Neck Pain

[Siffaliss]

Yep, bone cracking (high velocity-low amplitude (HVLA) in osteopathic manipulation) has been known to cause dissecting aneurysms, however when the procedure is done correctly the complication rates are extremely low.

Good point. In support of this treatment, I have been seeing the same chiropractor for over 16 years. There are risks with any form of treatment provided by any type of practitioner. I have a good one.

[DartmouthDave]

Hello,

Ok, so the crew arrives at the hospital. They treated with NTG, O2, ASA and gave Morphine 2mg IV.

On arrivial, his VS are as follows:

GCS 15/15

BP 200/100

HR 110 S.Tachy with depressed T-wave in V1,2 & 3

As he is being transfered from the cot to the bed he has an epsiode of emesis and still is c/o a numb arm and 'band-like' sunsternal pressure.

An u/s and CT is done and no AAA is noted. CXR shows claer lungs. A stat Tn-I is elevated at 0.80. Lytes are normal and Hbg is normal.

Also, serial 12-leads show no changes.

He is started on a NTG drip (80 mcg/min) and Labetolol infusion (.5mg/min). Given an other ASA, Plavix 300mg, Lopressor 5mg IV, Enoxaparin 100mg SQ (he is 100kg). His BP is lowered to 130/50 from the infusions. He is still tachy (100-120). More worrysome he is still having chest pain that he describes as 'bad'. No addition pain control has been given.

He is being transfer out for angio and admission to a biggger CCU.

You are the fixed wing flight team. Transport time is a hour. What are your thoughts?

Cheers....

[Just Plain Ruff]

Hello,

Ok, so the crew arrives at the hospital. They treated with NTG, O2, ASA and gave Morphine 2mg IV.

On arrivial, his VS are as follows:

GCS 15/15

BP 200/100

HR 110 S.Tachy with depressed T-wave in V1,2 & 3

As he is being transfered from the cot to the bed he has an epsiode of emesis and still is c/o a numb arm and 'band-like' sunsternal pressure.

An u/s and CT is done and no AAA is noted. CXR shows claer lungs. A stat Tn-I is elevated at 0.80. Lytes are normal and Hbg is normal.

Also, serial 12-leads show no changes.

He is started on a NTG drip (80 mcg/min) and Labetolol infusion (.5mg/min). Given an other ASA, Plavix 300mg, Lopressor 5mg IV, Enoxaparin 100mg SQ (he is 100kg). His BP is lowered to 130/50 from the infusions. He is still tachy (100-120). More worrysome he is still having chest pain that he describes as 'bad'. No addition pain control has been given.

He is being transfer out for angio and admission to a biggger CCU.

You are the fixed wing flight team. Transport time is a hour. What are your thoughts?

Cheers....

Hell, why no additional pain meds? Morphine is definately indicated here.

He's having an MI with the elevated troponin. The chest pain is atypical but still, give the guy some pain relief, it's obvious that the Nitro aint workin for the pain.

[mobey]

Just to back up a step, I would have initiated Beta Blockade whith transport.

We carry Metoprolol, 5mg doses x3.

My DD would be ACS, and he would get standard care for such.

[armymedic571]

Just to back up a step, I would have initiated Beta Blockade whith transport.

We carry Metoprolol, 5mg doses x3.

My DD would be ACS, and he would get standard care for such.

I need to agree. ACS would be my first choice of DD and any treatment of such would be more than appropriate. However, I am not 100% convinced that it really is ACS. I would continue to work through my other DD's as necessary.

Dave,

Upon exam, were there any findings to the neck or back with palpation? IE tenderness, radiation of pain, traumatic finding.

Did the pt take his medications the day of the call? Specially seeing how the patient has a history of HTN, Anxiety and chronic back pain.

Your "Bandlike" finding makes me wonder if this is more MSK and involving a dermatone and some type of nerve impingement, etc.

The great part is that the treatment for ACS will help with the HTN and anxiety if MSK is found to be the underlying cause. My only concern would be what traumatic findings on exam you would find, if any? And whether they would necessitate any spinal precautions?

Hope you follow up soon.

[DartmouthDave]

I need to agree. ACS would be my first choice of DD and any treatment of such would be more than appropriate. However, I am not 100% convinced that it really is ACS. I would continue to work through my other DD's as necessary.

Dave,

Upon exam, were there any findings to the neck or back with palpation? IE tenderness, radiation of pain, traumatic finding.

Did the pt take his medications the day of the call? Specially seeing how the patient has a history of HTN, Anxiety and chronic back pain.

Your "Bandlike" finding makes me wonder if this is more MSK and involving a dermatone and some type of nerve impingement, etc.

The great part is that the treatment for ACS will help with the HTN and anxiety if MSK is found to be the underlying cause. My only concern would be what traumatic findings on exam you would find, if any? And whether they would necessitate any spinal precautions?

Hope you follow up soon.

Hello,

Sorry for the delay. It has been a gong show around work.

The patient has taken all of his medications. Also, his BP is usually well controlled (according to pt).

The patient kept describing the pain as 'sqeezing' and 'band-like' with numbness to his right arm. Good question about the dermatone. I never though about checking this.

The neck had noraml range of motion.

Dave

[DartmouthDave]

Hello,

This patient was transfer out for angio by fixed wing. The Dx was NSTEMI (he had a postive Tn-I).

His pain was an issue. EMS gave one dose of Morphine. He got sick.

We gave one dose of Morphine(with Gravol) in the ED just before the flight team arrived. Emesis++ and he had mild allergic reaction. So, we tried some Fentanyl IV. This worked well and he settled. Less pain. Less anxiety.

He left on NTG at 100mg/min. The crew d/c the Labetolol infusion and gave Fentanyl PRN, Metoprolol IV x3 and called it a day. BP was down in the 140 range and his heart rate settles around 80 or so.

As a side note, the EKG (t wave depression) fit the classic patter of Wellen Syndrome. Anybody with Dubin's EKG textbook will find it in there. Also, I read a article called 'Wellen: The Forgotten Rhythm' as few days before this. So, it was fresh in my head!! =)

Here is a link about it:

http://www.onlinejets.org/text.asp?2009/2/3/206/55347

Cheers

Edited March 7, 2010 by DartmouthDave

[Just Plain Ruff]

Hello,

This patient was transfer out for angio by fixed wing. The Dx was NSTEMI (he had a postive Tn-I).

His pain was an issue. EMS gave one dose of Morphine. He got sick.

We gave one dose of Morphine(with Gravol) in the ED just before the flight team arrived. Emesis++ and he had mild allergic reaction. So, we tried some Fentanyl IV. This worked well and he settled. Less pain. Less anxiety.

He left on NTG at 100mg/min. The crew d/c the Labetolol infusion and gave Fentanyl PRN, Metoprolol IV x3 and called it a day. BP was down in the 140 range and his heart rate settles around 80 or so.

As a side note, the EKG (t wave depression) fit the classic patter of Wellen Syndrome. Anybody with Dubin's EKG textbook will find it in there. Also, I read a article called 'Wellen: The Forgotten Rhythm' as few days before this. So, it was fresh in my head!! =)

Here is a link about it:

http://www.onlinejets.org/text.asp?2009/2/3/206/55347

Cheers

Excellent thread. Plus 5

Wellens sign makes me nervous and if I see it I'm going to be extra vigilent. This is a rhythm that is not taught in school

Good link too.

Glad your guy did ok

[NRPinNEPA]

I'm definitely thinking ACS on this one. If there is ST segment depression in V1, V2, and V3, but no ST elevation on the 12-lead, I would get V7, V8, and V9 into the mix for a 15-lead. Sounds like a posterior MI. Standard ACS treatment... 15lpm O2 NRB, IV access NSS KVO, 12-lead, 15-lead, ASA, nitro, morphine, draw labs if I'm in a system that lets me do so, rapid transport to the closest appropriate facility (preferably one with interventional cardiology).

As for the fixed wing aircraft stuff, I don't have any critical care experience so I'm not even going to touch that one.

[DartmouthDave]

I'm definitely thinking ACS on this one. If there is ST segment depression in V1, V2, and V3, but no ST elevation on the 12-lead, I would get V7, V8, and V9 into the mix for a 15-lead. Sounds like a posterior MI. Standard ACS treatment... 15lpm O2 NRB, IV access NSS KVO, 12-lead, 15-lead, ASA, nitro, morphine, draw labs if I'm in a system that lets me do so, rapid transport to the closest appropriate facility (preferably one with interventional cardiology).

As for the fixed wing aircraft stuff, I don't have any critical care experience so I'm not even going to touch that one.

Hello,

Nice call on the 15-lead. Alas, I don't think one was done. An oversight. However, luck was on our side. The fellow did ok for the flight (...not me..) and an angio showed a 95% occlusion of the LAD. Plus some other areas of concern. I called. I was wondering.

There are a couple of things I liked about this case. One, it made me remember Wellen Syndrome again. Also, the fact that this was an atypically presentation. Normally, from my experience and from what I have read Wellen Syndrome is pain less and a forerunner of more serious troubles to come.

What I think is this fellow had these depression (v1,v2,v3) for quite awhile before he came in. I am sure if he hung around in the ED his ST would have started to rise at some point.

Cheers