Daisys Dilema

[MrBrown]

It's a very hot day and you are called to an elderly lady who has had a "spell" while tending to her flowers. She was removing some weeds and her husband took them down to the mulch pile on the tractor, when he came back she was collapsed on the ground. They are on a country property about an hour by road to the nearest hospital.

The patient relates she felt dizzy then had back, jaw and neck pain then crushing heavy chest pain; she does not remember what happened after that and woke up on the ground. When her husband found her he was not sure if she was breathing and said it looked like she was dead. She has no cardiac or medical history apart from taking oral antihypocglycaemics for diabetes.

BP 80 systolic
HR 48
RR 8, shallow and laboured
SPO2 97% on 10lpm
BGL 5mmol (about 85 mg/dl)
GCS 13 (3/4/6)
Appears very pale/grey and shut down
Pain described as heavy, central chest pain 7/10
Anterioseptal infarct on 12 lead with ST elevation in V1-4
Underlying ECG is a sinus rhythm

Intensive Care (ALS) are coming towards you and will locate in approx 15 minutes, HEMS are avaliable but will take about 20 minutes to land at a local sportsground and its an hour (in good traffic) up the interstate to hospital.

1) How do you manage this patient, and
2) What is wrong with them?

 

[usafmedic45]

What meds is she taking specifically? What's the weather like? What was she specifically doing with her flowers when this all started?

I'd give her some glucose for starters to correct the BGL being a little low. I'd probably drop her back to a nasal cannula as well if she maintains her sat. What is out exact capabilities here since you mention we're not an ALS unit but you're giving us info that up here we would have to be an ALS unit to obtain (BGL, 12-lead)

 

[Outbac1]

If HEMS will fly medical cases from scene ask for them. They can deliver to the cath lab quicker. BGL is OK. Pt is on O2. Apply pacing pads. Start IV, load pt in ambulance(you know one of those old fashioned ground mobile thingys). Get onroute to LZ (if Brown coming), or cath lab (if only an hour that would be my 2nd choice) Bolus pt with 500cc ns. If b/p doesn't come up give 0.5mg atropine. If no HEMS or cannot get to cath lab in under 3 hours from onset head to nearest hosp that can thrombolyse or initiate field thrombolysis.
She is having a good oldfashioned MI. She is symptomatic and although one could go straight to pacing I would try the bolus/atropine first. One could also consider dopamine or another pressor, also nitro if her b/p comes up sufficently.

Thats my 2cents.

 

[lightsandsirens5]

but you're giving us info that up here we would have to be an ALS unit to obtain (BGL, 12-lead)

Not here.

Anyhow, so we are an hour by road from the nearest hospital? Hmmmmm......prolly not a cath lab, right? I am guessing it is a small rural hospital. Ie. Level IV Trauma center, nearest cath lab is an hour from them. :huh:

So, I would defiantly be calling for a bird as this gal appears to be needing quite a bit of care with as much quickliness as can be mustered. I am guessing we are looking at a fully evolved anterioseptal MI.

As for treatment, 314 mg of ASA, no NTG at this time due to B/P. I'd start a line, keep a close eye on that 12 lead. Small fluid bolus (500ml?) to to try to bring that B/P up a little. That is about as far I as an intermediate can go. If I was ALS though. I'd have pacing/defib pads on, atropine if the B/P doesn't come up with the bolus. Prolly try some sort of pressor maybe.

Start rolling and hopefully meet up with the bird pretty soon.

 

[Scott33]

HR 48...
Underlying ECG is a sinus rhythm

So what is the rate showing on the monitor?

Anterioseptal infarct on 12 lead

Have you ruled out any possible STEMI mimickers? Any reciprocal changes noted?

 

[MrBrown]

Here is what each level can do

Paramedic
Oxygen, OPA, NPA, LMA, manual defibrillation, synchronised cardioversion, 12 lead ECG interpretation, IV fluid administration, combat application tourniquet, entonox, methoxyflurane, aspirin, GTN, salbutamol nebules, glucagon, 10% glucose, ondansetron, adrenaline, morphine, paracetamol

Intensive Care Paramedic
All of the above plus intubation, cricothyrotomy, intraosseous needle access, pacing, atropine, frusemide, ketamine, midazolam, rapid sequence intubation (select Officers only)

A BGL of between 4 and 11 mmol (75-198mg/dl) is considered normal here so personally Brown would not give her any glucose.

Aspirin and one litre of fluid are administered

New vital signs
BP 90 systolic
HR 70
Pain is still heay 7/10

No reciprocal changes on the 12 lead and no, this is not an MI do you think Brown would post something that easy?

 

[usafmedic45]

Was she using any chemicals on her flowers? It sounds like organophosphate or carbamate toxicity. What are her breath sounds?

 

[lightsandsirens5]

Was she using any chemicals on her flowers? It sounds like organophosphate or carbamate toxicity. What are her breath sounds?

Oh! Good one! Didn't even think of that. :blush:

Now, I also might venture to say that it was a heart attack caused by her finding out that her husband was putting the weeds in the mulch pile. Cause I would have a heart attack if someone put weeds in my mulch pile. That is supposed to be weed-free. Weeds go in the burn pile. :angry:

 

[usafmedic45]

Weeds go in the burn pile.

You know what they call a burn pile in Australia? Victoria.



*waits patiently as he's going to have to explain a Black Saturday joke to all the non-Aussies on the forums*

 

[mycrofft]

Victoria? Ouch!!

And as far as nerve agents, drooling, constricted pupils, asphyxia, and other signs of acetocholine overload would be evident. Think of the oppposite of atropine and you get typical organophosphate intoxication. Another danged mnemonic from eMed:
"Mnemonic devices used to remember the muscarinic effects of organophosphates are SLUDGE (salivation, lacrimation, urination, diarrhea, GI upset, emesis) and DUMBELS (diaphoresis and diarrhea; urination; miosis; bradycardia, bronchospasm, bronchorrhea; emesis; excess lacrimation; and salivation)".

Let's see...if subjective sensations mimic a heart attack, maybe we are talking about a thoracic event affecting the same sensory pathways as the heart, oesophagus, trachea, and mediastinum, or arising from the mid thoracic spinal nerve roots, even if that effect per se is not the cause of primary concern. Sure as heck sounds like MI or something else that swatted her down, then let her recover enough to give a hx....??

 

[usafmedic45]

drooling, constricted pupils, asphyxia, and other signs of acetocholine overload would be evident.

You're thinking the "faucets on" syndrome: lacrimation, salivation, diarrhea, nausea/vomiting, diaphoresis. That's the classical syndrome for organophosphate toxicity, but let me remind you that you don't always have classic presentation. How many head trauma patients have Cushing's triad? How many patients with tamponade have all three signs of Beck's triad?

Copious secretions are often a late sign and not always present with all chemicals in those classes. Also, you're not always going to get constricted and non-reactive pupils until you reach a certain threshold. Pulmonary edema, bradycardia and altered mental status are going to be much more prominent in early or mild exposure, particularly to the carbamates. Remember that most of the "asphyxia" is related to the obstruction of the airway from secretions. Only in either massive exposure or exposure to weapons grade agents are you going to get sustained asphyxia in a true sense.

I'm not 100% certain that this is a toxic exposure but it sounds a lot like a case I worked where the lady had mixed up the agent in a glass and took a sip of it, mistaking it for her lemonade after being distracted by a phone call.

 

[MrBrown]

Brown LOL'd at Victoria .... anyway

Breath sounds are OK and not using any chemicals on the flowers.

What else would you like to know

 

[usafmedic45]

Brown LOL'd at Victoria .... anyway

Breath sounds are OK and not using any chemicals on the flowers.

What else would you like to know

She wasn't eating her precious foxglove was she? LOL

Any other pertinent findings?

 

[MrBrown]

The patient states she has a heavy, crushing pain in her chest and feels tired. Pain is centralised and also radiates inferior 7/10, did have pain her jaw and back but they have gone.

Very pale and shut down, does have a radial pulse and while palpable is weak and irregular. Was bradycardiac, remains hypotensive.

The ST elevation on the 12 lead remains.

Husband thinks he remembers the patient taking a voltaren tablet (diclofenac) this am for an inflamed knee she saw the doctor about yesterday.

 

[usafmedic45]

The diclofenac would put her at a slightly increased risk of an MI and there's a couple of case reports of it being associated with renal failure which resulted in hyperkalemia and bradycardia.

BTW What's her temp?

 

[ClarkKent]

From Mr. Browns first posting about this scenario

2) What is wrong with them?

From what I have read from all of Mr. Browns scenarios, he likes to hint at things. Is this just a misspelling , or are we missing something?? I know that I am not the best speller in the world, but just a thought?

 

[MrBrown]

It is an oversight on Browns part, its just the one patient.

 

[ClarkKent]

When it come to your scenarios Mr. Brown, I try and not look over anything. But almost 99.9999% of the time it is over my head since I have not able to find work in the EMS field and I am trying to keep my education and training up to speed.

 

[Veneficus]

all these experts

This time Brown has a textbook scenario, but you have to know your textbook real well to get it.

The devil is in the details and everything needed is in the OP

 

[Aidey]

Room SpO2? Capnography? What does that leg look like on exam, any redness or swelling?

It could be a PE...

Alternative route. What is her temp? Heat stroke?