The most important aspect of finding a dx or complications is knowing what they might be. Earlier in the discussion I posted the 11 complications of an MI. If you never covered them, your educators have failed you.
I have a very significant interest in physical diagnosis, I wish more people outside of Europe shared such a passion. Especially EMS providers who don't have all kinds of data gathering technology. (which often is not required anyway)
It's a very hot day and you are called to an elderly lady who has had a "spell" while tending to her flowers.
Elderly, involved in physical activity in a strenuous environment. This is very ripe for a cardiac event or a ruptured aneurysm
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;
In both aortic aneurysm and myocardial aneurysm or rupture, the initial pain is worse than the constant pain, in this case probably great enough to make her pass out, but either way the loss of circulation acute enough to cause neuro deficit. So the blood is either blocked, not transferring oxygen, or leaking.
When her husband found her he was not sure if she was breathing and said it looked like she was dead.
Obvious shock state, the only question is what kind? (accepting 1 or more can be present together)
She has no cardiac or medical history apart from taking oral antihypocglycaemics for diabetes.
"3. Myocardial rupture Not often seen, but usually seen in
females, over 60, with no prior history of MI, history of hypertension, and
no evidence of left ventricular hypertrophy.(mitral or aortic murmers) Most often seen in
Anterior transmural infarcts. (STEMI) 90% to the free wall, 10% to the ventricular septum."
this is the textbook example of the risk factors for acute myocardial rupture. If you don't know your pathology though, how would you know to look for it?
This could point to aneurysm, cardiogenic shock, right sided MI, CVA, hypoglycemia, PE, or cardiac rupture with what we have so far. The BP is still high for typical right sided MI.
RR 8, shallow and laboured
SPO2 97% on 10lpm
Late shock state, doesn't help with differential
BGL 5mmol (about 85 mg/dl)
GCS 13 (3/4/6)
Diabetic emergency ruled out, still inadequate cerebral perfusion of profound shock.
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
Doesn't get more typical for an Anterior MI.
Pt meets qualifications for MI and complication of myocardial rupture.
Underlying Sinus further excludes the possibility of right sided MI with lack of compromise of sinus node.
Gray appearance, lack of perfusion to brain, suggestive of hypovolemic shock. Consider places for blood loss. Assess heart tones.
No murmers, rubs, or gallops mentioned, tamponade happens over time, consider baseline volume and reasess in a few minutes.
Consider QRS amplitude, diminished amplitude sensitive, but not specific for tamponade. But many other things point to MI with textbook complication. Significant clinical probability has been established. This complication is also the most life threatening. So if you are going to make a bet prehospital, most lethal and most evidence for. Can't be faulted for that.
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.
If you had a bullet hole in your heart, you'd be looking for a surgeon. Mechanism of the hole insignificant. ALS rendezvous insignificant. ASA is out, fluid out, pressors not useful, survival will be determined by fixing the hole, not by respiratory support or correcting blood pressure numbers. Anyone not bringing blood to the party isn't contributing.
1) How do you manage this patient, and
No ASA, no fluid, no waiting, call helo, advise them of likely Dx. Start some IVs TKO, support ventilation.
2) What is wrong with them?
they have a hole in their heart.
If it looks like a duck, walks like a duck, and quacks like a duck, until proven otherwise, it is a duck.
