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


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#21 burngirl

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Posted 09 September 2008 - 07:03 AM

Do we know where his pain is? I'm kinda leaning toward a viral process, too...at that age, any exposure to viral agents? This is a good one!!
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#22 Gila

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Posted 09 September 2008 - 08:08 AM

Thanks Medic Nurse, with the XII lead, my theory may be incorrect.

Heart tones is a good idea in addition to all of the other questions. We have a 22 year old male with sudden onset complaints of chest pain? At this point I am still thinking about substance abuse. These changes, while impressive and atypical, appear in the inferior leads with possible reciprocal changes in the V leads. I still advocate a right sided and posterior ECG.

Things I have considered:

Dissection or aneurism-Relavant questions asked.

Peircarditis- usually note diffuse changes with different ECG characteristics.

Tamponade- Tachycardia is an early sign. This guy does not appear to have a significantly elevated heart rate. Perhaps something causing increased parasympathetic tone, conduction defect, or other anomaly?

Pnemothorax - Lung sounds, JVD, low voltage QRS complexes.

Congential or structural defect- Possible. Any history of CHD, transplant, valve replacement, or other cardiac problems.

Electrolyte abnormalities- Calcium and potassium if we have i-STAT resources avaliable.

Do we have doppler resources on hand?
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Christopher Bare
"Non fui, fui, non sum, non curo "

#23 Sbastian

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Posted 09 September 2008 - 11:56 AM

mtnmedic8, I have to admit to a little "googleing" on this one too. I would also agree with you, atrial ischemia due to increased intrathoracic pressure.

Jim M, Miu R, Siu C. CASE REPORTS: PR-Segment Elevation in Inferior Leads: An Atypical Electrocardiographic Sign of Atrial Infarction, J of Invasive Cardiology 2004; 16 (4): 219 - 221

"PR-segment represents the period of atrial repolarization. Significant PR-segment depression in inferior leads with reciprocal PR-segment elevation in lead I is used as one of the diagnostic criteria for atrial ischemia. However, the sensitivity of these diagnostic criteria is low, in the range of 5.46.9% due to low voltage generated by the thin atrial wall. PR-segment elevation in inferior leads was previously reported, by Strizik and Forman, in left tension pneumothorax". (Strizik B and Forman R. New ECG changes associated with a tension pneumothorax. Chest 1999;115:17421744.)

This could be a pneumothorax, or some other cause of "pressure" against the atria, as Speed has suggested. If it is a pneumothorax, than a needle decompression should "fix" the problem temporarily. If it is not there is not much else that we can do in the field , but recognize the need for supportive measures and rapid transport to a tertiary cardiac center. So now what?

To needle or not to needle, that is the question.
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Audiatur et altera pars!

#24 rfdsdoc

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Posted 09 September 2008 - 12:00 PM

Hey folks

Even 22yo men have STEMIs. The ECG looks like acute inferior STEMI with possible right sided extension. INdeed there are low voltages and it would make you consider pericardial tamponade. In this age group you should also consider acute aortic dissection as mentioned in recent posts. Prinzmetal's angina is another differential diagnosis in this age group.

What you do in the prehospital setting depends upon your local protocols and availability of acute cardiac hospital care. Ideally he should be assessed urgently at an acute interventional cardiac unit within 90 minutes of chest pain onset.

If its a long transport to a cardiac centre you might have to seriously consider prehospital thrombolysis. The tamponade issue would worry me though and portable USS would help me in this situation to decide if it was a real issue or not before deciding on lysis.

Anyway try to get him painfree first. Oxygen, IV access, SL nitrate ( but be careful and prepared to give a fluid bolus if BP drops a lot post nitrate).

Sorry to hear of the recent HEMS tragedies in your country. My thoughts are with you all.
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Minh Le Cong
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#25 Gila

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Posted 09 September 2008 - 12:29 PM

Not sure I want to give NTG. Blood pressure is 100/60. Not sure of his base line; however, the history and XII lead screams very bad things to me. I am not sure I really want to give any preload reducing agent. Especially if we are concerned about RVI. Liberal doses of fentanyl may be helpful however.

I also did some googling and the PR elevation 12 leads that I have been able to locate did not resemble what we are seeing here.

May also want to consider a PE; however, his saturations are not low. Any cyanosis?
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Christopher Bare
"Non fui, fui, non sum, non curo "

#26 Mike Flight

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Posted 09 September 2008 - 02:57 PM

Not sure I want to give NTG. Blood pressure is 100/60. Not sure of his base line; however, the history and XII lead screams very bad things to me. I am not sure I really want to give any preload reducing agent. Especially if we are concerned about RVI. Liberal doses of fentanyl may be helpful however.

I also did some googling and the PR elevation 12 leads that I have been able to locate did not resemble what we are seeing here.

May also want to consider a PE; however, his saturations are not low. Any cyanosis?


Nitro can be titrated and lowering pain helps lower oxygen consumption. 100/60 is not that bad...no fear.
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Mike "Flight"
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#27 Speed

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Posted 09 September 2008 - 03:10 PM

PR-segment elevation in inferior leads was previously reported, by Strizik and Forman, in left tension pneumothorax". (Strizik B and Forman R. New ECG changes associated with a tension pneumothorax. Chest 1999;115:17421744.)



Did they say why? What was the reason it caused..., well what looks like ischemia (any associated patho specific to this PR elevation pattern?)? Was this just with air or effusion, how rare? What you're saying seems very relevant, but why the elevation? The more I ponder about it, the trapped air seems likely. I'm thinking that if it were the pericardium that was dampening the voltage it would be more diffuse across the leads. This appears to be more specific to the far lateral side, and the R waves are almost non-existent. I'd think that air is more of an insulator than exudate, blood, serous fluid or whatever solid/liquid substance that's in there (no/low conduction). Maybe a big tumor with exudate? Febrile? Lung sounds, hello? Anyway, the hypotensive theory for causing the elevation makes sense too, but it's happening in a really weird location for that. We would usually see neuro stuff happening as well, and I'd bet that cardiac wise we'd see more ventricular changes or ectopy first with the way the coronary artery's filling pressures are characterized. This kids pressure isn't bad, he's overall not that bad. I'd be willing to let him move around a bit and see if he gets any orthopnea or deteriorates (or gets some more crazy ECG changes) in different positions. I agree don't drop his BP because his heart doesn't have enough room to fill so his output is already compromised. He really looks surgical to me. I'd have a plan to crack his chest if he gets worse. Needle? I don't know yet, we really have no idea what this is, but the research you've found there obviously fits this picture especially that someone has seen PR elevation in this pattern before, that's key. The one thing we're working with here is crushing chest pain, and to be that bad from just a pneumo that's not causing dyspnea? Well, I guess that atria is ischemic and he's having pain from that? Seems more appropriate for CP at "10", if he's not just a baby about pain? So then again maybe ASA, MS, and nitro would be appropriate if everything else checks out OK cause it looks and smells like ischemia. But it's not just ischemia alone? So frustrating it would make you want to go to the nearest facility just for a CXR and US. This is one that I'd rather be picking up from a facility versus a scene. :angry: :angry: :angry:
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Mike Williams CCEMT-P/FP-C

#28 Speed

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Posted 09 September 2008 - 04:19 PM

OK, I'm sorry for being so annoying but this is bugging the hell out of me. I've been sitting here staring at a 3-d model of the heart and I think I've got it. I've been focused on the RCA and whatever branch of that which feeds the atria and wondering why he doesn't have some atrial arrhythmia with that (SA node, PR elevation in AVR or V4R). Forgetting that the circumflex feeds the atria as well it makes more sense since it's on the left side. So here we go. If he had a tumor near or sitting on top of it (I've never heard of a pericardial tumor or nodule?), maybe on the medial-posteriorly top left lobe? That would occlude it and cause CP, not from the inside but form the outside? The only thing is I've never heard of this happening in any other space occupying disorder of the chest before? Kind of like pressing your finger into the artery? This would also cause an accumulation of fluid in the pleura that would cause a low voltage QRS pattern. It could also cause an air leak as well but that would be more acute and cause SOB & desat. The only thing that doesn't go with this theory is that his symptoms sound sudden and woke him up. This would have evolved over time?
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Mike Williams CCEMT-P/FP-C

#29 Mike MacKinnon

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Posted 09 September 2008 - 06:10 PM

General Impression

Healthy looking in great shape.

Primary survey - ABCD.

All appear normal. Bilateral BR

Detailed PE. Esp - Neuro? Lungs? Abdomen?

No neuro issues
Lungs sound fine
Abd n/t not distended

History - SAMPLE and PQRST the Chest Pain?

No real hx. Pt states he "woke up from the pain"

Account for last 24-48 hour activity

Was out doing buisness all day and with his friends. Nothing special same as every day.

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)

Denies all types of meds.

PO intake - food and water, any exercise or strain?

Nope was asleep. Last meal was 8 pm its now 2 am.

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?


Thats a negative Houston

Alcohol and Tobacco History

Smokes and drinks regularly.

Also, is this patient "well known" to the local responders?

Nope first call on him.
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Mike MacKinnon MSN CRNA
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It's what we know for sure that just ain't so" - Mark Twain

#30 Mike MacKinnon

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Posted 09 September 2008 - 06:11 PM

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


All negative
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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

#31 Mike MacKinnon

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Posted 09 September 2008 - 06:12 PM

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...


Appears to be a nice home (his parents) in a nice suburban area, nothing appears shady..
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Mike MacKinnon MSN CRNA
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"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

#32 Mike MacKinnon

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Posted 09 September 2008 - 06:15 PM

No Istat ;)

This will be 100% clinical decision and NOT an easy one to make. This was an actual case BTW with some additions by me


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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Mike MacKinnon MSN CRNA
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"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

#33 Mike MacKinnon

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Posted 09 September 2008 - 06:17 PM

Heart tones is a good idea in addition to all of the other questions.

All normal

Do we have doppler resources on hand?


Yes. heart tones normal. All pulses sound strong.
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Mike MacKinnon MSN CRNA
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"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

#34 Mike MacKinnon

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Posted 09 September 2008 - 06:19 PM

Someone please dissect that 12 lead for me.

Where you see what and what it is. Also, explain how you know.
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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

#35 Gila

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Posted 09 September 2008 - 06:29 PM

History of IV narcotic use? Need to consider endocarditis. Possible abscess?
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Christopher Bare
"Non fui, fui, non sum, non curo "

#36 BamaFlightRN

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Posted 09 September 2008 - 08:14 PM

Someone please dissect that 12 lead for me.

Where you see what and what it is. Also, explain how you know.



Ill take a stab at it...12 lead obviously has PR elevation in the inferior leads, poor Rwave progression, probable ST elevation in AVL, nearly isoelectric lateral leads. Can't pick out any obvious pathalogic qwaves.

Given the information we have so far, I think we have to treat this as acute MI. Im curious to know if he has a protein C deficiency or any other coagulopathy. ?Arterial thrombosis? Keep it coming, this one has peaked my interest.
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#37 lems1169

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Posted 09 September 2008 - 08:25 PM

anything to do to the fact that he's AA?
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Serge LeMay

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#38 Mike MacKinnon

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Posted 09 September 2008 - 08:25 PM

You mention PR elevation


Explain what this means, where it involves on the heart and what it commonly (or uncommonly) indicates. Give differentials for it :)
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Mike MacKinnon MSN CRNA
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"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

#39 jwalshfan

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Posted 09 September 2008 - 08:31 PM

Nothing on recent dental work or tatoos?

I'm thinking Viral Endocarditis vs. Cocaine Associated Chest Pain.

Routine day......out with his buddies....... doing business.........hmmmmmmm........

22 y.o. with a Hx substance abuse may just be in the Peruvian Marching Powder "business".



Warren, RN/LP
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#40 KingAirNLA

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Posted 09 September 2008 - 11:11 PM

Very interesting case!

Isolated PR elevation, in this case, would indicate Atrial ischemia. The PR segment would involve the conduction from the sinus node to the AV junction. PR depression in aVL and V1-V3 would be reciprocal changes.

Given that there also appears to be ST elevation in the inferior leads this looks like and inferior MI high in the RCA involving atrial branches.

Viral origin would be unlikely since the pt went to bed symptom free.

Diff Dx: embolic event vs. Prinzmetal's angina

Tx: Treat as AMI starting with generous fluid boluses, ASA, Plavix, Lovenox, NTG IV, and Fentanyl. Fluid should assist with loss of atrial kick. If pressure allows, IV Dilt.

Does anyone have a thrombolytic protocol that mentions PR segment elevation?

This Pt needs someone that makes a lot more money than me with a much longer catheter!!
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