STEMI - Inter Facility Transfer

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BobBarker

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I'm gonna throw in a call we had. Interesting stuff happened.

You are a CCT crew called code 3 to a hospital's telemetry floor for an urgent STEMI transfer to a hospital with a cath lab. Your transport time will be 11min from hospital to hospital and you have 1 CCT-RN and 2 EMT's on board.
You arrive on scene to find 6 RN's and a crash cart next to the room of an elderly male patient, AX0X4 but appears very weak lying supine with the following vitals: HR118, BP 69/49, R8 labored, SP02 77% on 6L NC. PmHx: Hyperlipidemia, hypertension. No current meds, no current allergies. A 1L NS bolus is running wide open, no additional meds have been ordered.
The patient's primary RN states that the patient is DNR/DNI. The staff says that the patient was admitted for stomach pain 2 days prior and diagnosed him with new onset gallstones. He developed sudden chest pressure in the AM and when a 12 lead was sent to the hospitalist, he arranged transfer for his diagnosis of a STEMI.
At this point, the CCT-RN asks the patient to confirm his DNR status given the situation and the patient now says he wants everything to be done to save his life, so his status was changed to a full code.
The patient is raised to semi-fowlers from supine and a 15L NRB is applied in addition to the 6L NC already on. SP02 raises to 87%, R10 but still labored. The patient now says that he needs some suction to help him spit and you notice bright red blood, approximately a handful's worth.
One of your EMT's is helping suction the patient and keep him calm while the other is hooking him up to the Zoll transport monitor.
CCT-RN begins asking for pressors. What pressors/medications would you ask for since only NS is running? Would you ask for an MD or and additional RN to come along with you on this call as well?
12 lead from the hospital is attached as well as the rhythm strip from the transport monitor. Be advised, there was a 3hr delay from when the 12lead was taken/sent to the Dr and when urgent transfer was arranged.
More to come...
 

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In regard to pressors, I would probably start off with something that doesn't increase the heart rate much, levophed.

Personally, his 12-lead doesn't even look like a STEMI to me. Is that the one they called a STEMI? Any immediate info on what made them think STEMI? Troponin? Since they are going down the STEMI route, did they give him any medications like aspirin, nitroglycerin (I know he's hypotensive, lol), any anticoagulants, heparin?

I am confused about the bleeding in the mouth too. It's bright red blood you said so I feel like it can't be far. Is this the patient's first time producing blood? I'd be checking the mouth to see if maybe they were too aggressive with the suction. Consider upper GI bleed. I am not really picturing CHF frothy sputum here.

Temperature and lung sounds?
 
Aprz said:
In regard to pressors, I would probably start off with something that doesn't increase the heart rate much, levophed.

Personally, his 12-lead doesn't even look like a STEMI to me. Is that the one they called a STEMI? Any immediate info on what made them think STEMI? Troponin? Since they are going down the STEMI route, did they give him any medications like aspirin, nitroglycerin (I know he's hypotensive, lol), any anticoagulants, heparin?

I am confused about the bleeding in the mouth too. It's bright red blood you said so I feel like it can't be far. Is this the patient's first time producing blood? I'd be checking the mouth to see if maybe they were too aggressive with the suction. Consider upper GI bleed. I am not really picturing CHF frothy sputum here.

Temperature and lung sounds?
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The info we got was that was the only 12 lead done prior to getting the call for a stemi transfer. Didn’t get exact lab values on this call but remember the RN saying the trop was “high”. No other meds given at all besides 1L NS bolus. First time producing blood yes
Temp was normal and lung sounds were diminished on both sides.
Our CCT-RN asked for Levophed and Dopamine and the ER physician who came to the room for help agreed. After starting the pressors for a couple minutes while loading the patient, the HR stays in the 110’s and the BP improves to 80s/50s
 
Did you guys do both at the same time or ask for dopamine after trying levophed? How come dopamine?

Did you guys have a chance to do another 12-lead?

I forgot to answer one of your questions. I wouldn't be asking for a doctor or nurse to come with me, but I wouldn't be opposed to one coming, if they asked. Sometimes I feel like it is better if it is just me and my partner. If they are riding with us without bringing their own equipment, there isn't usually much more they can add to the care even with extra brain power.
 
Aprz said:
Did you guys do both at the same time or ask for dopamine after trying levophed? How come dopamine?

Did you guys have a chance to do another 12-lead?

I forgot to answer one of your questions. I wouldn't be asking for a doctor or nurse to come with me, but I wouldn't be opposed to one coming, if they asked. Sometimes I feel like it is better if it is just me and my partner. If they are riding with us without bringing their own equipment, there isn't usually much more they can add to the care even with extra brain power.
Click to expand...
Levophed then dopamine. No additional 12 lead as the stemi transfer was already initiated. Cant remember why dopamine was also requested. In LA County, CCT-RN’s are not allowed to intubate on ground transport, only use i-gels which is why a Dr might be helpful. BP raises to 112/92 halfway through transport with a HR of 118 but sats wont go above 85%
 
My guess is someone said non-stemi and non part did not get relayed. Did anyone try a forehead or ear pulse oximeter?
 
As stated above, BP improves to 112/92 enroute with a HR still in the 110's. As soon as you arrive at the STEMI center and are backing into the ambulance bay, patient goes into PEA arrest. You start CPR, give 1 dose of epi and transfer the patient to the ER staff. After 25min of resus efforts, the patient is pronounced deceased with no shockable rhythm the entire time.
 
Very interesting, 12 lead doesnt look like a STEMI, they probably correllated it with " high" troponim levels that were mentioned. Trop was probably elevated due to demand ischemia from tachycardia. With the abdominal pain and gallstones, sounds like he was in septic shock. Levophed is the go too if blood pressure doesnt respond to 30ml/kg bolus. As far as the bleeding, I'm not sure what his platelets and liver function tests were but it's possible he was in DIC from the ssepsis. I would have intubated the patient after resuscitating his pressure, or asked the doc to do so. He was hypoxic for a long time sounds like.
 
Any way you slice it, I don't like the look of lead II on the "en-route" strip. The hospital 12-lead doesn't look too bad to me, but because of the chest pain complaint, a trop was probably drawn then, was probably "high" and that was probably what triggered the transfer. OP: do you recall if the QRS segment was wide or narrow on the monitor in the hospital? Looks narrow on the initial 12-lead. Do you recall what the neck veins looked like?

This doesn't have the "feel" of a septic/DIC patient to me. Multiple problems, quite likely but I don't see sepsis in this, at least not without labs (which would have been done with this).
 
Levophed and diesel, rapid transport to cath lab. Dude is in cardiogenic shock and the “care” rendered by the sending facility is minimal.
 
RocketMedic said:
Levophed and diesel, rapid transport to cath lab. Dude is in cardiogenic shock and the “care” rendered by the sending facility is minimal.
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Exactly what we thought and what we did. The sending facility basically let him sit there in shock for hours and didnt do any treatment until we arrived and asked for it
 
Not a whole lot more to add except that I wondered if the evolving MI was secondary to an occult bleeding/hypovolemia problem. Doesn't sound like the type of place to have sent of recent blood counts, coagulopathy panel, lytes etc...thinking of the bloody show zebra mentioned in the OP.

All the inopressors in the world don't help a heart that is empty. As far as the low sats go, that could very well be do to the patients cardiac output/O2 delivery being lower than the patient's metabolic O2 demand. Very commonly reflected in the SaO2 without a problem in the lungs.
 
A bit of V/Q mismatch perhaps…
 
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