Jump to content

SCENARIO: Chest pain


DFIB

Recommended Posts

Allergies? Specifically to aspirin or nitro. Any cialis or Viagra in the last72 hours? Any nausea? Rate the pain on 10 scale.

Let's get him on the stretcher and on some oxygen. I would also be moving toward the ambulance and get a line in him.

No allergies to nitro or ASA.

Patient denies viagra or any other ED medications.

His SPO2 96% -97% on room air. How much O2 do you want to give him?

What specifics on the line, gage, rate, gtt, solution?

Yep. Marfan's syndrome. He's tall, got pectus excavatum, hypertension, a history of a "connector" disease, sharp chest pain radiating to his back.

No aspirin, definitely no nitro, no oxygen. Let's get a couple of large bore IV's NS TKO and take him in nice and easy non-emergency traffic. Let's also consider an anti-hypertensive (labetolol or metoprolol I'm thinking) and get him in. Let's also get another blood pressure and compare it to the opposing arm.

He's got a bum aorta.

"Lincoln, I think you may have a tear in one of the large arteries of your body. We're going to get you in and checked out by the docs. Try to relax and not worry, we're going to take very good care of you."

BINGO! Good call on Marfan's His vitals are unchanged from the initial ones.

BP in left arm is 80/40 and his arm in numb and mottled.

Now he seems to be nodding off and his LOC is not as good as it was.

And he says his right arm is numb, and you notice that his right pupil is now larger than his left.

His speech is slurred now also. He can't say "NO if's and's or but's" without slurring.

Good call on the beta-blockers.

How much Metoprolol, or Lebatalol?

What should our target systolic pressure in the main circulation be?

Would we change our transport decision? Where would you take him?

Link to comment
Share on other sites

I wondered when you said his name was Lincoln and he was tall and skinny...

  • Like 2
Link to comment
Share on other sites

I wondered when you said his name was Lincoln and he was tall and skinny...

You noticed!

Edited by DFIB
Link to comment
Share on other sites

But didn't that Lincoln die of a big hole in the head and not Marfans?

Indeed! In fact although many suspect that Marfan's was the etiology of Honest Abe's body habitus it was never proven, in fact geneticist believe it to be unlikely. That said he remains the "poster child" for the Marfan's general impression because of his body shape.

Link to comment
Share on other sites

How about one of you brainiacs explaining Marfans and the cause of the signs/symptoms?

And if you Googled that Biebs I'll hunt you down and kick your little Bieber nuts up next to your tonsils...

Good scenario DFIB!

Link to comment
Share on other sites

Damn.... really wish I would have come into this earlier.

His LOC is decreasing?? Better recheck the vitals.

If his BP is still up (which I doubt), I want to spray 1 nitro while starting a nitro drip. *That ought to start some discussion*

If his BP is falling, start the fluids, but it is too late really.......

Maybe just some fentanyl so his last moments can be less painful?

  • Like 1
Link to comment
Share on other sites

How about one of you brainiacs explaining Marfans and the cause of the signs/symptoms?

The increased rate of myocardial infarction and sudden cardiac death for patients with a connective tissue disorder has got something to do with the dysfunctional connective tissue I think; there was a recent case here of a 12yom who died from cardiac arrest 2° to EDS

  • Like 1
Link to comment
Share on other sites

If his BP is still up (which I doubt), I want to spray 1 nitro while starting a nitro drip. *That ought to start some discussion*

Agreed about the discussion. Why would this treatment be a bad idea?

Link to comment
Share on other sites

Because nitro can cause reflex hypertension and tachycardia. Beta blocker first.

How about one of you brainiacs explaining Marfans and the cause of the signs/symptoms?

And if you Googled that Biebs I'll hunt you down and kick your little Bieber nuts up next to your tonsils...

Good scenario DFIB!

Haha, nah, I actually knew about Marfan's myself. It's a genetic disease of the connective tissue that can cause spine and especially heart problems--especially valvular and aortic disease.

Look for tall patients with long, slender limbs and fingers, pectus excavatum (or carinatum), and a family history of Marfan's syndrome. It's a dominant trait, so one of their parents should have had it as well if I'm not mistaken.

  • Like 1
Link to comment
Share on other sites

×
×
  • Create New...