crotchitymedic1986 Posted December 7, 2008 Share Posted December 7, 2008 His allergies suggest he may be a drug-seeker (prescription), as few people are really allergic to Toradol (without having an aspirin allergy), and few are allergic to ibuprophen who arent allergic to NSAIDS. So my guess is that he has a back pain, and is hooked on prescription drugs. He can not admit it, because he can not take those drugs and drive a truck. I would not administer Morphine for his pain. Without knowing if the cough is productive or not, I can not rule out cardiac at this point, but my guess is that this is a respiratory event, not cardiac. As stated previously, I would be prepared to treat it as a cardiac if further symptoms proved that I should, but at this time I would not. Link to comment Share on other sites More sharing options...
Arizonaffcep Posted December 7, 2008 Share Posted December 7, 2008 Treat the patient, not the monitor. I would call it a junctional rhythm, which we can argue all day (it is not sinus, and it is not wide enough to be Vtach in my opinion). Regardless, he is A&Ox3, with a good b/p. There is no reason to treat the rhythm. Which isnt to say you shouldnt BE PREPARED to treat the rhythm when indicated. With the history of pericarditis it is not impractical to believe that any vagal stimulus might change his rhythm. The AHA defines V-Tach as "Ventricular tachycardia is defined as three or more beats of ventricular origin in succession at a rate greater than 100 beats/minute." Link to comment Share on other sites More sharing options...
Arizonaffcep Posted December 7, 2008 Share Posted December 7, 2008 His allergies suggest he may be a drug-seeker (prescription), as few people are really allergic to Toradol (without having an aspirin allergy), and few are allergic to ibuprophen who arent allergic to NSAIDS. So my guess is that he has a back pain, and is hooked on prescription drugs. He can not admit it, because he can not take those drugs and drive a truck. I would not administer Morphine for his pain. Without knowing if the cough is productive or not, I can not rule out cardiac at this point, but my guess is that this is a respiratory event, not cardiac. As stated previously, I would be prepared to treat it as a cardiac if further symptoms proved that I should, but at this time I would not. Why not? This guy-regardless of if he's a drug seeker or not-is having a very real event. Morphine would be an appropriate treatment if time allotted. Link to comment Share on other sites More sharing options...
crotchitymedic1986 Posted December 7, 2008 Share Posted December 7, 2008 morphine is the drug after ntg, if you believe this to be a cardiac event. The rhythm is not vtach. Link to comment Share on other sites More sharing options...
Arizonaffcep Posted December 7, 2008 Share Posted December 7, 2008 Morphine does come after NTG, but he does have CP...if unrelieved by NTG, Morphine is the next appropriate med. Link to comment Share on other sites More sharing options...
crotchitymedic1986 Posted December 7, 2008 Share Posted December 7, 2008 If you practice cookbook medicine it is the next thing to do. Maybe ntg didnt relieve his pain because it was not a cardiac event. Just because a patient has chest pain, does not mean you have to go the automatic path of cardiac treatment. I hope you dont give NTG to patients who have chest pain after striking the steering wheel with their chest during an MVC. With what little info I have so far, there is just as much pointing to a respiratory problem versus a cardiac problem (unless the pericarditis was diagnosed in recent days. I am not saying I wouldnt go the cardiac path yet, but i wouldnt until i have more information: Is the cough productive, if so, what color When did the cough start Does he have other symptoms that point you away from cardiac (one leg with pain instead of all over, fever, other flu symptoms) Is he on any pain meds now that he failed to mention or can not report on his medical record due to DOT rules. What kind of ortho injuries and surgeries has he had Does he have any other PE symptoms Does he have any left sided heart failure symptoms Remember he has all-over general body pain -- rarely cardiac. My best guess is that he is in withdrawal from a presecription narcotic. Link to comment Share on other sites More sharing options...
Arizonaffcep Posted December 7, 2008 Share Posted December 7, 2008 If you practice cookbook medicine it is the next thing to do. Maybe ntg didnt relieve his pain because it was not a cardiac event. Just because a patient has chest pain, does not mean you have to go the automatic path of cardiac treatment. I hope you dont give NTG to patients who have chest pain after striking the steering wheel with their chest during an MVC. With what little info I have so far, there is just as much pointing to a respiratory problem versus a cardiac problem (unless the pericarditis was diagnosed in recent days. I am not saying I wouldnt go the cardiac path yet, but i wouldnt until i have more information: Is the cough productive, if so, what color When did the cough start Does he have other symptoms that point you away from cardiac (one leg with pain instead of all over, fever, other flu symptoms) Is he on any pain meds now that he failed to mention or can not report on his medical record due to DOT rules. What kind of ortho injuries and surgeries has he had Does he have any other PE symptoms Does he have any left sided heart failure symptoms Remember he has all-over general body pain -- rarely cardiac. My best guess is that he is in withdrawal from a presecription narcotic. I would disagree with withdrawal issues. When this is present, people become very jittery, anxious and diaphoretc (Pt was reportidly dry). They also get hypertensive and tachycardic-neither of which was really present (at least not the tachycardia). The reason why I'd go with morphine post NTG if pain is unresponsive...is 2 fold...1-it will help with the CP. Second, I have only a limitted amount of things I can do for this Pt. I don't practice "cook-book medicine." The only drugs that I have that can treat respiratory stuff are: Albuterol, Atrovent, O2, Epi, Lasix, Benedryl, Solu-Medrol. With that in mind, if this is a respiratory issue (I also think there's a good chance it's a PE) how would I use them to deal with it? I've included a link to the ADHS drug list. The only things I don't carry are Succinylcholine and Etomidate, Recemic Epi, Vassopressin. Just keep in mind, as you look at the drugs, that some of the list given are for interfacility only (Aggrastat, etc.). http://www.azdhs.gov/diro/admin_rules/guid...Drug%20Profiles Link to comment Share on other sites More sharing options...
jwraider Posted December 7, 2008 Author Share Posted December 7, 2008 I recovered my PCR so I can answer this stuff better. Is the cough productive, if so, what color - Not productive When did the cough start - He just noticed it Does he have other symptoms that point you away from cardiac (one leg with pain instead of all over, fever, other flu symptoms) No but he did vomit 3x after waking this morning and denies BRB or coffee ground emesis. He had coffee to drink and that came up. The pain has been getting gradually worse nothing relieves it (constant) Is he on any pain meds now that he failed to mention or can not report on his medical record due to DOT rules. I can't go back and ask that but definetely possible. Sorry being an intern I didn't think of this until later but the allergies did trigger this line of thinking. What kind of ortho injuries and surgeries has he had - Sorry I dont know, he actually said ortho injuries, I did not see any scars on his chest Does he have any other PE symptoms - Well his lung sounds are good and he stopped complaining about the SOB after 02, RR 16 Does he have any left sided heart failure symptoms - Clear lung sounds, no edema, BP 140/90, Remember he has all-over general body pain -- rarely cardiac. - That was just my impression, he didn't vocalize that... He only complained of CP and SOB but the way he moved looked like someone who was in general discomfort and had general weakness. He did not want to move. Link to comment Share on other sites More sharing options...
crotchitymedic1986 Posted December 7, 2008 Share Posted December 7, 2008 OK, so what was the final diagnosis ? PE, MI, or other ? Link to comment Share on other sites More sharing options...
jwraider Posted December 7, 2008 Author Share Posted December 7, 2008 When I had to clear and take off the MD was giving a beta blocker which I think means he doesn't know either and he was trying to protect the heart from possible ischmemia? The reason I posted this was to see how many would treat with lido and amio versus not doing that. Link to comment Share on other sites More sharing options...
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