To treat or not to treat?

[AnthonyM83]

Don't have a comment on what may be going on, but I appreciate the well-written post. Paints a good picture of a real call versus just throwing VS and numbers at us.

[EMT Foose]

Great description. Not that I know much at all, but I agree with holding off on ASA. There's no telling what her warfarin levels are like and it's impossible to know exactly the cause of the event.

The things swirling around in my head-

She had a pretty good amount of O2 administration before the 12 lead was done, and you did mention some slight ST abnormality. Possibly the O2 altered the 12 lead..? Did you ever see a follow up ekg?

With exception to ASA and keeping her home meds in mind, she got the full MONA treatment for MI when you gave nitro.. Or maybe it was TIA and the nitro vasodilated enough for a clot to head on down the highway..?

It's hard to rule out psych on this one too, I think. Schizophrenia and/or Bipolar in the geriatric brain (especially with benzos/narcs) can be pretty unpredictable. I assume the daughter handles the meds.. Was she compliant with all meds?

Good food for thought. Any chance of a follow up?

[Doczilla]

You are describing global weakness rather than focal neurological deficit, and this would tend to argue against a typical ischemic stroke. I don't think you should call a "stroke alert" on this patient and bypass a hospital for a stroke center based on these findings. What you seem to have is chest pain, weakness, and altered mental status.

I agree with ERDoc with regards to a possible dissection, as well as pneumonia or UTI. Other stuff on my list:

hemorrhagic pericardial effusion (like from a dissection)

pericarditis, with or without effusion (small QRS can suggest effusion)

myocarditis

any infectious process, really

intraabdominal disaster (perforated viscus)

acute heart failure

pneumothorax (does she have COPD?)

Always beware the "chest pain AND" syndrome, like CP and headache, CP and back pain, CP and stroke-like symptoms, CP and weakness of the legs, CP and hematuria. This should get you thinking along lines that are not strictly cardiac.

'zilla

[jwraider]

Thanks everyone I learned alot from this experience and your advice. My best guess is cardiac with some other disease process (infection) like Doczilla is saying. Maybe even due to her thyroid disease I saw a patient last week who had had a cardiac tamponade as a result of thyroid disease (although thats supposed to be rare).

[firedoc5]

I'll just throw in a couple of cents here. If I remember rigt, either hosp. had short ETA's. I'd just continue O2 tx. and take vital often. Make comfy. No nitro or ASA for chest pain in case of TIA/CVA. And no MS in case of OD. There's too many, "what if's" and all to really treat her with EMS. Needs hosp. and all their fun gadgets.

[mobey]

I am with the majority with this one:

Try a Narcan if no effect that rules out Morphine OD. It is highly unlikely she had enough Lorazepam to OD on but I would do the math on the perscription anyway, in absence of missing pills and waking up with Narcan I would not be scared to give a little MS. (Remember pupils were normal)

As far as the chest pain..... I too would have a strong suspicitian of aneurism, however the bilateral arm pain leads me down the Cardiac trail.... but I would still withold the ASA. I would definatly have given Nitro, as you did, even if it is a aneurism (dissecting or not) decreasing the BP and taking some pressure off the system can only do good.

I am not sold on the CVA, TIA with this patient, as was mentioned this sounds like global weakness and decreased LOC. I am not saying there is no chance of a CVA, but it seem less likely than the other 2 options.

Was she on home O2.....