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Case #43 Woke Up With Severe Cp... Uh Oh...


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#1 Mike MacKinnon

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Posted 07 September 2008 - 07:22 PM

Sorry for the lateness of this case, got a bit busy. Here it is tho, submitted from an East Coast Flight Team.


The Story:

You have been kicked out at 2 am for a 22 y/o 70kg AA Male with severe CP, woke up from sleep. Once you arrive on scene you are greeted by the volunteer FD, they are glad your here. This is a suburb just outside wilmington NC, nice area.

The patient appears in severe distress c/o pain 10/10 with no SOB and diaphoretic. He is moving all over the stretcher.

VITALS:

HR 88 BP 100/60 RR: 21 Sat: 98

He denies Drugs.

Now what?
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Mike MacKinnon MSN CRNA
WWW.NURSE-ANESTHESIA.ORG

"What gets us into trouble is not what we don't know
It's what we know for sure that just ain't so" - Mark Twain

#2 Speed

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Posted 07 September 2008 - 09:26 PM

Send some ECG 51
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Mike Williams CCEMT-P/FP-C

#3 mtnmedic8

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Posted 07 September 2008 - 10:30 PM

Start with the basics. IV, O2 Monitor and 12 lead. I don't think I would start treating for MI just yet. Start talking, we need some history here. Probably not trauma related but you never know. Make our differential diagnosis when we get some more info. Knowing these cases it probably won't be as simple as an MI or PE.
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CCEMT-P Ski Patroller Extrordinaire

#4 medicerik

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Posted 07 September 2008 - 11:15 PM

100 percent agree with the other posts. Get oxygen going. Get the patient on the monitor. Establish IV access. Recycle the vital signs. Get a history. Work on a 12 lead possibly with right sided and posterior views as well. It will be much easier to develop a treatment plan once I've got a 12 lead and history from the patient.

Erik
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Erik Glassman, BS, CCEMT-P, FP-C, EMT-T

#5 shortnurse75

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Posted 08 September 2008 - 01:46 AM

I agree -- O2, monitor, 12 lead, Iv access. Definately need at little more history. (Sorry for being new to this, but I'm going to give it a stab anyway. I'm thinking that his BP is a little borderline too. So I'm wondering why- normal for him, or something going on.)
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#6 MedicNurse

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Posted 08 September 2008 - 02:59 AM

I'll play. Sure beats my focus for the past few days.
Patient care. Yep, that is why we do what we do.

Immediate Treatment
O2 via NRB
Monitor with 12 lead
Vascular Access - NS

?????'s
General Impression
Primary survey - ABCD.
Detailed PE. Esp - Neuro? Lungs? Abdomen?
History - SAMPLE and PQRST the Chest Pain?
Account for last 24-48 hour activity
All meds taken - legal (Rx and OTC) and illicit in past few years. (History for abuse and prior treatment - including narcotic tolerance - could narrow DD)
PO intake - food and water, any exercise or strain?
Any problems with "elimination"
Any fever? Night sweats? Rash? Headache? Visual problems? General health - any illness in past few months? Last time seen by MD and reason?
Alcohol and Tobacco History, Also - History of Blood Transfusions or clotting disorders
Any family present for relevant history?
Also, is this patient "well known" to the local responders?

Considerations
Keep patient alive (I find that this is a good practice - regardless :lol:)
Optimize oxygenation
Maintain perfusion
Treat pain as indicated/allowable
Prep for definitive care/transport

Differential at this point
"Squirmy" pain (IMHO) in this population:
Sickle Cell Crisis
Transection/Impending rupture of great vessels
Kidney Stones/Obstruction
Cardiac cause (including viral disease process)

I'm waiting on answers.

Stay SAFE out there everyone!
:rolleyes:
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#7 buffettrn

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Posted 08 September 2008 - 08:15 AM

If his lungs are clear and no other indications of failure hit him up with a NSS bolus for his BP.
Any family history maybe some sibling having an MI at age 25 (you know Mike's cases).
I would think about some ativan for his "agitation" moving all over the stretcher. If this is cardiac all this motion is just eating up oxygen and increasing comsumption and demand. If not will make it safer in the air. But again knowing Mike's cases are we going to be RSIing shortly.
What is our expected transport time?
Any trauma history or reason to suspect PE?
Abdominal exam?

Medicnurse I like your consideration "Keep patient alive"
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Jeff Fein
"We are right, they are wrong, END OF STORY"

#8 Gila

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Posted 08 September 2008 - 09:46 AM

Pulses in all extremities?
Differences in pulse quality and B/P's from right to left arm?
Hoarse voice?
JVD?

Agree with additional assessment considerations as well. Not sure I would go for a NRB at this point, appears very anxious and this treatment may exacerbate his anxiety.
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Christopher Bare
"Non fui, fui, non sum, non curo "

#9 LWTRF14

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Posted 08 September 2008 - 10:43 AM

Can we get a general impression of what the house and the room he is in looks like? Anything laying around that makes a red light come on....Danger Will Robinson Danger - Get through the SAMPLE and concentrate on events maybe he was doing before he went to bed. Also, if he's clean....Is he athletic, etc....Can we get a more in depth description of the pain and any radiation with it...
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Earl F Bakke III, NR-EMT-P, CC-EMT-P, PNCCT

#10 Speed

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Posted 08 September 2008 - 04:17 PM

Pulses in all extremities?
Differences in pulse quality and B/P's from right to left arm?
Hoarse voice?
JVD?

Agree with additional assessment considerations as well. Not sure I would go for a NRB at this point, appears very anxious and this treatment may exacerbate his anxiety.



And heart tones, an ascending will usually tamponade a bit. That's when you'll see the dropping pressures/pulsus paradoxus. I'm feeling ya' though...
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Mike Williams CCEMT-P/FP-C

#11 Mike MacKinnon

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Posted 08 September 2008 - 04:36 PM

And here is the 12 lead:


Posted Image
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Mike MacKinnon MSN CRNA
WWW.NURSE-ANESTHESIA.ORG

"What gets us into trouble is not what we don't know
It's what we know for sure that just ain't so" - Mark Twain

#12 Speed

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Posted 08 September 2008 - 05:31 PM

Geeze Mike, why? Am I seeing PR elevation? Where do you get this stuff? It looks so strange because there is really bad R wave progression, almost reversed? If it were pericarditis I'd expect to see changes in some more/different leads. These are the inferior leads, and with reciprocal changes? I'd ponder at atrial infarct, but again... different leads, different pattern... maybe? This isn't classic anything that I'm seeing. Crap!
If it were a sheared ascending aorta that got the "off-shoots" of the coronary arteries maybe, but I don't think that's it either.. so much. Lung sounds, heart tones, JVD, try to find something structural that's taking up space in the chest before we start going down the AMI pathway. I know that sometimes you can feel a bulge or strong pulsation above the sternum in a dissection, any thing here? His sats are good and he's not SOB? Anyway, ABC and everything that everybody's doing so far. I'd hold off on anything that would complicate a possible surgical chest. He's too young for P-pulmonale, damn Mike?
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Mike Williams CCEMT-P/FP-C

#13 mtnmedic8

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Posted 08 September 2008 - 06:09 PM

Like Speed, is that PR elevation? Like anything found in the inferior leads I would do a 15 lead just to be thorough. Atrial MI? Looks like some elveation in V1 also. Inferior PR elevation could also be a left tension pneumo. (yeah, I had to look that up) How are the lung sounds? But, patient reports no dif. breathing? Hmmmmm...
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CCEMT-P Ski Patroller Extrordinaire

#14 mjcfrn

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Posted 08 September 2008 - 06:18 PM

WOW! That EKG is UG-LY!! (using the scientific HEMS nomenclature, of course)

agree w/most everyone else.

Athletic? Been weight-lifting intensely recently?
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#15 Speed

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Posted 08 September 2008 - 07:38 PM

Inferior PR elevation could also be a left tension pneumo.


How and/or why? I can see the displacement and pressure causing the small R waves and "bad/reversed" progression, but where's the elevation coming from? If they were pulmonale waves I wouldn't think they'd be limited to just the precordial leads. And these don't even look close to the pronounced wave you'd expect. This is segment elevation, just like ischemia? Vasospasm? Strange... Also, I would imagine that there would have to be a pretty good amount of air trapped in there to cause so much change, and he doesn't even look symptomatic of a pneumo? We haven't heard lung sounds yet, so what do you say Mike?
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Mike Williams CCEMT-P/FP-C

#16 Sbastian

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Posted 08 September 2008 - 10:28 PM

Posterior wall MI?
Get thee to a heart center!
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Audiatur et altera pars!

#17 Speed

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Posted 09 September 2008 - 12:44 AM

Not on this ECG. I can tell you with confidence that there is something sitting in between this kid's AV/bundle and the V4-6 electrodes, something is there. Either fluid or air. If it were air he'd be breathing hard and tachycardic, getting shocky (sweating alone?). If it were fluid this wouldn't be all of the sudden and there would probably be a history (CA, neoplasm, etc..) The PR elevation is what throws it all off, to me? I'm sure there's somebody out there laughing at me, but this is a good case. Anyway, this is sitting in the pleura or pericardium. There may be two separate issues going on. If he's making little clots somewhere they could be breaking off and floating around slowly. Hitting the lung first causing the slow development of an effusion, and then separately landing one somewhere in the atria (but no SOB? Maybe the only initial effect would be a reduced pre-load?). Most people's SA node is fed off of the RCA, but you usually see a whole bunch of arrhythmias and rate problems with that? I'm waiting for the heart tones & lung sounds, until then I'm gonna force myself to not think about it.
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Mike Williams CCEMT-P/FP-C

#18 MedicNurse

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Posted 09 September 2008 - 01:25 AM

Hey there buffettrn - glad you like the "keep patient alive" consideration - I'll bet that you do the same thing. And we all know that death is very still - and that causes us to move fast. Seems simple. No doubt - keeping a patient alive, still a best practice ;)

Well, I agree with mjcfrn - that is one UG-LY EKG.

And Gila (Chris) - you rock! (from a war zone - even! Stay safe - a prayer is always coming your way!!)

Agree with Speed Mike that II, III, and AVF are elevated. You know your stuff - I covet that in a partner and you might even provide entertainment (friendly debate!). :lol:

Now - as I restrain myself from treating the monitor and work toward treating the patient - I will agree with Sbastian in the "Get thee to a heart center!" However, if I can get thee to a heart center in an academic/tertiary care setting - the patient will most likely get the most benefit.

Off the top of my head - I would think that the etiology of CP with these changes in a patient of this age would be narrow - congenital cardiac disease, drug use, dumb luck or (my working favorite) some type of vaso-occlusive disease/crisis.

I still have to think that this patient may have sickle cell disease and has some history that may have provoked a crisis. Or I could just be wrong - and then I will have to come up with something else. Some days you eat the bear - other days the bear eats you. Grrrrr ... this patient is sick so ...

I have to think that this patients history will guide a working diagnosis and the remaining treatment.

Regardless, as I cannot "fix" this - I will focus on rapid transport & treating to optimize patient oxygenation/perfusion and decrease pain and MvO2. Further considerations from detailed history/physical exam.


Hey Mike - need answers ...

All the history and assessment questions noted ADD class of airway for impending RSI - to decrease cardiac workload. I would have to consider RSI in a patient with this presentation to decrease cardiac workload/oxygen consumption. I'll bet that trying to treat the pain/anxiety without RSI will put the patient at risk for severe hypotension and since he needs as much perfusion as we can maintain - well, I think RSI may be the best option. Of course, before any RSI/meds I need that history and good PE. Got Jet Fuel?
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#19 mtnmedic8

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Posted 09 September 2008 - 03:15 AM

How and/or why? I can see the displacement and pressure causing the small R waves and "bad/reversed" progression, but where's the elevation coming from?



Well, I didn't want to get tunnel vision with atrial MI so I googled PR interval elevation. It came up with a few studies on ECG changes caused by the building interthorasic pressure. Strizk and Forman's study has been referenced a lot.

This is from an article out of the American Journal of Critical Care.
"Strizik and Forman31 suggested that the ECG changes may be related to the hypotensive state induced by the tension pneumothorax, with resulting decreased coronary artery blood flow and myocardial ischemia that resolves without infarction."

I've never seen it personally and don't usually have trauma/tension pneumo patients on running 12 leads, but it something to keep in mind for sure.
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#20 jwalshfan

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Posted 09 September 2008 - 04:44 AM

I'd like an ISTAT with gas & lytes and any history of recent dental work or tattoos? In addition to the items requested above.

Not enough info yet. Could be a number of things, but what is running through my mind is viral endocarditis.


Warren, RN/LP
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