First call for a paramedic student

[captaindepth]

You are dispatched for a 60-70y/o male pt with chest pain @ 0630

U/A Pt was pale/cool/ and extremely diaphoretic. Pt appeared lethargic but alert and able to answer questions appropriately. BP unobtainable (manual attempt x 2), no distal pulses, and a RR of 20. The wife sates he had been awake for approx 30minutes before he had sudden weakness and shortness of breath.

You are in an urban system with about a 15 minute transport to a Level I trauma center with all services available.

Here is the initial 4 lead EKG obtained in the house:


What are your treatment priorities? Any pharmacological interventions you would consider? How long should the on scene time be? and how would you transport the pt, emergent vs. nonemergent?

 

[cprted]

History? LOTAARP? Rx?

 

[Handsome Robb]

No 12-lead?

Pretty confident calling it a STEMI but a 12 needs to be done.

Pacing, fluids aspirin, activate the lab and let's boogy.

There's som evidence out there that even is rushing around isn't changing mortality but I'd rather not sit in traffic if there's lots of it. 15 minutes is only gonna change to ~12-13 ish emergency traffic. Not really worth the risk,

 

[DesertMedic66]

History? LOTAARP? Rx?

LOTAARP?

 

[DesertMedic66]

No 12-lead?

Pretty confident calling it a STEMI but a 12 needs to be done.

Pacing, fluids aspirin, activate the lab and let's boogy.

There's som evidence out there that even is rushing around isn't changing mortality but I'd rather not sit in traffic if there's lots of it. 15 minutes is only gonna change to ~12-13 ish emergency traffic. Not really worth the risk,

This would be my treatment list as well. Try to get a quick 12-lead on scene if possible.

 

[Angel]

you guys are too fast! same as robb though.

 

[OnceAnEMT]

This would be my treatment list as well. Try to get a quick 12-lead on scene if possible.

Third, except I'd be heading in lights & sirens. I am yet to see a truck come in where I'm at non-emergent with an EKG-diagnosed MI in addition to signs of deterioration.

Edit: Balls. Fourth.

 

[captaindepth]

After the initial 4 lead EKG we moved the pt to the ambulance and got a full 12 lead EKG, here it is:

 

[DesertMedic66]

Third, except I'd be heading in lights & sirens. I am yet to see a truck come in where I'm at non-emergent with an EKG-diagnosed MI in addition to signs of deterioration.

Edit: Balls. Fourth.

I think Robb was also saying lights and sirens. Normally when he says "let's boogy" it means L&S haha

 

[captaindepth]

Pt has a hx of HTN and diabetes. No cardiac history. No recorded medications.

Once in the ambulance bilateral large bore IV access was obtained, pt placed on O2 via NRB @ 15LPM, pacing pads placed and serial EKGs obtained.

here is V4R:

 

[teedubbyaw]

Hello right sided MI. Did he respond to a fluid bolus or did y'all go straight to pacing?

 

[captaindepth]

What do you think about the rhythm? Pt remains lethargic but AAOx 4 with a GCS of 15 but you are still unable to auscultate a BP. Do you treat the rhythm and attempt to pace or administer atropine?

 

[teedubbyaw]

I'd be giving a fluid bolus and go from there.

 

[DesertMedic66]

What do you think about the rhythm? Pt remains lethargic but AAOx 4 with a GCS of 15 but you are still unable to auscultate a BP. Do you treat the rhythm and attempt to pace or administer atropine?

Just briefly looking at it I would call it a slow junctional. Pace and fluid bolus

 

[Angel]

id bypass atropine and go straight to pacing

because: he's symptomatic enough that i'm not going to wait for atropine to work when cardioverting will (should) work right away

I agree with the junctional because i see no pwaves anywhere on the second strip you posted

 

[STXmedic]

id bypass atropine and go straight to pacing

because: he's symptomatic enough that i'm not going to wait for atropine to work when cardioverting will (should) work right away

Do what? [emoji15]

Exactly what's been said. RVI, pace, fluids, ASA, STEMI alert, boogy.

 

[captaindepth]

By the time we arrived the receiving ED we had administered 800ml of fluid and still were unable to auscultate a BP. The pt remained alert throughout transport with no changes in mentation, so we did NOT pace and only administered ASA and O2. Cath Lab was activated prior to us leaving the scene and the pt went up 15 minutes after arrival in the ED. I did not get follow up and know nothing after that.

I called the rhythm a sinus brady with a significant 1* AV block, ST segment elevation in the inferior leads and reciprocal changes in the high lateral leads. I believe the RCA is the involved coronary artery.

 

[DesertMedic66]

Do what? [emoji15]

Exactly what's been said. RVI, pace, fluids, ASA, STEMI alert, boogy.

Make sure you try adenosine first....

 

[Handsome Robb]

I think Robb was also saying lights and sirens. Normally when he says "let's boogy" it means L&S haha

I wouldn't necessarily take him in emergent. Gonna depend on traffic conditions and how many lights we're going to have to deal with.

I've brought in plenty of confirmed STEMIs non-emergent.

Not gonna **** around on scene though.

Even being alert if he's not responding to fluids I'm going to pace him and make him sleepy with small serial doses of versed.

Even if he's alert he's lethargic which indicates poor perfusion to his brain and that also means every other organ system. Things tend to fail if they go extended periods of time without perfusion.

 

[Angel]

Do what? [emoji15]

Exactly what's been said. RVI, pace, fluids, ASA, STEMI alert, boogy.

bahaha no!! i was talking on the phone and typing at the same time. definetly wont be cardioverting. pacing...my bad..