and I do not think it's a bad thing to consider every possibility and not just go with "she's some chick that didn't take her daily Xanax."

Very true, but if you start to treat for anxiety, an it resolves, then considerable resources and grief for the patient can be reduced.

If she is stable, why not give it a go?

 

[firetender]

Couldn't resist!

Did you try to get her to vagal down enough to see if it was sinus tach or not?

I'm sure...

"Hey Lady," he calls to the back of the ambulance as he's DRIVING, "bear down like you're gonna poop!"

 

[SanDiegoEmt7]

An ECG can be read in either monitor or diagnostic mode. Elevations and such can only be definitively read in diagnostic mode. The next time you go to work, hook yourself up and see the difference in the two modes. Also check out the rhythm generator as well. I've seen obvious ST evelations in the inferior leads on the pt in monitor mode and then see nothing whatsoever on the diagnostic mode. Hope this helps.

Thanks, I will check it out

Looks like SVT due to stress, sleep deprivation, and caffeine (on an empty stomach too?) .

By ST elevation do you mean enlarged T wave? Also, why the nitro? Good question about the BC.

This is my poor ECG skills! I haven't covered SVT yet, although I should have recognized it

 

[EMS49393]

Could I respectfully inquire how you came to that decision, and given the current state of western society what alternative treatment you would advocate?

(I do agree, and have some ideas, but I am interested in your thoughts)


Are benzo's supposed to be PRN drugs or are they supposed to be taken three times a day whether you need it or not? They are highly addictive and sudden withdraw is extremely dangerous. I ran on two separate patients that "ran" out of their 1 mg TID Rx of Xanax inside of a week. Both were status seizures. I swear they both laughed inside when I used my puny benzos to try to stop the seizures. Both bought tubes and ICU beds during their hospital course. A few weeks later I ran on a girl that was prescribed 10 mg of Valium TID as well. It took the ER doc nearly 20 minutes to stop her seizure. Her total time in status was over 50 minutes and she was admitted to the ICU following intubation in the ER.

Perhaps they are not over prescribed and I've just been unlucky in my calls.

I've got a pretty raging case of hate my career coupled with "PTSD" (if that is a real illness) and I do not take any benzo's regularly (but probably should). The three patients above had a raging case of disability secondary to depression and anxiety of unknown etiology. I know what my problem is, I haven't found the right doctor to get the good stuff. Such is life.

I'm interested in your views. I've read several of your posts and find them intelligent and well written. It's actually refreshing since the main reason I hate my career is the lack of required education and subsequent progress. I enjoy a good dialogue.

 

[FLEMTP]

EMS49393 I wasnt picking apart your post.. im sorry if you took it that way. I was speaking in a generality. I see many many many many paramedics who throw a drug at damn near any problem someone has. There is a time and a place for pharmacology, and then there is a time and a place to hold off. I've heard more than once.. from a very well respected ER physician, that if you LISTEN to your patient, they will TELL you EXACTLY whats wrong with them.

Most paramedics are no longer clinicians, they are cooks, and they are told they're going to bake a cake. sometimes its a chest pain cake, sometimes its a Breathing problem cake, but either way, they can't make it without following the recipe.

I try to be like the little old lady that grabs a pinch of this and a pinch of that, and throws the cake in the oven without needing to set a timer, or check the temp every 5 minutes.

It just saddens me that most people jump into the ACLS routine for SVT whenever they see a narrow complex rate above 150ish. SVT comes in many flavors, and sizes, and sometimes it might look like SVT and not even be close.

So please, dont take offense to my post, i wasnt trying to tear anyone apart.. I like to get people to open the top to the box they live in, step out, and look around a little. You'd be surprised at what you'll find.