71 y/o Male - SOB

[Cawolf86]

This was a relatively straight forward call I ran last night. I picked up overtime on a double medic ambulance and was driving - so I did not make patient care decisions during transport. Just curious what your plan of treatment and working diagnosis would have been. I will try to obtain a follow up in a few days from hospital.

Dispatched for difficulty breathing to a single family residence - wife and daughter on scene called 911 for a 71 year old male with difficulty breathing and chest pain.

Patient is a 71 year old male, 170 lbs, 5'9", appears well taken care of, ambulatory and handles his own ADLs.

Pt is complaining of a transient chest pain since last night - approx 24 hours. He states that it lasts for a few hours, is absent a few hours, and then returns. The pain is described as non-provoked, "squeezing", sub-sternal, non-radiating, 2/10, x 2 hours - he claims it is a "annoyance" or "discomfort".

Patient advises that the "squeezing" pain isn't as bad as the pain where he just had a new pacemaker installed last week....left anterior chest wall.

Patient also reports weakness, dizziness, nausea, vomiting, and difficulty breathing - all symptoms onset after the pain.

No pain on palpation, inspiration, or movement. Patient denies cough, fever, chills, flu-like symptoms.

History - Hypertension, hypercholesteremia, NIDDM, and one week prior a new implanted pacemaker - demand A/V. Family advises patient had it placed after a "possible code".

Allergies - PCN

Medications - Aspirin, warfarin, glipizide, atenolol, simvastatin, lisinopril, amiodarone.

Assessment

GCS 15, airway is patent, breathing is slightly labored with slight crackles bilateral in the bases, weak irregular radial pulse.

Physical exam shows a bandaged implanted pacemaker in the left anterior chest wall and a surgical scar on the abdomen from a surgery 20 years ago.

Vitals are BP 88/50, Pulse 110 weak and irregular, RR 20 crackles bilateral bases, SP02 95% RA, Sinus Tach with PVCs on 3 lead, 12 lead attached.

Transport time is 25 minutes to our cardiac facility. What is the plan of action? It's not a tricky one, I just want to see what others think and their 12 lead analysis.

Thanks.

 

[Handsome Robb]

Hmm, I don't see any elevation, T waves could be argued as tall and peaked but that may be a stretch. PVCs look unifocal. Has he felt his pacer fire at all? With SOB and PVCs I'd give him a bit of O's, 2 lpm on a NC, but he seems like he's perfusing decently.

Maybe a conservative fluid bolus to see if helping his preload resolves some of the ectopy as well as the borderline hypotension. Seems more like a force of contraction problem rather than a volume problem though.

Wow I just realized how dumb I feel even after being in medic school for 6 months

 

[abckidsmom]

I wonder if there's a pericardial effusion...it's almost certainly related to the pacer installation.

I would give him a small bolus and see what his pressure does. Also give him a couple of liters of oxygen, and mostly just transport.

If he started to look sicker, we would have to do something more invasive, but I would rather keep my hands off of him.

 

[mycrofft]

Timeline suggests pacer relation, but check for zebras.

Maybe the pacer isn't working properly and he is teetering on the edge of myocardial ischemia, thus providing the classic s/s of MI but without the outright "crash"? Sort of a clinical angina? The bolus would seem to be a good idea. In a case like that I would nonchalantly run a 1 minute rythm strip to take back to the MD, especially if he reports an attack coming on.

Zebras: hiatal hernia, mediastinal complaint, pericardial complaint, exotoxic or endotoxic food poisoning, and artifact of surgery (electrode placement failure, suture failure, adhesions) which could directly or through anxiety cause the complaints.

 

[Cawolf86]

Haven't been able to follow up on this patient so no resolution yet. A 250cc fluid bolus was given - pressure went to 102/60 and pulse/HR/ECG/symptoms remained unchanged. I was mainly leaning towards pacer malfunction because at no point did I see a paced beat with this patient. The rhythm was Sinus Tach with unifocal PVCs/ectopics at approx 10-12 a minute - appearing in groups of 2 or so.

Pericardial effusion post surgery? Could it onset a week later? I didn't consider that at the time.
He was given ASA as well. Thoughts on meds for PVCs? We have Amiodarone, Lidocaine, and Procainamide available. Our first line IF we treated would by 150mg of Amiodarone.

 

[triemal04]

Inverted T-waves in avr and V1, some ST-depression and maybe some hyperacute T-waves...pericarditis, maybe with a pericardial effusion. Makes sense if he had a recent invasive cardiac procedure done. Aspirin, small amount of O2 and fluid, and transport. If the facility where he had the procedure done is near, might be appropriate to go there.

I'm curious why a pacemaker malfunction was mentioned. Many pacemakers will allow the heart to beat on it's own as long as the intrinsic rate is above the minimum...so seeing someone with a pacemaker and a rate of 110 wouldn't be abnormal.

 

[Cawolf86]

Pericarditis makes sense with that 12 lead analysis. The reason I bring up pacemaker malfunction - from what I have seen if there are frequent pvcs the pacer will generally fire. Is that incorrect?

 

[triemal04]

Pericarditis makes sense with that 12 lead analysis. The reason I bring up pacemaker malfunction - from what I have seen if there are frequent pvcs the pacer will generally fire. Is that incorrect?

To the best of my knowledge it will depend on the specific pacemaker and what it's rate is set at, but as long as there isn't to long of a pause after the aberrant beats and the overall rate is acceptable, then no.

Kind of like someone with a pacemaker-defibrillator being in vtach at 160; it's not a paced rhythm, it is a shockable rhythm, but it's outside the parameters that their device is set for; not to slow, and not to fast.

Just noticed, I should have said PR depression in my first post, not ST depression. Stupid alcohol, you drunken me.