60s yom full arrest

[vcuemt]

60s yom

dispatched for altered status to a chain restaurant less than a mile from the station

arrive on scene prior to ALS-bearing fire truck

elderly man seated on the asphalt, back to the car he came to the parking lot in, wife hovering over - worried

put him onto the stretcher and into the ambulance as ALS walks up

pulse: 80s bp: 76/35 resp: 14 spo2: 96 on room air, lungs clear bilaterally

he's clearly not well but able to answer questions in complete sentences, complaining of chest pain

12 lead reveals arrhythmia

no history of diabetes, stroke, he hadn't eaten a meal but was rather going to the restaurant to eat

had a stent put in less than two weeks ago

start driving to the nearest hospital (10ish miles away) l&s but nice and easy with ALS on board

complains of right side weakness

unable to establish a line but 324mg of aspirin given plus 5L/min of O2 via NC

en route patient starts vomiting

2 minutes from the hospital patient very suddenly becomes unresponsive and pulse is lost

CPR started as the ambulance turns onto the road to the hospital

no ROSC at hospital

thoughts?

 

[STXmedic]

What kind of arrhythmia? Any ST changes? How did the chest pain feel? Radiating? As with a lot of the scenarios posted here, there's usually too many questions left unanswered to give anything other than a very speculative guess.

My Ddx's off of the information presented:
AMI
AAA
CVA

 

[vcuemt]

What kind of arrhythmia? Any ST changes? How did the chest pain feel? Radiating? As with a lot of the scenarios posted here, there's usually too many questions left unanswered to give anything other than a very speculative guess.

My Ddx's off of the information presented:
AMI
AAA
CVA

Speculative is good. I just drive an ambulance. I don't have all the answers.

I can say the chest pain was more like pressure (5/10) and the computer didn't think it was an MI.

 

[STXmedic]

Without knowing more about the 12 lead beyond "arrhythmia", it's impossible to say what was going on. It could've been an AMI. It could have been runs of VT. It could have been PVCs that fell in the wrong spot and threw him into VF. That ECG is a pretty vital part of knowing what was going on.

 

[OnceAnEMT]

Sounds like an R-on-T, but as mentioned its pointless to guess without a confirmed 12 lead.

 

[J B]

Seems extremely likely that this is a right-sided MI. He just had a stent put in so we already know he has some serious cardiac issues. All of his symptoms point in this direction - crappy vitals, chest "pressure", nausea/vomiting, weakness.

If no line can be gotten, this guy gets an IO and a bunch of fluids - sorry guy. Agree with the aspirin. I'd rather use the time it took to put the cannula on to run a right-sided 12 lead.

Given that he just had surgery 2 weeks ago, fibrinolytics may be contraindicated. I hope your 10-mile-away hospital has PCI capabilities? Without good evidence from a 12 lead we pretty much have to go to the closest hospital either way, though, I guess.


Aside from the weakness (also seen with MI), I don't really see much evidence for CVA? Though he is the right age for AAA, it seems astronomically more likely to be something cardiac related given history and signs/symptoms.

This guy was in bad shape before he went unresponsive. With a HR of 80 and BP in the 70's he's either decompensating, or something is preventing him from compensating with heart rate (maybe he has a block, which is the arrhythmia the monitor detected?).

 

[Ewok Jerky]

my guess would be either a new MI or more likely acute stent thrombosis...but again its hard to tell without a 12-lead.

not much you could do for this guy, even if you got ROSC, this guy's days are numbered.

 

[Uclabruin103]

I know it's hard when someone else is running the call but why the cannula when his pulse ox was above 94?

 

[J B]

I know it's hard when someone else is running the call but why the cannula when his pulse ox was above 94?

My new protocols actually say absolutely do NOT give this guy O2. I know a lot of people still will, and whatever, 3Lpm on a cannula probably never hurt anybody. I suppose if fire had put it on PTA I'd ask pt if it was helping at all and leave it on if so - sometimes it can give patients peace of mind just because it feels like you're doing things and in control and everything is gonna be okay. I'd probably turn it down a few notches though...

my guess would be either a new MI or more likely acute stent thrombosis...but again its hard to tell without a 12-lead.

http://www.sharecare.com/health/heart-attack/what-is-stent-thrombosis

I didn't know this was a thing that happened. Makes sense, though - you're probably right. I guess you could ask if he's been compliant with post-surgery medications and if he hasn't been 100% on them you can be pretty confident that's what is going on. I suppose it doesn't really change our treatment or transport decisions, but maybe we can make ourselves look smart when we give our report in the ED.