Chest Pain with a twist

[anastamosis]

acute mitral regurge

[chbare]

Nailed it.

Acute mitral regurgitation with pulmonary edema. So, the story was most likely: Pt had an MI in the past few months, atypical signs and symptoms most likely a result of his diabetes, mitral valve papillary muscle dysfunction ensued, and sudden rupture of the papillary muscles occurred following the MI.

Treatment in the pre-hospital setting will be similar to most types of cardiac pulmonary edema. The aim is to reduce afterload. The tachycardia is a good thing and to a point may actually prevent some of the mitral backfill.

Even with normal blood pressures, nitrates should be considered to assist with afterload reduction.

I hope everybody enjoyed this scenario. I thought something a little different from the typical massive MI leading to LV dysfunction and L sided failure would make for a great learning experience.

Take care,

chbare.

[anastamosis]

good case.

[Just Plain Ruff]

good scenario. I've got one coming up.

[captainstandup]

Thanks for an awesome scenario! I sit here a bit red faced for failing to properly assess the patient which includes HEART SOUNDS! How embarrassing, ok back to paramedic kindergarten for me........................

[Just Plain Ruff]

ok, to go further on the scenario, how would we in the ambulance treat this patient other than what we already are doing?

[captainstandup]

Wow we have standing orders for virtually everything and rarely call medical control but I would call them on this one. Other than treating his respiratory issues there seems to be little we could do on the ambulance. Possible exceptions include NTG drip as mentioned earlier and since we carry heparin we might consider a heparin drip but not without an order given this fellow isn't in A-fib. What he needs is an ACE inhibitor and as sick as he sounds he needs a swan-ganz for hemodynamic monitoring. He also needs to have an echo. It's quite likely he may need a balloon pump placed until valve repair or replacement can happen.

[chbare]

I am glad the scenario was well received. Actually, the pre-hospital course is very similar to the "standard" interventions we typically associate with acute cardiogenic pulmonary edema.

Some experts suggest using nipride because it specifically targets afterload, even if the blood pressure is normal. In addition, beta blockers should not be considered because they can blunt the compensatory tachycardia associated with this problem.

One of my points is also based around the physical exam. While we may not have picked up on this in the field, it is important to make note of our assessment findings. While we may not have initially put the puzzle together, having the history and assessment to include heart sounds could actually benefit the patient during their course within the hospital. Advising the receiving facility of your findings very well could hasten diagnosis and definitive care for this patient.

The consideration of past step infection would also have been valid. Somebody in a prior post had considered this problem. Rheumatic heart disease as a result of a strep infection is in fact a leading cause of mitral valve problems. This is especially true in younger patients with mitral valve disorders.

Many people will not develop the sudden severe signs and symptoms of our patient and you may actually see more chronic problems develop. Chronic signs and symptoms of heart failure can occur. Atrial fibrillation is also commonly seen in patients with mitral valve problems.

Take care,

chbare.

[Just Plain Ruff]

Great scenario Chbare

One thing I would note is that I would bet that fully 85% of us on this site, my self included are not or were not educated in heart sounds. Sure the s1 and s2 and a little more might have been covered in your medic class but anything beyond that seems to be left out of many many classes.

So to move on to the obvious next question - What can you do as a provider to bone up on or to increase your knowledge and understanding of heart tones?

Suggestions - I am open to any and all

1. There is a great book out there with a accompanying cassette or cd of heart tones. I suggest that as the first step.

2. See if you can get a physician who you feel comfortable with to go over heart tones with you. Preferably an ER physician or a cardiologist.

3. See if you can take a day or two in an ER and shadow that physician and have him/her allow you to listen to every patients heart tones and see if what you hear is what they heard

That would be an ideal education experience wouldn't it.

[chbare]

Sounds good. A review of cardiac A&P along with the cardiac cycle is also recommended. Check out this link for a basic review. The tutorial is pretty neat and you not only have sounds, but a real time diagram and text that explains the sounds.

http://www.blaufuss.org/

Take care,

chbare.