38yo Shortness of Breath

Shishkabob

Shishkabob

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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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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?
 
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.
 
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 ....
 
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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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.






How's your treatment?
Click to expand...


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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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?
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?
Click to expand...


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


We are getting fentanyl but I don't know if it will IN I'd rather use IV fent

The great thing is how fast you can administer IN fent, no waiting for canulation, no pissing about trying to get a vein and its particularly good for trapped pts when you can't get at them to canulate. And its pretty much equivalent as far as pain relief goes with IV morphine. Ambulance Paramedics (as opposed to MICA) don't have IV access on paeds here (for now<_< *shakes fist at the medical board*) so it gives us more options than just methoxy and IM morph.

All in all, its quick, reliable, safe, non invasive and very effective.

also methoxy is contraindicated for cardiac chest pain here

Really!? Whatever for?
Click to expand...

10char
 
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.
Click to expand...

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.
 
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.
 
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!
 
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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