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MVA with chest pain


Posted · Report post

Hello everyone been practicing some scenarios while I sit at an airport awaiting a flight back overseas to work.... its been a long time since I have been in a classroom.

Here it goes, also all the medics here are at least EMT-I, with a few military medics thrown in...

You arrive to the scene of an Humvee accident. A female Command Sergeant Major has lost control of her vehicle and driven into a ravine at a slow rate of speed. She is complaining of chest pain, and skin is cool, moist, and pale. She is having difficulty breathing. Your first assessment, you find a seat belt imprint on her chest.

Her vital signs are B/P 178-90, HR 104, R 22, and pulse oximetry is 95%.

She has numbness and tingling down her left arm

Age: 55 years old

Prior history: she tells you she hurt her back a week ago

How do you treat this patient?

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Posted · Report post

hmm, im going with spinal proticals, o2, pulse ox, IV TKO, GCS and vitals.. a lot of times though overseas i dont have nitro.

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Posted (edited) · Report post

Just wondering, why does it matter that she's a Command Sergeant Major? Does that modify your assessment or treatment in any way?

I think she has pericarditis.

Edited by Arctickat
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Posted · Report post

no it does not matter at all, its just the way it was written. guess because its miltiary

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Posted · Report post

Why are you participating in your own scenario? Which came first the chest pain or the MVA?

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Posted · Report post

Kat is always looking for the elusive pericarditis case. :-}

How big of a ravine? 10 feet or 100 feet? steering wheel bent or deformed?windshield intact? LOC?

Rib cage intact. lung sounds equal?quick set of vitals.

What does her presentation show as to history. recent problems beside back pain, co-morbitities, Medications prescribed?

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Posted (edited) · Report post

Welcome to EMT city EPmedic. Good on you for starting a scenario with your first post!

So tell us about our soldier patient,

When did her chest pain begin?

Has her chest pain been evaluated before?

What was the nature of her back injury and the MOI that caused it?

At what level was her back injury?

Is the Command Sargent Major an overachieving hard charger that may have ignored that might have neglected to report a injury?

Was her back injury evaluated?

Did she have tingling in her arm before the accident?

Did she have difficulty breathing before the accident?

Why did she loose control of her vehicle? Was the loss of control of the vehicle provoked by an existing medical condition?

Edited by DFIB
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Posted · Report post

Chest pain began just before the accident causing her to loose control of vehicle, and drive off road down ravine 50 feet, hitting small bumbs and holes on the way down. until coming to rest. steering wheel is not best, and seat belt is still on, when seat belt marks on chest.

no prior history of cardiac problems.

She started noticing the tingling and breathing problems after she stopped.

Prior back injury, seems to be from lifting something to heavy she says, and she did not go to medics to have it checked out, only taking OTC meds for the pain.

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Posted · Report post

Ask the the typical chest pain questions since this is more likely to be something medical since it started before the trauma. Can she tell us a little more about the back pain? What was she doing when it started? Is she still having it now? What did it feel like? Is it worse after this accident? What is her general overall appearance? How about pulses, lung souns and heart sounds?

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Posted · Report post

Treat her as a trauma PT with an eye to her possible cardiac symptoms. I personally wouldn't give NTG or ASA due to the possible chest trauma, but would consider Morphine if her LOC is good. I would also focus the assessment on possible chest trauma, LS, physical exam, and 12 lead. Then work out cardiac as much as I could.

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Posted · Report post

I'd get a very good history from the patient regarding previous cardiac history and chest pain questioning. While I'm doing that do a cervical spine immobilisation, 3-lead ECG to see underlying rhythm and get an IV in. Morphine for the pain as mentioned above. Once in the back of the ambulance do a 12-lead to see if there is anything cardiac. My first thought would be cardiac chest pain but I'd be looking for any signs of traumatic chest injury and ruling those out before treating for cardiac chest pain. I'd try and rule out:

- referring muscular chest pain from previous back injury

- pneumothorax

- fractured ribs and/or sternum

- flail chest

Then if my provisional diagnosis was cardiac chest pain I'd do aspirin and GTN. Some might say that if she does have traumatic injuries they could include internal bleeding which aspirin is not going to help, but I'd still go with it unless there was a strong index of suspicion there was an internal bleed. Also if she is compensating, the GTN could push her into decompensating shock. But again I'd have to have a strong suspicion there was a bleed.

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Dependant on the extent of impact as previously questioned (how deep of ravine, etc.) you have the initial cardiac symptoms to think about, the traumatic event and possible injuries sustained from this, and with the seat belt marks, this would indicate enough impact to cause any structural chest injury. Another concern would be cardiac contusion.

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Posted (edited) · Report post

Then if my provisional diagnosis was cardiac chest pain I'd do aspirin and GTN. Some might say that if she does have traumatic injuries they could include internal bleeding which aspirin is not going to help, but I'd still go with it unless there was a strong index of suspicion there was an internal bleed. Also if she is compensating, the GTN could push her into decompensating shock. But again I'd have to have a strong suspicion there was a bleed.

I have to assume that the 12 lead ruled out a Right Side MI. Nitro administration is a real risk if you are not sure.

And I am curious, why would you risk hypo-perfusion with your patient?

I think I would explore PTSD and emotional stress as a possible chest pain etiology as well.

Edited by DFIB
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I have to assume that the 12 lead ruled out a Right Side MI. Nitro administration is a real risk if you are not sure.

And I am curious, why would you risk hypo-perfusion with your patient?

I think I would explore PTSD and emotional stress as a possible chest pain etiology as well.

Absolutely. No GTN if the 12-lead did show that.

I don't think the risk of hypo-perfusion is that great unless (as stated above) there would be something that strongly indicates internal bleeding. Based on the vital signs we've been given I'm personally happy to provide cardiac chest pain treatment until anything cardiac is ruled out.

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