have fun with this one

[afib]

ok here we go ill give you all the issues and you figure it out and what the possible outcome maybe and a bonus question who can guess the troponin level.

47 y/o/m c/o chest pain for on / off period of 10 days, last night being bad but relieved with rest. today started again roughly 8 am but does not seek treatment, calling 9-1-1 due to chest pressure that makes the left arm go numb pt stating that the pressure is a 10 / 10 (-) diaphoresis, n/v/ha/ vision disturbances, no meds history and or allergies. pt placed on high flow o2, with room air saturations 97%.

monitor started with subsequent 12 lead showing sinus bradycardia with no ectopy as per monitor " otherwise normal ecg" b/p 102 / 60 respirations 16 - 18, skin warm dry (-) pallor, motteling, flushing.

how would you treat pt presentation, and what would you expect to have happen. bonus ? what is pt's troponin level????

have fun

[ERDoc]

First, I wouldn't waste my time reading what the 12 lead says, I would look at it myself. As far as the troponin, I'm going to go with positive. Outcome I would guess would be transvenous pacer followed by Pacer/AICD and a positive cath.

[chbare]

What is his neurological status?

Keep him on oxygen, establish vascular access and obtain a BGL at the same time. Do we have a copy of the 12 lead? The bradycardia and chest pain always raises my index of suspicion for inferior wall involvement. We can also obtain a V4R and V7, 8, & 9. This can be done enroute to the receiving facility.

Do we have any known or suspected contraindications to ASA? I would be very careful about giving NTG, morphine, or beta blockers at this point. Actually beta blockers are on hold with the bradycardia. Fentanyl would be a good choice for pain control however.

What one of the troponins are we looking at?

Take care,

chbare.

[firedoc5]

First, I wouldn't waste my time reading what the 12 lead says, I would look at it myself. As far as the troponin, I'm going to go with positive. Outcome I would guess would be transvenous pacer followed by Pacer/AICD and a positive cath.

I'd go with that.

Don't be surprised if this get's moved to the "Scenarios" area.

[afib]

1-2 mm elevation in the inferior leads, this is what ya get for blowing off chest pain after days. troponin was 7.0, 100/ 64 next b/p no i didnt want to touch that b/p with nitrates i hit him with 2mg of mso4 and his pressure dropped to 88 / 54 fentanyl is not avail here. i didnt do a v4r but due to his presentation i didnt want to screw with it much more and he is set for a cath i do believe tonight. i think with a trop. level that he has significant damage has been done, ill let ya know.

[triemal04]

1-2 mm elevation in the inferior leads, this is what ya get for blowing off chest pain after days. troponin was 7.0, 100/ 64 next b/p no i didnt want to touch that b/p with nitrates i hit him with 2mg of mso4 and his pressure dropped to 88 / 54 fentanyl is not avail here. i didnt do a v4r but due to his presentation i didnt want to screw with it much more and he is set for a cath i do believe tonight. i think with a trop. level that he has significant damage has been done, ill let ya know.

Why did you not run check V4R? Because you "didn't want to screw with it"? Explain please. Inferior and right-sided go together fairly regularly which hopefully you guessed based on his presentation. As well, why the morphine before checking to see if there was any right-sided involvement? Why? Whywhywhy?