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chappy

ASA and NTG or no?

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Okay, I am humbly submitting myself for review - not humiliation or ridicule, but some good, constructive criticism.

I've had my Paramedic card in my wallet for two years, but I work for a convo service. Our service has just started transporting ALS and well, here I am. I am proud of the fact that I am a fairly good student, but a good student is not necessarily a good practitioner. I have no experience and I am working with a Basic EMT. So, can we do a case review? I may ask for more of there :)

In short, I feel like I missed something. So, here goes.

Patient history: 58 yom, CVA with slight right side weakness and speech deficit, HTN, NIDDM. NO CARDIAC HISTORY.

We are dispatched to a nursing home for a "routine transport" of a patient who has fallen and has a head laceration.

On arrival, we found an elderly man seated in a wheelchair, with a patent airway, spontaneous respirations, slightly pale skin color, with a bulky bandage on his head. Facility staff stated the patient had fallen while attempting to transfer himself from the wheelchair to the commode. Stall also states the patient had been discharged from the ER earlier today for hypoxia, as indicated by their pulse oximetry meter and that the patient had expierenced numerous syncopal episodes over the las four days. Regarding his LOC, the staff said he seemed more disoriented than normal. Despite his injuries, patient was very independent and insisted on transferring himself from his wheelchair to the stretcher.
A cervical collar was placed. The patient resisted being placed on a long backboard and was not forced.
Vital signs were obtained: 138/68, 70 and irregular, 18 c/e. Pupils were slightly irregular and slightly sluggish to respond. Patient's hands were cold and appeared blanched. Though he had good radial pulses, we were unable to obtain SpO2.
Based on the history of falls and likely history of syncope, a Lead II ECG was obtained. Initially, Lead II indicated a sinus rhythm with tri-gemini PVCs. The patient did not appear hypoxic, but he was placed on high-flow oxygen via mask. PVCs seemed to resolve. Patient's ECG converted to A-Fib at a rate of 50-100.
A twelve-lead ECG was obtained. The initial twelve-lead indicated 2-3 mm elevation in V1 and V2 with reciprocal changes in V5, V6. After about ten minutes, a second twelve-lead was obtained. The second twelve lead indicated continued elevation with the return of the PVCs.
IV access was obtained in the LAC and a saline lock was placed.
Due to the patient's head laceration due to a fall and possible closed head injury, Nitroglycerin and ASA were withheld.
Like I said, I feel like I missed something. Did I? What would you do differently?
ECGs are attached,
Chappy

mw.pdf

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What do you think the 12 lead was telling you? elevation in leads v1 and v2 with recriprocal changes in V5 and V6. What does your education and understanding tell you?

Do you think that maybe the sycnopal episodes might have been cardiac in nature?

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Were you moving when any of those EKGs/rhythm strips were obtained? If you have a head injury, it would be best to hold the aspirin. I'm not sure where ntg has a role here.

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Unfortunately your tracings are of too poor a quality to have any real diagnostic value. A safe expeditious ride to the hospital where a CT, lab work, and better quality tracing can be obtained is in order. I wouldn't be administering ASA or nitro to this patient. IV, O2 if needed, monitor, and transport. If things change with regard to the patient's rhythm along the way treat as per ACLS guidelines or local protocol (whichever you're held too).

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What do you think the 12 lead was telling you? elevation in leads v1 and v2 with recriprocal changes in V5 and V6. What does your education and understanding tell you?

Do you think that maybe the sycnopal episodes might have been cardiac in nature?

Since there is no previous cardiac history, I have to believe there is an infarct. Typically, I would followup with NTG and ASA.

Were you moving when any of those EKGs/rhythm strips were obtained? If you have a head injury, it would be best to hold the aspirin. I'm not sure where ntg has a role here.

Yes, we were moving.

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I agree, the tracings are too hard to interpret because of movement. I would have obtained a baseline 12-lead on scene as they are notoriously inaccurate in a bouncing ambulance. Just curious, why did you place a c-collar, was there midline tenderness?

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I'm not convinced that any of this is afib. I can see things that could easily be argued are P waves. Other than the PVCs, it's really hard to interpret this. I wouldn't fault them for the collar. Using CCS or NEXUS, he seems to require a work up.

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Chappy, remember your STEMI foolers, BLEPPP. One is present in this tracing and DR Lifepak picked it up too.

***Personal experience alert***

I had a Stemi Code who was revived after 1 shock. He became A&O within 5-10 minutes post arrest. When he arrested he fell to the ground from standing and had a small raspberry on his forhead. I withheld ASA for fear of head bleed. I was told by the receiving physican "Treat what you know. You know he has a STEMI, the head will require a scan and is only a maybe. Treat what you know. 324mg ASA!"

BAYAMedic

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This is a damned if you do, damned if you don't situation. I've had several people with head injuries and STEMIs and the cardiologists want a head CT and nothing that will affect bleeding (ASA, heparin, brilinta, motrin, toradol) until the CT is negative.

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