C/P SOA ("our bread and butter")

[pumper12fireman]

1400- cold day about 25 degrees outside.

Dispatched on 72 y/o female with CP/SOA. Upon your arrival, ambulance is able to be parked 10 feet from apartment door. You have a crew of 3, 1 medic, 2 EMTs. You find a well kept floor level apartment. Pt is sitting in recliner in visible distress. Pain at a 9/10. Radiating to left arm.

Vitals: P 90, regular at carotid. No palpable radial. BP- 70/50, RR 20, labored. Pale, cool, diaphoretic. 92% RA, GCS 15

EKG: NSR, 12 lead- Q wave indicative of old MI pt. had 6 years ago. No elevation or reciprocal changes.

Med Hx: HTN, MI 6 years ago

Meds: "something to slow my heart down" (we assumed beta blocker), "something for my high blood pressure"

O2 was started via NC at 4LPM
EMT spiked bag and prepped IV, medic decided to withhold. (more on that later)

EXAM: PEARL, No JVD, no distension/ tenderness. PMSX4, no pedal edema. Skin pale throughout.

Pt. was loaded onto stretcher, and moved into ambulance. En-route 20G started R arm, wide-open to NS. 2nd IV not attempted. Another 12 lead was taken, same as before. 324mg ASA given, nitro withheld as BP had not improved.

So, for medics: would you have done anything different??

 

[Epi-do]

She'sobviously in shock. What were her breath sounds like? What about doing a right side 12 lead? When did symptoms start? Any more info about history of current complaint - has the patient been sick lately? Does anything make the pain change? What was shse doing when it started? Is this pain similar to her previous MI?

With that blood pressure, you wouldn't want to give nitro, so that was a good call. From what you have said, I too would be leaning towards cardiac issues. At this point, I can't think of anything else I would have done. Given her blood pressure and my protocols I would be pretty limited on treatment options for this scenario.

 

[vquintessence]

Yeah agreed, would definitely need to know lung sounds for starters.Wouldn't necessarily jump toward cardiac solely on what you're giving, I would be willing to bet more on there being a good chance of sepsis.

Was she febrile at any point (you mentioned cool, but that could be now that she developing shock)? How long was her SOB? Was the SOB gradually increasing? Was there a cough and if so was it productive? Did the CP come later (weeks/days/hours/whatever) and/or was it a result of the SOB (pleuretic CP)?

 

[VentMedic]

Breath sounds would be important as would a temperature although in cases of sepsis, a rectal (core) temp is preferable but not practical in the field. PNA can quickly lead to sepsis in an elderly patient.

Heart sounds?

Did you measure the BP in both arms?

Also, just because your EKG does not show changes may or may not mean a cardiac event. Often EKGs are compared with one on record to look for changes. Some structural issues and malfunctions within or around the heart may not show EKG changes immediately. Acute MR from various etiologies and pathologies can be an example.

 

[Jon]

I'll second the request - Breath sounds?

O2 @4lpm? Will Pt. tolerate a mask?

Maybe left-sided failure?

 

[pumper12fireman]

Okay, sorry for the delay. I'm a medic student and was the EMT on this call. So, I had to double check with my partner on exacts of lung sounds. Lung sounds were clear in all fields. CP/SOA started 2 hours prior to our arrival. BP was equal in both arms. Also, no complaints of "feeling sick" or fever.

As a medic student, my main concern was her pressure. I wanted to bolus her in the house, and thought my partner wanted the same. I set-up the IV, only to have my medic say she wanted to hold off. I apparently gave her a "look" and we had words after the call. She thought it was too cold to bolus her in the house. Regardless, she was admitted to the hospital with a PE. No meds of birth control, and hadn't taken any long trips lately. Also, she said she was "fairly" active with gardening etc. I'm not saying that those things prevent all PE's..it just kinda caught both of us by surprise.

 

[mycrofft]

Glad to see mention of temperature.

Something to watch for, especially in elders, but not mentioned because we tend to sort of do it automatically, is level of hydration.

 

[csykes]

Some things that can be considered in a case like this is hx of irregular heart beats (a-fib), and evaluate bilateral calves (looking for differences in circumference size, tenderness, and color for possible DVT). Has she been sedentary for longer periods of time than normal or traveled on a long trip, esp in planes and small cars. It is hard to know in the field if someone is suffering from a PE, but these are some signs that could point you in the right direction.

 

[NolaRabbit]

Personally, I would have preferred a NRB and a larger gauge IV gauge cath for this patient, if possible.

Good scenerio, thanks for posting this.

 

[BossyCow]

Personally, I would have preferred a NRB and a larger gauge IV gauge cath for this patient, if possible.

Good scenerio, thanks for posting this.

Large gauge in an elderly pt? Many times those veins are fragile and larger gauges blow them out.

 

[NolaRabbit]

Large gauge in an elderly pt? Many times those veins are fragile and larger gauges blow them out.

That's why I added "if possible."