New Cardiac Scenario

[johnrsemt]

Here is one I ran into last Sunday:

57 y/o, w/m. Substernal chest pressure, radiating to left arm (alternating pain and pressure). Chest Pain 9/10, arm 8/10. Pale, cool, Diaphoretic. 12 leads at the hospital were ok, none to attach; they wouldn't give me any.
Slight wheezing, lower lobes.

Hx: Asthma. No DVT, but 9 PE's 5.5 years ago. No cardiac history. Lots of stress over last 10 days, some dehydration periods over same period. Lousy sleep over same period.
135/77, HR 94, RR 30. Temp 97.0.

More to follow. Along with Dx. after awhile

 

[MonkeyArrow]

I'll start.

Let me get my zebra in: Takutsubo's cardiomyopathy (even though the pt. doesn't really meet the epidemiological risk factors).

Any workup 5.5 years ago to figure out what caused the PEs? Is he on anticoagulation?

 

[johnrsemt]

P.E.'s were 10 day's post Knee Scope; and he wouldn't listen to his wife; so 4 days later after going to the surgeon to get cleared for work he went to the family doctor to find out why the Asthma was acting up so much. Doc was in the room for less than 1 minute, walked out, 2 minutes later walked back in and sent him to the hospital for an emergency CT. 6 months of Eliqus; and Eliqus for a week either side of plane trips.
Wife hasn't let him forget it.

 

[silver]

Conveniently our pulse oximeter on the truck broke?

 

[johnrsemt]

oops missed that;

90-94% normal for patient due to asthma history; Cap 34-38.

 

[johnrsemt]

2nd round VS:
SPO2 and Cap approx the same, HR 80. BP 124/60.
Chest and arm pain still about the same; at least until 1st dose of 5mg Morphine was given; along with Zofran. Patient felt like vomiting but Zofran finally kicked it.

All of this is at the hospital; it was a walk in.
324mg Chewable ASA on board, no NTG (didn't ask why). Chest X-ray clean, heart looked normal, No PE's.
1st set of Troponin normal, D-Dimer normal

 

[E tank]

I'll start.

Let me get my zebra in: Takutsubo's cardiomyopathy (even though the pt. doesn't really meet the epidemiological risk factors).

Any workup 5.5 years ago to figure out what caused the PEs? Is he on anticoagulation?

My zebra was a screw driver sticking out of his chest...

 

[johnrsemt]

Good Zebra;

No all medical. No trauma.

Turned out to be all stress related. Walk in to ED at 2130, walk out (of floor) at 1530 next day.
CT stress test showed 24% EF (Ejection Fraction); but the cardiologist didn't believe it; so he ordered a bedside Ultrasound Echo which showed 64%.

Slight glitch: at 0500 they took VS (on the floor) BP was patients normal per patient (who was a little high at the moment due to 4th dose of Morphine) at 84/40. But it woke the patient up Hour later the nurse came to give NTG paste; and the patient was like, wait 'problem with that, but give me a minute to think of it'. "Oh yea, check VS. BP 82/36. Nurse called doctor who ordered NS 1 L.
Patient never did get the NTG.

 

[johnrsemt]

The patient was me: and yes that is my normal BP; worries people sometimes. I was glad that I was sort of awake both when they took my BP and when the nurse came to give me the NTG paste. Although it would be kind of interesting to find out what happened (especially since I was already in bed, with the rails up, so I wouldn't fall out).

The stress I was under: My 90 year old father had fallen on 4/1/22 and fractured his C2 on the kitchen counter. No displacement on the fracture, and no spinal cord damage. But he spent 2 weeks in Acute Rehab (same hospital I went to). So I was spending 14-16 hours a day in his Rehab room with him
The morning I ended up in the ED I watched him go grey and help check VS: (Normal BP is 160/90) he was 66/30, semi responsive. Dropped to 60/20. Rehab doctor ordered WO fluid bolus (which for the Rehab unit means 125mL/HR).
I had to walk out and walk around the outside of the hospital for a few minutes to try and cool down: I know they have their protocols, but wow.

So my stress which was already high, skyrocketed.
Cardiologist who saw me and talked and listened to me, didn't think it was an anxiety attack; he thinks it was a Stress Attack (never heard of it) but he said it was a relatively new finding. And I fit the criteria.

My wife says that it goes to show that I am weird in more ways than she already knows.