70 y/o male , chest pain short of breath

[jwraider]

So this is a patient I saw last night in the ED (I'm finishing up medic school clinicals). He's not neccessarily a fascinating case but I'm interested in what your guys treatment would be based on what I saw in the ED.

-70 y/o male

-AOx4

-Acute onset of chest pain and shortness of breath (pain is 3/10, "kind of like pressure but -just uncomfortable", no relief, no movement "seems to bet getting worse (the symptoms in general)"

-Airway patent, RR 34 (shallow due to speed?) with crackles in R base SP02 88%

-Radial pulse present but irregular and 150 BPM

-BP 150/96

-Skin Pale (and pardon my poor interpreation he was caucasian and just looked musky or dark in the upper body)

-EKG: Uncontrolled A-fib with a RBBB no ST elevation or depression although leads V3 and V4 have mostly negative triphasic QRS complexes and the machine suggests "consider anterior infarct"

PT seems calm but wont tolerate a NRB. on NC @ 6lpm SP02 92%

Hx: No allergies, takes plavix "I've had an irregular heart beat before but this is worse" (Pt was seen in an ED 2 months prior but denies cardioversion, MI and the visit he says was "unconclusive". "I just had some blood work last week I'm waiting to hear back from my MD"

-The current symptons came on suddenly while watching TV and his wife drove him in to the ER.

-Denies Hx of MI, CHF, HTN, Renal disease

Physical: Skin signs and lung sounds above... Pt wants to be sitting up.. MD thought there might be some edema around shins but patient stated they looked normal to him.

-No JVD, no pain (other than chest)

So would you guys treat for chest pain? pulmonary edema? try and convert the rhythm?

[Mateo_1387]

mostly negative triphasic QRS complexes

Please show me a negative triphasic QRS complex.

[emt322632]

Please show me a negative triphasic QRS complex.

Agreed, I'd like to see a strip if at all possible. Was he in this ER previously? If so I want to see prior EKG if obtained at all?

I'd like to bring his rate down first, knock out the most obvious candidate, then let's go from there.

Labs, chest x-ray, echo?

Let's think possible CHF, P.E., AMI...

[jwraider]

Sorry I couldn't take a copy of the EKG. The complex was a short R wave going down into a W with the left side being bigger than the right.

Prior EKG showed NSR with the same BBB in most leads but v3-4 still look different now. The chest xray will show the fluid in the ® base

I didn't get a chance to see the labs (sorry for the incomplete case presentation!)

I can give all the answers to how this PT ends up but I'm really interested in how you guys would treat him in the field initially. He presents in obvious distress and just looking at him you'd want to do something.

I have my own treatment and then what I saw the MD do (totally different damnit!) so thats why I thought this was an interesting case.

Do you treat for chest pain?

Do you treat for pulmonary edema (or both)?

Do you try and convert the rhythm? (adeonisine,amiodarone,cardioversion are available here but this is afib so only.. cardioversion for me to use..)

I told my preceptor (if this had been my patient) I would treat with nitro and ASA (the guy wouldn't tolerate a NRB much less cpap although I probably would have given him a harder time over the NRB issue than the MD did) and transport. My dillema was I also wanted to control the rhythm but I didn't want to sedate and cardiovert.

[Mateo_1387]

Just from initial impression, I would have probably treated his rate problem, which was the uncontrolled a fib.

When dealing with patients, there are chances that different people will treat the patient with different modalities. In my opinion, this patient would probably be having a rate problem, which is causing his chest pain and shortness of breath.

Think of it like this, his heart beats 150 times a minute for a long period of time. It is bound to get tired. You have to remember how closely the heart and lungs are related. Often times when you stress either the heart or the lungs, it is going to affect the other organ. For instance, you have pulmonary edema, The fluid builds up in your chest wall, you become short of breath, it causes your heart to race, you get tired, you have lower oxygen levels, the heart keeps using more and more oxygen until it is starving, and thus causes the patient to have chest pain.

The same goes for a patient having a cardiac event. For instance, an MI patient. They have ischemia in their heart that causes them to have less cardiac output. Oxygen is not delivered as well to the body. They already have the chest pain, but they feel like they are not getting enough air. Hence they are short of breath.

Your patient may very well have been having a nonSTEMI, but the part I think others see is that he has a rate problem. His problem will probably be fixed by it. There are also links to A-fib and pulmonary edema. So if they fixed the uncontrolled a fib, I would imagine it will take care of the pulmonary edema.

From the ECG you are describing, it sound like a possible right sided MI. Maybe you can find an ECG that is similar to the one you saw that is online.

Had this been my patient, I probably would not have cardioverted. The patient had moderate pain, has a stable blood pressure, and was conscious. Electrical cardioversion would not have been indicated. I would have probably used a drug such as diltiazem or possibly amiodarone to bring his ventricular rate down by slowing impulses through the AV junction.

How did the doctor treat the patient?

[jwraider]

Diltiazem =) Took 3 rounds to get his rate back to normal...

We don't have any calcium channel blockers in our protocols here so electrical cardioversion would have been the only option (amiodarone is in some protocols around here for afib but only after electrical cardioversion fails).

Thanks for the responses... While watching this patient get his treatment in the ED I just had to wonder how I wold handle him prehosital with a different set of options.

[Mateo_1387]

If you were looking a treatment modalities, your first option of nitroglycerin and aspirin may not have been the best of choices. Being that this is a rate problem, slowing his rate down would have been the best choice. Remember that you patient is stable at this point. A call to medical direction may get you what you want. Pain a clear picture for the doctor in the emergency room. The doctor may allow you to use amiodarone, but it is obvious that this patient does not need cardioversion. The doctor may say for you to just bring the patient in. In which case he just made your day easy. You would want to monitor the patient, make him comfortable, start an IV, some O2, and take him to the hospital. To me, if you are not allowed under protocols, call the doctor and get their advice/permission.

[firedoc5]

A lot of people live with A-Fib and don't even know it. But in this case I'd see how Verapamil (Calan) would help. I was on it for a short time due to an irregular rhythm.

I agree with Matt, cardio version should not be attempted.

[EMS49393]

I agree with administering diltiazem. Your patient most definitely sounded like a rate problem. I'm interested in knowing how the patient felt once he finally converted to a controlled rate.

Keep in mind that pulmonary edema is a contraindication for diltiazem. If you are blessed with the option of diltiazem and amiodarone on your ambulance, you may want to consider the amiodarone. From your description of the patient presentation, it seemed that his pulmonary edema was slight, and more than likely a result of that uncontrolled rate. Personally, I have had a much higher success rate with diltiazem then with amiodarone.

Now, young grasshopper, I do not advocate electricity without sedation with any patient that is alert enough to talk to me. However, for your testing purposes, I will tell you that any tachycardiac heart rate with associated symptoms requires cardioversion, regardless of how alert they describe the patient in the scenario. If they have any Chest pain, Hypovolemia, Altered level of consciousness, Pulmonary edema (shortness of breath), or Syncope, you are to cardiovert in your testing scenario with national registry. This is one of those registry questions that just sucks. We all know the right answer, and people get this question wrong because they aren't following the actual textbook criteria (like any patient is kind enough to follow the textbook in presentation). Just a tip. The mnemonic brought up in my class for cardioversion is CHAPS, see above. I rarely give out mnemonics, I don't like them, but I know how people often rely on them, and I'm in a good mood tonight.

Look at the whole picture when you assess your patient. He was having chest pain, he was short of breath, sudden onset with a history of a-fib, and the clue that his a-fib had never been that bad. I would have asked him if he had chest discomfort like this before. If so, what was his diagnosis? He may have had symptomatic a-fib and had to undergo a chemical cardioversion before.

I'll bring up a quickie about a chest pain patient I had a few years ago. He complained of severe acute chest pain and shortness of breath. I performed a 12-lead and it showed SVT somewhere in the 200's, and it was regular, so I wasn't so concerned with a-fib. The machine had it's little useless interpretation thing turned on, and it spit out ACUTE MI SUSPECTED. I knew I wasn't going to be able to see what was going on unless I slowed down that rate. He did not convert with vagal maneuvers, he did convert with the first dose of 12 mg Adenocard. No MI, just too damn much coffee and cigarettes. Along with the uncontrolled rate, the chest pain and shortness of breath went away. Sometimes you really have to slow that rate down and proceed with treatments for the other symptoms if they are still present after conversion.

It's all a learning experience. Although I really don't like my job on the ambulance, I love my job in the ER. I soak up anything the doctors and nurses are willing to teach me. I hope you continue your desire to learn and become a truly great paramedic. Good luck, and my cardiology PM door is always open.

[Mateo_1387]

Keep in mind that pulmonary edema is a contraindication for diltiazem. If you are blessed with the option of diltiazem and amiodarone on your ambulance, you may want to consider the amiodarone.

Why would Pulmonary Edema be a contraindication for Cardizem, especially considering some pulmonary edema is linked to afib? Not that it would always be my first treatment for pulmonary edema, but why would it be contraindicated?