EMS is called in the very early morning to a 68 year old male complaining of chest pain and shortness of breath.
On arrival, the patient is anxious and appears acutely ill. He is oriented to person, place, and time.
Skin is cool, pale, and diaphoretic.
The patient feels light-headed and admits to nausea but has not vomited.
Onset: While sleeping
Provoke: Nothing makes the pain better or worse
Quality: Poorly localized heavy pressure
Radiate: The pain does not radiate to the arms, back, neck or jaw
Severity: 8/10
Time: Patient states he occasionally "feels bad" but "not like this"
Past medical history: MI with stents x 2 years ago.
Medications: ASA, Lipitor, Tenormin, NTG
Patient states he took NTG x 1 prior to EMS arrival which made him "feel worse"
Vital signs:
Resp: 22 shallow
Pulse: 140
BP: 88/54
SpO2: 92 on RA
Breath sounds: rales - patient becomes very light-headed sitting up
The cardiac monitor is attached.
A 12-lead ECG is captured.
What now?
First things I'm thinking on treatment is O2 via non-rebreather, ASA 324 mg, IV, STEMI center. With the rales & decreased B/P I'm worried about cardiogenic shock. All we carry for B/P support is dopamine, but his tachycardia makes me think twice about that. One of our ED docs will still give a fluid bolus to people who are hypotensive w/ rales based on the theory that often times they are not really hypervolemic, especially with diuretics, but he isn't on any. Could the tenormin (B1 blocker) be responsible? Curious as to what he means that he felt worse w/ NTG? Dizziness, chest pressure worsening?
ReplyDeleteIn terms of the ECG, to be honest, I am not sure about what to look for in terms of STEMI w/ IVCD. Is there anything specific? Looks like STE maybe in V3, STE V4, abnormally large T Waves V5 & V6. I'm going way out on a limb here, but, w/ the positive R waves in V1 & 2 w/ depressed ST & upright T wave, do we need to worry about posterior involvement? Is this a normal pattern kind of similar to a BBB? Is there anything else going on that might cause this? Hyperkalemia? Do we know what is abnormal based on his previous MI?
I'm anxiously waiting to find out what is going on.
Thanks