"I'm Having A Heart Attack"

[Tigger]

Your ALS ambulance is dispatched on an unknown medical sometime after midnight to a private residence located approximately 20 minutes away. Enroute you are advised that the patient is being exceptionally impatient with the call taker but says he is having the chest pains. BLS Fire is also responding with a similar ETA to you. If you elect to transport, you have a six bed ED with no specialty services 30 minutes away and several full service medical centers 70 minutes away. The helicopter will not be flying.

You arrive on scene to find a less then well kept single-wide. Fortunately for you, as you exit the ambulance the patient comes running towards you, clutching his chest and yelling that he is dying of a heart attack. The patient wastes no time hopping in the side door and plopping himself down onto the cot, where he then promptly vomits. The patient is 58 and will not stop carrying on about his imminent demise.

What do you want and what do you do?

 

[zzyzx]

We can start by giving him a vomit bag.

 

[PotatoMedic]

So the pt is not answering questions? If they do answer questions onset, anything make it worse or better, describe the pain/discomfort, med history, allergies, medications.

What does their skin look like? Lung sounds.

Have my partner start working in a 12 lead.
Start an IV and give zofran.

And what does the vomit look like.

Vitals?

We'll start there.

 

[Akulahawk]

Your ALS ambulance is dispatched on an unknown medical sometime after midnight to a private residence located approximately 20 minutes away. Enroute you are advised that the patient is being exceptionally impatient with the call taker but says he is having the chest pains. BLS Fire is also responding with a similar ETA to you. If you elect to transport, you have a six bed ED with no specialty services 30 minutes away and several full service medical centers 70 minutes away. The helicopter will not be flying.

You arrive on scene to find a less then well kept single-wide. Fortunately for you, as you exit the ambulance the patient comes running towards you, clutching his chest and yelling that he is dying of a heart attack. The patient wastes no time hopping in the side door and plopping himself down onto the cot, where he then promptly vomits. The patient is 58 and will not stop carrying on about his imminent demise.

What do you want and what do you do?

The same thing we do every night, Pinky - try to take over the world!

Give him a vomit bag and believe him until proven otherwise. Then get on with things and assess the guy. Could he be experiencing a heart attack? Sure. Could it be a panic attack? Sure. Could he simply be insane? I'm already there.... but enough about me. Could it be that he needs to clear datum? Yes...

Bottom line is that we do what we always are supposed to do and begin assessing the guy for a possible cardiac problem and go from there as the data we develop suggests.

 

[DesertMedic66]

Start off with a standard assessment.
Medical Hx
Medications
Location of pain
Onset of pain
Anything make it better or worse
Baseline vitals
12-lead
Had this pain before?
SOB? Lightheadedness?
I'll wait for results before I start jumping into possible treatments.

 

[Old Tracker]

Start off with a standard assessment.
Medical Hx
Medications
Location of pain
Onset of pain
Anything make it better or worse
Baseline vitals
12-lead
Had this pain before?
SOB? Lightheadedness?
I'll wait for results before I start jumping into possible treatments.

Besides all of the above, I'd be trying to calm him down. Whatever anxiety he is showing, if indeed he is having a heart attack, is not helping him in the least. I have next to no experience with potential heart patients, but the ones I have dealt with, haven't been feeling well enough to run anywhere.

 

[Underoath87]

Yep, never seen anybody with actual ischemic chest pain running around and agitated. They're generally on the lethargic end.

 

[Tigger]

You are able to calm the patient down enough to get a 12 lead which is attached. Thankfully, now that you have provided the patient a vomit bag, he stops (the vomit was unremarkable).

You elicit the following: the patient has had a previous MI, of which he says this feels similar. The pain started at rest and has been going on for "days," but it suddenly worsened for no reason. He won't describe the pain for you, just "it feels real bad and I'm dying!" When asked about his previous medical history, the patient states "I've been sick for years." Eventually you get out that he has hypertension, diabetes, and hepatitis C. He takes a hypertension med and oral diabetic control med. He has no allergies.

Vital signs: 254/110. Radial Pulse at 30. Respirations at 24. BGL 109. SpO2: 94%.

 

[Alan L Serve]

Radial of 30 vs monitor at 85. Super high BP with + hx of MI, DM, and HCV. Put on O2 NRB 15lpm, start IV tko, continue monitoring, place PT in position of comfort. Need to get that pressure down so might consider a beta blocker or SL nitro. I imagine his PVCs are due to his kidneys having failed from DM and severe HTN causing his K to skyrocket. Therefore I would start nebulized albuterol. Does this ambulance carry any insulin?

He's too sick for the doc in a box.

 

[Carlos Danger]

I wouldn't give a beta blocker to someone with a pulse of 30.

I'd give him a ntg or two and see what happens.

NC and IV, of course.

 

[Alan L Serve]

I wouldn't give a beta blocker to someone with a pulse of 30.

I'd give him a ntg or two and see what happens.

NC and IV, of course.

That is concerning but I have a feeling his radial pulse is an abnormality. Do we have any ACE-I or ARBs?

 

[Carlos Danger]

That is concerning but I have a feeling his radial pulse is an abnormality. Do we have any ACE-I or ARBs?

Anytime the pulse and monitor differ, it is the monitor that is the abnormality.

Even if we were going with the monitor over the pulse......a HR of 85 isn't an indication for a beta blocker.

 

[Alan L Serve]

Anytime the pulse and monitor differ, it is the monitor that is the abnormality.

Even if we were going with the monitor over the pulse......a HR of 85 isn't an indication for a beta blocker.

I agree with the monitor vs pulse, but if his pulse is in fact that high we can use a beta blocker to help in quickly reducing his pressure which is so high he's likely to burst somewhere and soon.

 

[Alan L Serve]

Forgot to add I'd give PO ASA for suspected ACS.

 

[Tigger]

I suppose I should add that the rhythm strip above the 12 lead is continuous, we didn't have to catch this. He was in that upon placing the four lead and did not spontaneously stop.

 

[Carlos Danger]

I agree with the monitor vs pulse, but if his pulse is in fact that high we can use a beta blocker to help in quickly reducing his pressure which is so high he's likely to burst somewhere and soon.

Well that's just it; the pulse is NOT in fact that high. It was only 30.

You give a beta blocker to a patient with a new onset BBB and a pulse rate of 30, and you may very well kill them.

Again, even if their pulse rate was 85 as indicated on the monitor, that is still not an indication for beta blockade. The HR is not the cause pf the HTN.

A pulse rate of 85 may reasonably be treated with metoprolol only AFTER the BP has normalized and and chest pain has stabilized.

 

[Alan L Serve]

Well that's just it; the pulse is NOT in fact that high. It was only 30.

You give a beta blocker to a patient with a new onset BBB and a pulse rate of 30, and you may very well kill them.

Again, even if their pulse rate was 85 as indicated on the monitor, that is still not an indication for beta blockade. The HR is not the cause pf the HTN.

A pulse rate of 85 may reasonably be treated with metoprolol only AFTER the BP has normalized and and chest pain has stabilized.

True, tho I suspect the radial pulse might be that low and I would use also get an apical pulse and compare the two. If indeed it was that very bradycardic then certainly no beta blocker should be used.

Any idea on the availability of insulin, furosemide, or an ACE-I/ARB?

 

[nater]

I would want a potassium level as well.The chest pain, nausea, bradycardia, 12 lead with peaked T waves suggest hyperkalmia. It looks like a sine wave might be forming which would raise concern that this patient is close to arrest.I would go to the closest 6 bed facility. D50, insulin, Calcium, bicarb and albuterol can help him, dialysis will also be needed.

 

[ERDoc]

There is no indication for beta blockers. Your pulse is what matters, not what the monitor says or what you hear apically. Your pulse is what perfuses and right now you are only perfusing at 30. I also think we are jumping the gun on hyperK. There aren't any peaked t waves. When someone who has had a heart attack before tells you they are having a heart, trust them. They know what it feels like. I'm not saying that is what this case is but it is something that should raise your suspicions.

 

[Tigger]

You are on a "mostly standard" ALS ambulance. No lab values, insulin, beta blockers or an ACE-I. We do have IV nitro, but aside from that it's a pretty standard formulary. Furosemide if you want.

What are everyone's rhythm and 12 lead interpretations? I feel like mine is very different than many here, or maybe not?