Would you treat for ACS?

[teedubbyaw]

http://www.ems12lead.com/2014/01/28/87-yom-complaining-of-chest-pain-and-dyspnea/

A lot of comments from people that would treat it as ACS, and others as CHF.

 

[DesertMedic66]

Based off of the information that was presented I would start down the CHF treatment route.

Let's clear his lungs up and see how his respiratory rate and heart rate change.

For my local protocols really the only thing that is in not in the scope for CHF is aspirin.

 

[Akulahawk]

This looks more like a HF/Pulmonary Edema case than anything else...

 

[Household6]

I'd treat for CHF too, thats what he's presenting. Id be railing him with nitro, ASA, and I'd consider CPAP if he's still in resp dist. Titrate to 5cm of h2o, go up towards 10, and depending on his lung sounds administer a lovely albuterol neb or two, or continuous nebs until I got the results I wanted.

Probably do a nitro drip, 80mcg/min if the transport time permits.

 

[Handsome Robb]

CHF.

12-lead shows a sinus Tachycardia in the 120s with PACs, besides the anterior leads there's diffuse ST depression, the STE in the anterior leads can be explained by the LBBB, axis is good as well. I wish they posted the EtCO2 waveform so we could see but I'm assuming it's non-obstructive. The elevated EtCO2 and RR shows a lack of gas exchange secondary to the APE. If the APE were secondary to an AMI it'd be due to cardiogenic shock, which this patient isn't experiencing...yet.

Probably try a small fluid bolus then definitely CPAP and NTG. A drip would be awesome but we only have SL so that's what I'm stuck with. Probably would start with sprays while I was setting up CPAP then place a transdermal patch. Start with a PEEP of 5cmH2O and work up from there. Dependent on their response to the CPAP RSI may be indicated but I'd like to see how they do on their own with NIPPV before dropping them and placing an ETT. If they're not tolerating the CPAP because of anxiety I'd like to use small serial doses of versed, preferably ativan but we don't carry it, and give the CPAP a chance to work before going to the tube.

 

[teedubbyaw]

I'd treat for CHF too, thats what he's presenting. Id be railing him with nitro, ASA, and I'd consider CPAP if he's still in resp dist. Titrate to 5cm of h2o, go up towards 10, and depending on his lung sounds administer a lovely albuterol neb or two, or continuous nebs until I got the results I wanted.

Probably do a nitro drip, 80mcg/min if the transport time permits.

Why ASA?

 

[Handsome Robb]

ACE Inhibitors would be an option as well if you carry them.

Brain fart on my part

 

[Clare]

I see widespread ST depression and T wave flattening but no signs of a STEMI.

No aspirin or clopidogrel.

GTN 0.8 mg SL and continue as long as it's effective. We do not have CPAP so can only give him either very high flow oxygen (15 lpm) or use a bag mask with PEEP.

 

[TheLocalMedic]

LBBB and hypertrophy are evident, which when combined with med hx, corresponding home meds and presentation all point to CHF.

NTG 0.8 SL q5 min until systolic below 150 mmHg, Lasix 40 mg IV and CPAP. $20 says that by the time you reach the ED he's 100% better and you get questioning looks from nurses about why you brought this apparently healthy guy to the ED in the first place.

 

[teedubbyaw]

Good replies. I completely agree with CHF. It seemed that quite a few people wanted to treat for ACS just to cover themselves. If it's acute onset, then I can maybe see why.

 

[jrm818]

I think everyone is right on. That said, "treating for ACS" in this context may just mean ASA, and I personally wouldn't consider that a wrong choice. ACS and CHF are certainly not mutually exclusive.

Though Robb had a good point that cardiogenic shock would be a really good indicator of a biggie MI might the cause of the heart failure, it also seems possible that some ischemia/a small MI tipped this pt. over the edge into SCAPE (to borrow from Dr. Weingart's term from EmCrit). SCAPE is a vicious cycle of decreased CO/EF, increased afterload, decreased CO, etc. and the initial insult that start's the cycle doesn't have to be massive. In the setting of an already weak and vulnerable heart that's forgotten how to follow starling's law properly, some ischemia/infarction induced hypokinesis or mitral insufficiency can decrease the CO enough to start the whole cycle a-rollin.'

In short, my 2 cents: treat as CHF however you normally do - Nitro, CPAP, lasix if you must, but I'd also think SCAPE is an OK anginal equivalent and that a dose of a pretty benign drugs like ASA isn't a bad move, and certainly not a decision to spend too much energy hemming-and-hawing over.

 

[DrParasite]

ABCs... if you don't have any breathing, the ACS is kinda moot (yes, gross over simplification, I know).

Nitro SL, 1-2 inches of NTG paste, CPAP, maybe even some vasotec if his SBP is still above 120, see if he improves. We haven't been pushing lasix in the field in years......

if he's is feeling better, have him pop an ASA, but more than that, I'm looking at this being a more pressing CHF issue than ACS

 

[Clare]

Lasix 40 mg IV

What's your rationale for using frusemide? We withdrew frusemide in 2009 and I know a lot of other places have as well.

 

[Rialaigh]

I would probably go SL nitro and then a nitro paste, CPAP would really depend on his level of difficulty breathing after placing some O2 on the patient and getting him comfortable in the ambulance. If his breathing improves a lot with O2 and hes in minimal distress I would give him the option of CPAP but would probably not place for now. If nitro is not bringing his pressure down at all (Systolic remains over ~200) I would likely use some labetalol to get his pressure down to ~140-150 systolic and see if that helps him out at all. I would transmit the 12 lead and notify the recieving hospital and probably proceed non emergent unless directed by a physician to do otherwise. If he has a good bit of peripheral edema I have no issue giving lasix 40-80 prehospital as well. Lacking a lot of peripheral edema I'm not touching that.

I'm giving ASA in the patient, because I'm getting my *** absolutely handed to me at the hospital if I havent...Our hospital gives 324 to every "chest pain" protocol patient including CHF, otherwise they are pissy about not hitting their metrics

 

[TransportJockey]

I'd say a nitro drip and possibly cpap if o2 doesn't help by itself. My treatment is similar to Rialaigh's above, just instead of lasix I'd give Bumex and not give the asa. We use drips for patients like this due to ease of titration.

 

[Household6]

Why ASA?

I've asked that question many times of my FTOs, but never had the chance to ask our MD. Our protocols for CHF and PE call for ASA. *shrugs*. I had one medic tell me to go ahead and skip that step and move right to Lasix.

The only answer I got from my FTO was "it's a heart issue, Dr Directors want us to treat it as one". I feel like it's an ongoing debate. But I work with a Critter Flight Sup on Friday, I'll have to ask him.

 

[teedubbyaw]

I've asked that question many times of my FTOs, but never had the chance to ask our MD. Our protocols for CHF and PE call for ASA. *shrugs*. I had one medic tell me to go ahead and skip that step and move right to Lasix.

The only answer I got from my FTO was "it's a heart issue, Dr Directors want us to treat it as one". I feel like it's an ongoing debate. But I work with a Critter Flight Sup on Friday, I'll have to ask him.

Gotcha. A lot of time it's associated with an MI, although probably an old one. I guess I can't see any fault in it.

 

[TheLocalMedic]

What's your rationale for using frusemide? We withdrew frusemide in 2009 and I know a lot of other places have as well.

Furosemide has been removed from many areas for two reasons; 1) it isn't a good "EMS drug", meaning the onset is long enough that we don't see any results with it in the field unless it's a long transport and 2) there are issues with medics confusing pulm edema and rhochi, giving lasix to pneumonia patients who actually could do with some fluid replacement. It's still a good drug though, and I think there is a place for it in EMS. There just needs to be a little more training for some of the *ahem* "less adept" medics who were confusing pneumonia and CHF.

On that note, I should revise my previous statement to say that I am more likely to give it if the pt has a CHF hx or edema rather than an acute episode that may be caused by an MI.