21 yo ACS: is it ACS or did we miss something?

[vs-eh?]

With a presentation like this in the ER, I wouldn't even work it up. Clinically, my suspicion is almost none.

Exactly...

There is a good argument to be made that you should treat as you think the average ER/MD will treat (not saying that the doctors on this forum are at all average, nor is saying that any EMT/paramedic are equal education)...The "horses not zebra's" argument applies as well...

You don't have to be Gregory House, MD on every call...That should be remembered....

EDIT - I think I took this out of context in the PE realm considering Doc's IHSS query...That being said, I doubt again (as a person walking in off the street or even as a continuing line of treatment) that the average/most ER MD would treat this (actively) as the paramedic did as ACS.

[medic5587]

Thanks for acknowledging my post and the utmost respect and appreciation for your impute.

[1EMT-P]

I agree with your treatment..... Did you check her blood sugar? If so what was it? Also is there any history of Asthma, Diabetes, Hiatal Hernia, HTN or GERD?

[paramedicmike]

Just to keep things in perspective, the youngest patient I've treated with an active MI was 11 years old. That's right, eleven! There were no known congenital problems with this kid prior to his MI. The last time I did any follow up on him, no congenital problems had been identified post MI. What's more, his presentation was similar to the original post. He was running through the yard playing tag with friends when he collapsed. (This kid, however, coded on the way to the ER and was successfully resuscitated.)

Don't let age fool you or throw you off. Use your assessment to narrow down the problem. But don't exclude something from your differentials simply because you think the patient may be too young.

Just food for thought.

-be safe

[Ridryder 911]

Good discussion, yes chances are it is nothing.. but there is always that possibility. If one has a has even a small suspicion one should listen to that small voice.

I agree, treat accordingly and symptomatically and definitely try to convince others not to wear "blinders" and get tunnel vision. I too have worked adolescent AMI's .. and after seeing one, fortunately they tend to stick in your mind and thoughts forever.

p.s. good H & P .. thanks

R/r 911

[fiznat]

In a young person with exertional chest pain and presyncope I would be concerned about IHSS.

Interesting find! It is odd though that the problem is a physical hypertrophy and yet it is documented that only about 25% of cases present with electrocardiographic changes. Still, it seems like common presentations of this condition - while similar in nature - often dont tend to resolve on their own like they did in this patient. ...Not to mention also that this is extremely rare, effecting only .05-.2% of the population. Cool catch though.

Dustyn, I agree with most both that this patient should be treated as ACS, and also that the patient is probably not suffering from ACS. Only other thing I can think to ask is if the pain - when the patient was having it - was reproducible or able to be made worse somehow. Even then though, it probably wouldnt change your approach to the treatment of this patient. I think MONA minus the M and N was perfect for this kind of "probably not" status post chest pain.

Strong work though man, nice assessment.

[paramaximus]

[/font:3691c885b1] As has been mentioned, once you've worked an adolescent who's had an MI, it tends to open up a nightmaric cornucopia of possibilities.

Given the presenting set of signs, symptoms and circumstances, I would concur with your treatment.

I give you a big smile and a cheesy MENTOS thumbs up!

paramaximus

[whit72]

You said she was African American, how about acute chest syndrome caused by an undiagnosed sickle cell disease.

Probably a reach but I thought I would throw it out there.

Although the symptoms seem to relate.

Just a thought.

[ERDoc]

Interesting find! It is odd though that the problem is a physical hypertrophy and yet it is documented that only about 25% of cases present with electrocardiographic changes. Still, it seems like common presentations of this condition - while similar in nature - often dont tend to resolve on their own like they did in this patient. ...Not to mention also that this is extremely rare, effecting only .05-.2% of the population. Cool catch though.

It's not really that uncommon. A lot of these young athletes that you hear about who die suddenly while playing usually end up with this dx. The symptoms from this do end on their own once the need for a higher cardiac output is reduced, except for the ones that go into vfib. In the given scenario, with the information that we have, an ER workup would consist of cxr, ekg, Bhcg. You might be able to justify a CBC, but there is nothing else really that needs to be done including a fingerstick. The rest of the workup is an outpt workup which should include an echo.

[emsbrian]

Im 21 and i have constant chest pain, mine is from a new addition to my sleep, CPAP. It is making all included muscles work harder to breath in my sleep, so bad that i woke up this morning almost convincing myself to call my buddy at the station to give me a 12 lead, but i recovered fast. While I personally have seen an AMI in a 8y/o male and in your case the fact that she is on BIRTH CONTROL automatically rules an age independent indicator for worry. If you follow your protocols for SOB and Chest pain then your fine anyways, Alway remember, the arrival at the hospital is the most important part of your care.