"I'm Having A Heart Attack"

[ERDoc]

I would not treat with Lidocaine in this case. Yeah, it's bigeminy and he is bradycardic but he is stable. The normal beats don't look concerning. I would sit on him and see if something else evolves.

 

[NYBLS]

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.

Why the oxygen? It doesn't appear hypoxia is the cause for it and it can cause more damage...

if it's 30 apical, I'm going to opt for I.V 18 g left AC if possible, with a lock..

I'd give atropine 0.5mg, I'd give morphine for discomfort(going for >60 palpable, since the pvc's are interfering with the monitor) continue monitoring all the way in, document.

Why an 18g? I think Fentanyl would also be a better choice. More hemodynamically stable, might calm him down a little and bring down his pressure.

Treatment?
ASA, 12 lead q5 minutes (or whenever he complains about something new), couple big boy IVs, zofran, Fentanyl

 

[zzyzx]

I would not treat with Lidocaine in this case. Yeah, it's bigeminy and he is bradycardic but he is stable. The normal beats don't look concerning. I would sit on him and see if something else evolves.

Is he stable? He's good a cardiac history, having excruciating chest pain, and is really hypertensive.

 

[ERDoc]

I haven't looked back through the thread but I thought the pain went away at some point. If he is bradycardic but mentating and non-hypotensive then I would say he is relatively stable. Sometimes not doing anything is the best thing to do, waiting can be therapeutic.

 

[Rialaigh]

Interesting 4 lead and 12 lead. I'm thinking liberal with some benzo's and maybe some narcotics. ASA, IV, Monitor.

I'm not sure I'm opposed to a moderate fluid bolus to see if it does anything for frequency of PVC's or Heart Rate or blood pressure, especially given the possibility of vomiting that has been going on longer than the last couple minutes, if he's been feeling bad for days its very likely hes at least a teeny weeny bit dehydrated.

And I think I jump straight to pacing in the event that we lose hemodynamic stability, but if that occurs its very likely I get very aggressive with this patient given a 45-60 minute transport in my area.

 

[zzyzx]

Actually, I think what this guy really needs is a transvenous pacer. His circulation has clamped down to compensate for his severely compromised heart rate, and now his tired old heart is having to pump against a massive systemic vascular resistance, the SVR being the only thing in the equation (BP=cardiac out x SVR) that is sustaining his blood pressure. I said earlier that I would consider externally pacing him, but I was never sure of that since it would be painful and just add to his stress and anxiety. Again, I think atropine is potentially a bad idea because you can't turn it off due to its long half life. So, I'll say that the best action for EMS is to hold off on pacing or atropine and just get him to the ER so a transvenous pacer can be placed. Once his heart rate is restored to a more normal rate, his cardiac output will be increased, and hopefully the SVR will relax, thus reducing the workload on his heart.

 

[systemet]

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

I realise this is an older thread, but I have very much seen this presentation several times with acute MI. Including a guy with a massive anterior who arrested in triage.

This guys presentation with hypertension and chest pain is concerning. Some considerations:

* Are there risk factors or physical exam findings suggesting thoracic dissection? Do we have equal radial pulses / bilateral BPs.
* Any neuro symptoms?
* Any degree of heart failure?
* Recent sympathomimetic ingestion?
* Prior hx neuro deficitis / unexplained syncope?
* Recent sentinel blood pressure events or changes in med?

I don't see a lot pointing to acute renal failure. The most reasonable course seems to be to given some ASA, considerate an anxiolytic, we could trial NTG, but we don't know what is driving the BP up right now, so we don't want to reduce the MAP too rapidly.

This is someone who needs some imaging. Then we can decide what we're going to do with the blood pressure.

Not overly worried by the bigeminy. If it progresses to something more sinister we can address it then.