Doc Flips About C/P and Nitro. Your Feedback

[Black Snow Slide]

Yesterday we had a call, 17yo female, stabbing chest pain, crushing, mid sternum, 7/10 pain, SOB, 90%RA,restless. She was working at her desk with sudden onset x2hrs. Had not eaten anything fatty or spicy. Pain did increase upon palpation. (thinking skeletal muscle) Also increased when she would take a deep breath. (pleural space) She has a history of a heart murmur but doesn't know exactly what it is but it was diagnosed by a doctor. Family history, Lost her grandfather very young but doesn't know how he died.
NKA alergys, No meds, Denise drug use

Vitals 146/84,BS 98,Pules 111, Clear BI lateral,PEARL, No JVD, Nuro intact, + CSMx4 with good perfusion. Ab soft non tender x4.

My treatment; O2 4L via N.C., Sinus tack 111, Line started, ASA 349mg, 1 shot of .4mg nitro 1/150 SL with no relief.(Ruled out MI pain) Called it in. AT ED 10 minutes later.

Doc Flipped," You should not have given this Pt nitro. At 17yo she is at a very low risk of an MI. A Pt at this age should have a major heart condition or on drugs, (I think he meant cocaine) before giving any type of nitrate"

I think, I hit it just about right, maybe a 12 lead should have been done but I didn't. I wonder what he would be saying if she was having an MI?

Your opinion??

 

[Flight-LP]

I actually do agree with the Dr. If you have a 12 lead available, you should always obtain one with any pt. experiencing chest pain. Without it and in the absence of any cardiac symptoms, I would not have administered any nitrates nor would I have given ASA. Based on what you describe it is not indicated and the physician is correct in his statement that an MI was unlikely.........

 

[Black Snow Slide]

I certainly agree that an MI is unlikely. MI is not likely with a 17yo.

Our protocalls tell use that with chest pain of unknown ideology(SP) we need to treat as MI untill rulled out by Hosp. Chest pain, stabing and cruhing, SOB, Feeling flush, and some type of cardiac history(pt thinks it is a murmer or something) isnt cardiac symptoms? In protocalls, those sighns and symptoms are noted as MI. Athough palpaion and breathing increases the pain helps rule it out as an MI.

I do agree about the 12 lead thing. The monitor that we had yesterday gives a REAL CRAPPY trace, though that is no excuse.

Next time I will throw it on Med controll

 

[Ridryder911]

Crappy protocols to treat all CP as AMI. I agree, that I would not presumed to be an occlussive or coronary spasm.. before the NTG, I would had performed the XII lead as well. If you are going to tx the chest pain and work it up a one, you might as well be sure before giving NTG.

Again, time for your service to review chest wall pain, pleuretic pain and AMI. Treat accordingly...

Good luck,
R/R 911

 

[TTLWHKR]

Since there was pain on palpation, that pretty much rules out cardiac pain. Not that it can't be a cardiac injury, but you didn't mention any injuries. Pain on inspiration or expiration, does either exacerbate the pain, how badly, when did it start, what was she doing. What was her respiratory rate, was she hyperventilating?

Back to the basics, get the questions answered.

The vitals are good, I wouldn't worry about a HR of 111.

I wouldn't have given the nitro. Pull it over, run a 12, print two feet of it, and be on your merry way.

CxPn w/ pain on palpation, sinus rythmn, no blocks or irregular complexes, probably not cardiac. And 1 in 3 have some type of cardiac abnormality, I throw a PVC every now and then, nothing to fuss with.

 

[Black Snow Slide]

Hey guys.. I am at work now. Just got back from a call and I ran into the RN that took care of this girl.

He smiled and handed me her lab work and said, "Anything jump out at you?"

Her triponin level was 2.8. But nothing was on her 12 lead that was done at the hospital. Nothing else in her lab work that I saw was out of wack.

Now I am really confused. What else could make triponin level rise?

 

[TTLWHKR]

Elevated levels of Troponin enzyme in the blood does not specifically mean cardiac. Troponin is a protein found in skeletal and cardiac muscle. It can mean anything from CVA, angina, PE, cancer, sepsis, excessive workouts, MI, etc. But if it is cardiac troponin I and T specific, it doesn't mean it's an MI or angina either. It can be any type of cardiac muscle damage.. Such as from an injury, or blunt chest trauma. Could mean the patient has suffered from SVT, or an arrhythmia. I'd need to see a complete history before I would change my treatment.


Being married to a physician does have it's benefits.

 

[Black Snow Slide]

TTL, Good Info... Thank you

 

[ResTech]

I personally would not have given this girl NTG. At age 17 with no congenital cardiac hx, her heart is likely to be 99% completely healthy. And reading the assessment findings a cardiac etiology doesnt even jump out at me... stabbing chest pain, increase of pain upon palpation and respiration doesnt normally point to cardiac. If anything, the exam findings presented with that age of pt.... the sudden onset, dyspnea, stabbing CP, and < SpO2 would alarm me to a potential pulmonary embolism as a worse case scenerio. I also would have asked her if she smoked and was taking any oral contraceptives.

Also, at her desk... Im assuming she was in school at time of onset. PE class today? Sports inuries maybe exacerbated somehow? High school drama raising the anxiety level?

Ive heard the "its protocol" argument many times before.. treat the pt. not the paper and if the pt. doesnt fit the protocol call MC if unsure how to proceed.

Also, I read a study one time in one of the trade journals that stated relief of CP from NTG is not reliable for diagnostic purposes and r/o cardiac chest pain.

 

[nsmedic393]

I agree with everyone else here. I don't think there were enough cardiac indicators to give NTG. I definatly would have done the 12 lead prior and if your protocols don't allow you any discretion as to give it or not, i think the protocols suck.

 

[bonedog]

Personally I wouldn't emperically R/O cardiac pain if palpation changes it, have seen two females who had AMI and change with palpation.

Age is the biggest factor with this patient.

I await with baited breath for the study of female chest pain, all the questions we now use were based on the elderly white male. Females usually don't fall into the accepted chest pain parameters. Burning, indigestion, plueritic CP seem more common....

 

[Markhk]

Even if was a cocaine-induced MI, the patient would still be treated with MONA, so I would hope the Doc wouldn't be pissed off on the basis of that. The major treatment change when it comes to cocaine is when treatment comes to beta-blockers.

I think we should all keep an open mind about this one, because there are crazier cases that involve young people with chest pain and OTC med use like Sudafed.

http://www.medscape.com/viewarticle/494562

http://www.pulsus.com/journals/abstract.jsp?jnlKy=1&atlKy=945&isuKy=139&isArt=t&HCtype=Consumer

Additional tools that may have been useful for screening include End Tidal CO2 (since low levels may indicate hyperventilation syndrome)

 

[akflightmedic]

Successfully resuscitated another thread over two years old...you got some mad CPR skills there mate!

 

[tydek07]

I have to agree with the doc. on this one. After reading her s/s it does not sound like it is cardiac chest pain or AMI. There are multiple things that lead me to this decision:
1) 17 y/o
2) Stabbing pain w/ sudden onset
3) Pain increases upon palp. and inhalation

I would not have given ASA and nitro on this call, from the info that has been provided. It would not have hurt to do a 12-Lead, just to rule it out even more.

As for your protocol, I think they should take a closer look at that and make some changes.

Take Care,

 

[Ridryder911]

Just think she went from being a minor to an adult since this post was originally done...

As well, ASA, NTG etc.. will NOT work in Cocaine induced AMI's so the treatment will still be wrong.

R/r 911

 

[bonedog]

Just think she went from being a minor to an adult since this post was originally done...

As well, ASA, NTG etc.. will NOT work in Cocaine induced AMI's so the treatment will still be wrong.

R/r 911

Well Rid she is now 19.

Would have gone in with BLS if it were me.....

 

[dmiracco]

I agree you probably should not have given the ASA and Nitro. I would also have done a 12 lead.

 

[MMiz]

I agree you probably should not have given the ASA and Nitro. I would also have done a 12 lead.

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