Chest Pain after flight

[ibemt31]

FYI, I AM A BLS PROVIDER THEREFORE THIS IS FROM A BLS PERSPECTIVE....you are dispatched for a chest pain on an airliner. upon your arrival yo find a 45 y/o female seated in airplane seat in no visible distress c/o chest pain. pain is currently minor, 2 or 3 out of ten. Patient states she developed severe chest pain during the flight three seperate times. pain is described first as a pressure but later described as a sharp pain/pressure, originating from area of zyphiod process, laterally along the thorax, and radiating up into the chest. when asked if pain was worsened by inspiration pt states she couldnt take a deep breath during episode. upon palpation of chest, pain was not worsened, it was not reproducible. three seperate episodes occurred, and family states pt "passed out" after each of three episodes, a few minutes after pain became severe.pt hx of hypotension, asthma and unknown stomach issues, claustrophobia and gallbladder removal. pt did not believe symptoms were related to claustrophobia, and has flown before without a problem. v/s hr 64 rr 16 b/p 100/70. pt states normal bp is 80 sys. additional sets of v/s were similar, and as we were pulling into the er the pressure was 80/35, which pt states is about normal. take it from here, als and bls providers please.

btw, flight was about a 4 hour flight

[Niftymedi911]

Any seizure activity noted prior to EMS arrival?? Patient AAOX4??, blood glucose level??, Any nausea/vomiting??, pain radiation?? family Hx of Cardiac??, Medications??, Last oral intake??, Allergies?? Skin diaphoretic??? Recent surgeries?? Has he been sick recently??? Patient have HX of alcoholism, portal hypertension, or Cor pulomonale??

BTW how are the lung sounds??? Is she in any apprent distress with bretahing during these episodes??? Flight travel time 4 hours..... hmmm gotta be thinking a possible spontaneous pneumo or PE that has developed in her legs and has gotten to her lungs.

[brentoli]

Did she do any SCUBA diving or any other activity with pressure differentials before flying?

[ibemt31]

no seizure activity noted pt aaox4, no nausea/vomiting, slight dizziness noted. bls in NJ is not allowed to obtain a BGL (retarded, i know tell me about it) pain radiation as i mentioned was up into the chest from pain orginating at about the level of the zyphoid process. do not recall a family hx. rx- singulair for asthma, an unknown med for her gallbladder removal, NKDA. last oral intake was inflight meal, pt denies eating fatty foods. negative diaphoresis, no other hx other than what i mentioned. no recent illness, gallblader surgery 1 year ago. Lung sounds clear bilaterally, and i do not know what she was like during the episodes, i wasnt on the flight :wink: she stated she couldnt take a deep breath during the episodes, and it sounded like she probably was in some moderate to sever distress during the episodes, but like i said i wasnt there. i would disagree with your differentials, no pneumo, she was moving good air with clear LS. and although you never know and i cant rule it out, she didnt seem to be in enough distress to have thrown an emboli. no SCUBA diving or anything like that to my knowledge

[brock8024]

" i would disagree with your differentials, no pneumo, she was moving good air with clear LS. and although you never know and i cant rule it out, she didnt seem to be in enough distress to have thrown an emboli."

Why would you disagree. Those where my first two thoughts that popped into my head. What was her Spo2. You can have very clear lung sounds with a PE, and she might not have enough occulson yet to be in the severe distress yet.

Ok so what are her SPo2?

Does she have any pain in her joints or numbness anywhere?

Does she have aa hx of anxiety?

[ibemt31]

spoz 100% on high flow 02. no joint pain no anxiety hx, but hx of claustrophobia, if you read earlier post

[ERDoc]

no seizure activity noted pt aaox4, no nausea/vomiting, slight dizziness noted. bls in NJ is not allowed to obtain a BGL (retarded, i know tell me about it) pain radiation as i mentioned was up into the chest from pain orginating at about the level of the zyphoid process. do not recall a family hx. rx- singulair for asthma, an unknown med for her gallbladder removal, NKDA. last oral intake was inflight meal, pt denies eating fatty foods. negative diaphoresis, no other hx other than what i mentioned. no recent illness, gallblader surgery 1 year ago. Lung sounds clear bilaterally, and i do not know what she was like during the episodes, i wasnt on the flight :wink: she stated she couldnt take a deep breath during the episodes, and it sounded like she probably was in some moderate to sever distress during the episodes, but like i said i wasnt there. i would disagree with your differentials, no pneumo, she was moving good air with clear LS. and although you never know and i cant rule it out, she didnt seem to be in enough distress to have thrown an emboli. no SCUBA diving or anything like that to my knowledge

Pneumothorax and PE are very real possibilities in this case. She can have a small pneumo that may not cause much change in her lung sounds. You do not have to be in significant distress to have a PE. No, it is not retarted for NJ to disallow BLS from using glucose machines.

Is the pain still present? Has she ever had anything like this before? I might have missed it but were pulses equal? What was the BP in each arm? Were there any carotid bruits or heart murmurs?

PS-you can throw an embolus or have an embolism or you can throw emboli (plural)

[KSEMT122]

With my spouses history I would say this sounds like a classic PE derived from a DVT caused by inactivity + other unknown factors during the flight. Passing out after each episode of the severe chest pain is classic when throwing a PE. Typically the BP will shoot through the roof right afterwards, but gradually returns to normal. This would be a critical patient in my mind even though she may appear stable to you. Based on the HX of the events and symptoms, I would say this is a critical situation and patient. The next PE she throws could be her last. Just my thoughts, always prepare for and expect the worst, hope for the best. Hopefully you will end up telling us that she was a nut and faked it all and was never in any danger.

[chbare]

Smoker?

Obesity?

Oral contraceptives?

HRT?

Take care,

chbare.

[firedoc5]

Could the pressure during the flight effect a possible minor aortic aneurism? Immediate transport to hosp. for CT or MRI to rule that out.