Longer term goals.

[aryan51]

Please bear with my explaining out of everything as I'm still learning.

Upon making patient contact I'd like a rundown on the pain. Onset, provocation, quality, radiation, severity, and time.

I'd like to do a 12 lead as soon as possible, and continue them every hour of the flight to show some trending, unless symptoms worsen where I would get another immediately. I'd also like to assess why her BP is so low. I can't think why a fluid challenge might not be in order to prep for some nitro. I'd like some lung sounds and to give her 250ml NS.

If I can get her pressure up to an acceptable level I'd start off with just 1 spray of SL nitro (0.4mg) to see if we can get some relief. If it works, I'll continue to about 3 doses, and if she still has some pain I'd titrate some MS starting with 2mg and going up from there. Due to how long the transport time is, I would most likely need to be giving multiple doses of MS PRN.

I don't want to hog the whole scenario so that's all from me...

[chbare]

Onset was about 2 hours ago.

Physical activity exacerbates the pain.

Radiation into the left upper arm.

Pain is 10/10.

She describes the pain as a very "heavy pressure."

Lung sounds are clear throughout.

You initiate a 250 ml bolus of NS.

Answer a few other questions asked earlier:

Patient appears pale, warm, and slightly diaphoretic.

Heart tones: S1 S2 & irregular.

No history of any trauma.

Family History: mother died of breast cancer, father died of a MI at age 55.

Not sure on advanced directives: I assumed an otherwise healthy 41 year old female would be a full code. (never know I guess)

Your initial XII lead:

She is a little anxious, so there is artifact.

Take care,

chbare.

[scubanurse]

Looks like some ST-elevation? hard to tell from the small pic though so I can't count it out to see how elevated... Try some dopamine too to help the pressure, NTG once the pressure is up and some fluids running, MS PRN, and high flow O2. Agree with the others on the 12 lead q1 hr and continuous 3 lead monitoring. Treat acute symptoms as needed.

as far as transport... having never done inter facility this is a new area for me to think about, but like others said- enough meds/fluids for the transport, pt would be getting a cath before we leave if possible, food, water, a good book, blankets to keep her warm and comfortable. A working communications set for orders etc... telemetry if available so doc can check strips simultaneously and advise on treatment plan.

Long Term thinking:

warmth/comfort of crew

nutrition

resources/supplies

bladder control

thinking ahead for possible problems in the air such as:

pt coding, loosing an airway (appropriate room/resources for intubation)

[aryan51]

Awesome, we've got some ST elevation in at least three leads including some slight elevation in others, along with an outwardly symptomatic patient, so we'll definitely go down our MI treatment algorithm.

Any chance when we stop to fuel in Kandahar there is a closer hospital, possibly with a cath lab? Just throwing that out there.

What's our pressure after the bolus?

[mobey]

Do we carry TNKase? (not that I am ready to give it)

[BushyFromOz]

GTN for an inferiorm AMI??? :?

[scubanurse]

What is GTN???

[mobey]

ASSuming you mean NTG....

Yes

(OK ready to be schooled :wink: )

[scubanurse]

NTG in an inferior MI will completely bottom out their pressure if I remember correctly... I have very very very little experience reading 12 leads and so I wouldn't recognize an inferior MI if it smacked me in the face.... I can't wait to learn more about them this spring.

[chbare]

Ok, look at the XII lead and identify leads with changes. Then, with mad Google skills, find out what vessel/s (assuming "normal" coronary artery anatomy) is/are involved and what area of the heart is effected. This may help you with clinical decision making. Yes, GTN is simply another name for NTG. I am the only American surrounded by Africans and Australians, so I have had to learn a little about the Queens English. GTN means Glyceryl trinitrate.

Why are some hesitant to give GTN? What other problems may be associated with what we have already identified? Think about anatomy and physiology and structures possibly involved. In addition, look at the XII lead, are there any other disturbances of conduction. I have additional XII leads and a great rhythm strip; however, they will come after we initiate therapy.

Let's say we do have the ability to give fibrinolytic therapy. This adds a new dimension to our clinical decision making. Let us discuss the possibility of giving it. Are we sure of the diagnosis at this point? Risks versus benefit? Indications and contraindications? What do you all think?

After 250 Ml of NS the pressure increases to 90 systolic and you note clear lung sounds. You decide to give another 250 ML NS. Into the second bolus, the patient begins to report decreased pain. The current B/P is 102/66. Why do you think the pain improved?

There is in fact a Role III Canadian ISAF hospital at Kandahar; however, you cannot use them, sorry.

It is great that we have a few new faces to the scenarios. By all means, continue to discuss.

Take care,

chbare.