usmc_chris

Hello,

Posting the follow up now.

He was transported to the Level III trauma / PCI center. My system places great emphasis on customer service / destination requests, the transport time difference between the two facilities was minimal, and the facility he was transported to should have been able to handle the patient's condition. The final ECG printed as he was taken into the ER is attached.

Upon arrival at the hospital RSI is performed, pressors are finally successfully hung, and the patient is sent to CT. Cerebral hemorrhage and cervical spinal compromise are ruled out with CT.

After about 90 minutes in the ER he is finally sent to the cath lab. They identified a 100% proximal LAD occlusion but were unable to open the occlusion prior to the patient going into cardiac arrest. Unfortunately he was not able to be resuscitated.

I posted this case for a couple reasons:

1) Neither myself or any of my coworkers had ever seen ST elevation as severe as this patient had in the anterior leads, and I thought it would be interesting to share it.

2) I learned some things here, and wanted to continue to learn from this case. First, I may be beating myself up, but I feel I was a little too complacent on this case. We respond to a lot of "done fell out" at church on Sunday and what I was presented with was absolutely NOT what I was expecting. I wish I had brought more "stuff" to the patient's side, and I wish I had been more proactive with obtaining additional help in the back. Our first responders are normally good about riding in with us, but I honestly had no idea where they went once we got into the ambulance. In addition, given that it was "off" / weekend hours, the Level I may have been more promptly equipped than the facility he was transported to. Obviously, hindsight is 20/20, but the day we stop learning is the day we need to get off the truck.

Gag reflex intact. You are able to assist ventilations; his SpO2 returns to normal. You now arrive at the hospital.

You were unable to get the Levophed flowing prior to the seizure (crappy roads).

Midazolam is administered (he received 2.5mg IVP)

Heart rate is in the 80's again, pulses still present however breathing is now ineffective post-midazolam.

You're about 2 minutes out.

Two short strips are attached.

At this point the patient is unable to provide any additional history. The patient and his family indicated that his only known medical history was hypertension. Anything is possible, but nothing else is suspected in his history.

You're about 4 minutes out. His heart rate returns to about 86bpm and he starts seizing again.

Exactly. They won't send him to the cath lab until they have ruled out intracranial hemorrhage.

Meanwhile, as you're mixing up your drip the patients pulse rate drops to about 40. It still appears to be sinus in nature, however QRS complexes are beginning to widen. He still has a weak but palpable carotid pulse corresponding to the monitor. His Mentation also declines, he becomes nonverbal and withdraws to painful stimuli.

You normally carry Dopamine however due to shortages you have Levophed today. I suppose Epinephrine could theoretically be an option with online consult but it's not in your protocols.

Only history is HTN, no previous cardiac issues.

You place pads and tell your partner to head to the hospital. You glance out the door to take some help and the big red truck has disappeared - you're on your own.

500cc bolus is given with no improvement. Pt is placed on supplemental O2 and noninvasive ETCO2 monitoring. Lung sounds clear. You are having difficulty auscultating heart tones over the road noise. Mentation remails about the same. Mom is left behind and the patient isn't arguing about destination.

Latest vital signs:

BP 64/40

P 90 sinus w/ PVC's

R 36 / irregular

ETCO2 30 mmHg

SpO2 94% on 4L via NC

Cath lab is activated as is trauma team.

You are 10-12 minutes out, is there anything else we'd like to do for this patient?

The dizziness began during the service, towards the end, no more than 20 minutes before the collapse, however became much worse when attempting to walk outside, precipitating his collapse. He has otherwise been healthy with no recent illness. He is normally lucid with clear speech, however currently is speaking very softly and slowly, but is aware he is in the ambulance and that he was at church. He also knows his name, date of birth, and that is Sunday. He is very sleepy and but responsive to verbal stimuli, and will wake when you call his name. This was approximate mental status during the interim between the collapse and the seizure. Your response time from the initial 911 call for a "fall" was approximately 7 minutes. The seizure began almost immediately as you arrived on scene, prior to making patient contact. This was his first seizure, and he has no known seizure disorder, and has never had a seizure before in his life.

The last thing he remembers is walking out of church, does not remember falling and does not remember your arrival or being moved to the ambulance. The dizziness is mostly described as feeling as if he is going to pass out again.

Approximate depth of respiration is shallow but equal, and they are irregular however no noted episodes of apnea.

Further physical exam is essentially unremarkable, no noted obvious external manifestations of head trauma or to the rest of the body. Breath sounds are clear/equal bilaterally, pt is moving air with no noted wheezing/rales/rhonchi. Pt is soft-spoken but not apparently slurring his speech, no noted unilateral deficits and no noted facial drooping.

Mom is very insistent that he go to the Level III, they "don't like" that other hospital.

You acquire the 12-lead. It is attached.

Pt is stripped to the waist, placed in a c-collar, and full spinal precautions are taken. During this you manage to place one 16ga IV, saline lock, in the pt's right AC. Pt is subsequently moved to the ambulance.

Pt is now conscious but remains lethargic, is responsive to verbal stimuli but seems to be oriented. Pt c/o dizziness but denies other complaints including chest discomfort or shortness of breath.

GCS - 14 (3/5/6)

BP - 72/54

P - 100

R - 32 / irregular and shallow

SpO2 - 90% RA

You place the patient on the cardiac monitor. Rhythm shows a regular sinus rhythm with a rate of 100-110, however multiform PVC's are also noted at a rate of 10-15 per minute. Pt still has a palpable radial pulse, corresponding to the rhythm displayed on the monitor however it is extremely weak. Pt remains profoundly diaphoretic.

And now to bring the thread back on topic. Sorry it took me so long to respond; I was in the field for drill weekend (and I thought the stupid thing would email me if there were any replies)

You grab your equipment and approach the patient on the side walk. As you approach, you notice that the fire department (BLS first response) has arrived but are standing around the patient with confused looks on their faces, looking to you for instruction, and nothing has yet been done. The patient's mother is at his side, generally in the way, yelling at you to do something and that she's a nurse. You are able to obtain a more accurate history from her, she states that as they left the service the patient stated he was dizzy then suddenly collapsed. She states that his only known medical history is hypertension, he takes Lisinopril 10mg once a day, and he has no known allergies. He fell backwards from standing and struck his head on the sidewalk.

As you are able to clear enough of the crowd to see the patient, you discover that he is actively seizing, and is profoundly diaphoretic. The seizure ends (duration approximately 90 seconds) as you kneel at his side. Rapid trauma assessment is unremarkable for gross deformity or bleeding however the patient is severely post-ictal and unable to verbalize any complaints or responses to palpation / physical exam at this time. Pupils are approximately 6mm and sluggish but reactive. Peripheral pulses are rapid, extremely weak, and thready. You instruct the first responders to obtain vital signs, however they are unable to auscultate a blood pressure. BSL is 116 mg/dl.

You (I) am an idiot and left the monitor in truck, about 15 feet away. What is your next course of action?

Hello,

I haven't posted in a while, but I have an interesting case to run through the scenarios forums. So here goes.

You work for a busy urban service. You are working on a Medic/EMT truck. At approximately 12:30pm you are dispatched with the fire department BLS first response for a report of a 40 y/o male c/o dizziness who has fallen at church. While enroute the call is re-coded as a syncope/unconscious instead of a fall, but no further information is provided by dispatch.

Your scenario begins as you arrive on scene, you arrive within approximately 6 minutes of the initial dispatch. The weather is fair and sunny, around 60 degrees Fahrenheit. You see a crowd, including your fire department first responders, gathered around an approximately 40 y/o black male who is lying supine on the sidewalk outside of church.

Your two closest facilities are a Level I trauma center, with the full range of services, and a Level III trauma center which has PCI capabilities and off-site neurosurgical capabilities at a sister hospital about 5-6 miles further down the road. Both facilities are an approximately 10-15 minute transport from your current location, depending on traffic conditions.

What would you like to know / do?

2 things I'd really like to know before giving ANY pharmaceutical or electrical treatment, unless the pt is decompensating rapidly - BG and what he 12-lead looks like. Your partner can hook up the 12-lead while you go for the line. Is there any history of renal failure or diabetes? When you factor in the possibility of electrolyte imbalances, especially hyperkalemia, I've seen sinus tachycardia that looked an awful lot like VT in one lead only - the P wave unidentifiable in the downslope of the T wave in an isolated lead.

Well Ruff, this is going to stir up some controversy, but by the court's "disparate impact" argument, it absolutely is racist. If it weren't racist, why would only 23% of the employees be white?

I don't agree with that one bit, but that is EXACTLY the argument the Chicago FD people are using, just the "color composition" is reversed.

Yes, understand, I forgot that that the OP specified it was a nurse in the ER. I agree, in some circumstances, it may have been warranted, but I wasn't there either

To the OP: do you know any more about the scenario? Any more details about the pt and her overall condition? Thanks!

I don't believe I've ever shocked a fully "alert" patient. Most patients who need immediate cardioversion are going to show it - they probably won't be sitting up, chatting about the weather etc. - rather, they'll have unstable vitals, be short of breath diaphoretic, etc.

While it is true that this lady probably wouldn't have stayed up and cheerful for very long while in VT, I would imagine there would be time to premedicate. In an adult, average weight pt I will usually use 5mg Morphine and 2.5mg Versed IVP, assuming no allergies or other contraindications. The really neat thing about the Versed is it has some short-term amnesic properties, so if you give it and cardiovert within a couple of minutes, the pt will probably forget what you did to them, except for wonder why their chest hurts a little (and that's where the Morphine helps!).

Based on the condition you describe the pt, I see no valid reason to not to medicate the pt prior to cardioversion. Shocking a conscious patient [without meds on board], unless they REALLY, REALLY need it RIGHT NOW, is just plain mean, IMHO. Of course, I wasn't there, so probably shouldn't pass judgement without knowing more about the situation.

You want to feel good about survival, join the Marines and be a combat medic.

Not to be off-topic, but you CAN'T join the Marines and be a combat medic. We don't have them. Which is why, after 6 years in the Marine Corps Reserve, I'm working on re-enlisting in the Navy Reserve, in order to become a Corpsman, in order to transfer back to work with the Marines as a combat medic. Figures I should do the same thing in the military I do in the civilian world.

As to the topic, I too, believe that ACLS could be more in-depth. The first time I took it, I was an EMT-B. I scored 100% on the exam. Of course, I had no freakin' clue as to what the WHY was for any of the treatments, which is something, I think, that is much more important than the WHAT.

I missed this question, sorry. It was on the left side of his neck.

I don't know about everybody else, but I've NEVER had a problem shaving anybody, for defibrillation or for 12-Lead acquisition, with the 15 cent, single bladed disposable razor that my company provides us in our monitors. Sure, you need to knock the hair out every few strokes (swiping it backwards across a towel, or the pt's shirt, or the carpet, or whatever, works well for this), but they're quite effective, in my opinion.

Sorry it's been a while, I'm in Bridgeport, CA at the Marine Corps Mountain Warfare Training Center for my 2 week Annual Training for the Reserves, with limited internet access.

It wasn't actually his ear. No recent scuba diving. It turned out that he dissected his left carotid artery. When we picked him up it was a small hole, but it could have easily turned into a much bigger hole and bigger problem. Overall a very interesting case.

Fair enough about the possibility of a mechanism, however he more than meets our "selective immobilization protocol." Of course, there's people I don't board that technically don't meet the "letter" of the protocol, but after all they're guidelines, right? At least that's what the preface to ours says. We make the best clinical decision we can based on risk/benefit we can for each individual patient.

I completely agree with you on hating long boards though.

While I didn't see his lab values, based on the final diagnosis, I think it is safe to assume that his electrolytes were relatively normal.

The "pop" is the key to the final diagnosis (well, various tests were used to confirm it, but in hindsight, from a pre-hospital perspective, it's all we have). It is in fact what started everything. And it isn't his inner ear.

Any other ideas?

Let put a C-collar on him, no board as the cost benefit isn't there. I know the ER is likely to laugh/bitch at me for having a patient with a collar and no board, but I want to remind him not to move his neck. It sounds like he's damaged his C-spine in some way and though the benefit of the collar is questionable at best it will help him remember to stay still.

I did think CNS decompensation from the initial mention of the 'pop' but the vitals don't seem to speak to that. No tachycardia, B/P holding well. I went back to see if these values were maybe being controlled chemically but didn't see anything that would lend itself to that. Perhaps there was a previously undiagnosed osteopathy, or a damaged ligament or tendon caused swelling that is intruding into spaces reserved for the spinal column/nerves. Not sure.

Though I'm a pretty big advocate of relieving the discomfort of patients I'm not going to give an anti-emetic at this time. Not because we're so close to the ER, but because I don't really have any idea what's going on with this guy and I don't want to steal symptoms from the ER. The severity, quality, and possibly other descriptions of the nausea that might not mean anything to me but might mean something to the physician. Now, should the nausea increase and I believe that vomiting may be eminent, compromising C-spine management, then I may be forced to treat it.

If we were, say, an hour out I would call the Doc and consult. But at this point I won't likely even get him on the phone before I'll be going through the ER doors.

Otherwise I have no idea what's going on. I'm going to transport with the current interventions in place unless something changes that should push me into a certain direction.

Awesome, intelligently presented scenario man....thanks for taking the time to do it. I wish I had better ideas...

Dwayne

Edited to correct a spelling error only.

Well, I'll give a few hints. I'll tell everybody what it's not. Its not a cardiac event, and it's not an anxiety attack. It is not a c-spine problem, in the actual call I didn't even think of immobilizing for a few reasons. One, I'm a big fan of NOT backboarding people, because of some of the literature I've been reading about worse outcomes following immobilization. Also, there was a lack of any kind of mechanism. Finally, we didn't get the story about the "pop" in his neck until well on the way to the hospital.

We also did not treat the nausea as vomiting wasn't imminent. Also, we only carry Promethazine, and I didn't really want to sedate him anymore than he already was from being generally lethargic. We did call ahead to let them know what was going on, in that we had absolutely no freaking clue what was going on but he had that "pre-code-looking" look to him.

So, vitals remain "stable" through the transport. You bypass the triage line based on your prearrival report, going directly to a room. At this point, he is starting to be a little weaker on the left side, however no facial droop, no slurred speech. The ED doc meets you at the room and is initially thinking of an atypical CVA presentation. He allows you to follow him and the pt to CT, as as soon as a 3rd IV is placed and labs/cultures drawn, off he goes, he's only in the room for about 5 minutes.

Head CT w/o contrast is unremarkable, head and neck CT w/ contrast shows nothing per the ED doc and the radiologist brought in to assess the CT.

So, what else might it be? Any ideas?

And don't feel bad Dwayne, my partner and I had no clue whatsoever what was going on either. I only know because we followed up about 2 hours later with the hospital. Not telling yet though!

Hello,

V.O.M.I.T. acroynym?

I have never heard of it.

Cheers

Vitals

Oxygen

Monitor

I.V.

Transport

Let's see if I can get it right this time. I had my whole reply typed and my browser went back two pages instead of deleting something I was trying to edit before posting!

How do his pupils look/react? Is it a possible overdose? Did he eat or drink anything out of the normal (maybe early allergic reaction)?

Pupils are equal, round, and reactive to light and accommodation. Pt's last PO intake was a ham sandwich, a small bag of potato chips, and a can of diet soda, pretty much his normal shift. Pt works 2nd shift (3pm-11pm) and was just heading to work. Pt denies eating or drinking anything out of normal for him for the past day or so, denies any insect bites/stings or other possible allergens. You note no swelling, hives, or itching.

We know immediately that the presentation doesn't match the vitals. This guys could be in trouble, so lets look at other possible causes. Of course he could just be playing with some dope he's hiding from his wife.

I'm going to lift him from the car, no walking for now. Take the automated cuff from the fireman and cut off the friggin' hose off and get a new set of vitals on my own. We are going to need a better history than we've gotten so far.

Is he compliant on his meds? Does he have the bottles on him? Lets verify that the remaining pills match the dosage/prescription date. I want an IV on him right away, I'll ask my partner to do that. Pupils?

You state a rhythm strip shows no cardiomyopathy, yet a rhythm strip wouldn't show such things. Did you mean a 12 lead? If not, then he needs one right away. What is his pulse quality?

I guarantee you that there is something that this guy isn't telling us regarding this situation...we need to figure out what it is.

Dwayne

Dwayne, the pt is lifted from the car on the stretcher and placed immediately into the ambulance. There are no law enforcement present that he would feel the need to lie to (of course, I know they lie to us too), and he adamantly denies any recent illicit drug or alcohol use.

A new set of vitals is obtained. Manual BP is 128/86, HR is 77 in a NSR. RR 20, easy and unlabored. SpO2 is 98% on room air. He continues to tell you the same story of events: he just left home, was driving along, turned to look in the rearview mirror and felt that very mild "pop," no more severe than an insect bite. Shortly thereafter symptoms began, which are still the same. Upon assessing the neck you feel no point tenderness along the spine, normal range of motion, no evidence of a bite or sting, he does c/o 2/10 pain to the left posterior of the neck, but you can see nothing wrong upon visual inspection.

Pt states he is compliant with his meds, does not have them with him. He does state he hasn't been to his primary doctor in over a year. Pupils are normal. Your partner placed a 16ga IV in his left AC with a liter bag of 0.9% NS running at KVO.

As for the rhythm strip, I stated II thought) that those things that you can diagnose from a rhythm strip weren't there. But when you do the 12-Lead, you see no T wave inversions, no ST-segment elevation/depression in any lead. QRSd is 80mS, PRI is 150mS, QTc is 420mS, and R-axis is 10 degrees. Poor R wave progression noted in V1-V4 but nothing acute seen anywhere. Because this doesn't line up with what you're seeing, as he really looks like he's not doing so well, you go ahead and do a right-sided 12-lead as well, but you see nothing in V3R or V4R. Pulse quality is normal strength with a regular rhythm corresponding with the cardiac monitor.

As far as you can tell the patient is being open and honest with you in all regards.

It might be a panic attack

If he is that severely nauseous, put an IV in and give him some ondansetron

He has no history of anxiety or panic attacks and denies any recent stressors that might trigger one, however, it doesn't rule it out. He rates his nausea as a 4/10, doesn't feel like he is going to vomit. You have IV access, would you like to push the ondansetron? You have an approximate 5 minute transport time.

Imma go old school here but, here it goes.

Airway? is it patent?

Breathing?- RR, Lung sounds, depth and quality?

Circulation- Pulse, strength quality and regularity, major bleeds perfusion?

Place the patient on a nonrebreather 15 lpm

Reassess vitals

do full workup, pupils, skin tenting, grips, can i get a temperature in farinheit please? im not good in celsius, EKG followed by 12 lead, BGL, stroke test

also get a good look over of the vehicles, such as pill bottles, wallet with a file of life, medical id braclelets, any information that can lead you to any kind of conclusion.

Rapid transport with two IVs running on TKO for now just in case

Airway is patent.

RR 20, breath sounds are clear/equal in all fields. Symmetrical chest movement, normal depth, easy and unlabored.

Pulse is of normal quality with a regular rate. No abnormalities. Pt denies any recent trauma, GI bleeding, etc. No evidence of a hole in your patient's skin is seen anywhere. No bruising seen, abdomen is soft, non-tender, and non-distended.

Pt is now on high-flow O2 via NRB.

3rd set of vitals - BP 123/84, HR 80, RR 20, SpO2 100% on high-flow. GCS continues to be a 15, although he is slightly lethargic. Skin turgor normal, pupils as above. Grips are equal, pronator drift test negative, no facial drooping,

speech is regular and not slurred. 37.0 is normal temp in Celsius, so corresponding Fahrenheit temp is around 97.6. EKG's as above, BGL is 130 mg/dl.

Vehicle is in good condition, late model foreign sedan. No apparent damage, pt denies a collision, stated that when this began he pulled over into the parking lot you are currently in. No further medical information can be found.

You begin transport and place a second, 18ga IV, saline lock, in his right forearm.

Any thoughts? Anything else you'd like to know or do?