To treat or not to treat?

[jwraider]

Hi guys, had this call yesterday! I'm on the last bit of my internship so it was great experience for me (sorry if not so exciting for you). I'm very interested to see how each of you would approach the situation and how you would treat the patient. I'll follow up with what I did.

Dispatched for 94 yo female "possible heart attack"

You arrive on scene in a very nice home and are taken upstairs by the homeowner. On the way up she states her mother called her an hour ago and she came home from work then dialed 911. You enter an upstairs bedroom where the local FD has already initiated care. You see a 94 yo slightly obese woman sitting in a chair with her head tilted slightly back wearing a NRB who appears very lethargic and is not purposefully moving.

FD reports PT is actually AOx4 just slow to respond. She is complaining of chest pressure but they think it may be a stroke because her grips "are very weak and she can't smile". They also state she has a Hx of TIA's and are just finishing up her initial set of vitals.

You approach the patient and find a strong radial pulse, breathing is around 18 a min and adequate (CBL or clear bilat). When you ask the PT her name her eyes are open but she doesn't track you and she responds after 3-4 seconds in a quiet voice with the correct answer which she also does for the rest of your AO questions. Her answers continue to be sluggish and it's almost as if she's having trouble speaking because the answers are short and muffled. You determine that her chest "hurts" and both arms "hurt" and she is "very tired". You also confirm the very weak grips and when you ask her to smile she just doesn't seem to do it.

BP 150/90 HR 112 Sinus Tach on monitor.... RR 18 SP02 100% (on 02)

The decision to move to the ambulance is made and a stair chair is used. On the way down you talk to the daughter again who explains that her mom is usually able to move around with a walker and is "very active mentally". She says she has a Hx of TIA's and "heart stuff" and you grab the bucket'o'meds:

Morphine, Lorazepam, Celexa, Warfarin, Levothyroid, Zyprexia, Macro (thats all the FD wrote down and it wasnt in the bin), Coumadin, Nifedipine - No allergies (Daughter didn't mention anything about pysch issues on scene)

Hx: HTN, valve disease, CHF, Pulmonary Embolus, TIA

You get into the ambulance and while the EMT gets the 12 lead ready and a BP is being re-taken you do a physical. PT has circumoral pallor, edema in both ankles (chronic), skins is white/pale warm and dry, lung sounds are still clear and adequate. Pain is described as "pressure" and is mid sternum going to left arm. Nothing makes it better or worse (including palpation) and 1 to 10 = "alot". PT states 6 hours ago she began to feel weak. about 2-3 hours later she noticed the chest pressure then a headache. Everything is getting progressively worse. She denies any recent illness and says she's had this pain before but is unable to ellaborate.

New vitals: BP 176/96 HR 98 Sinus Rhythm RR 18 SP02 100%. EKG: (sorry don't have a copy!) No STEMI,the QRS is crappy looking (lots of zigs and zags) but never over .10 in size. No T wave inversion or depression (some leads show elevation and depression of less than 1mm).

So you are 12 mins from the Kaiser hospital she belongs to with another hospital that is a stroke center with a cath lab about 1/2 mile away from the Kaiser hospital.

I didn't find anything else out during the call and had to make my decision on where to transport and whether to treat her for chest pain or for a CVA. I was aware of the possible contraindications for ASA and nitro in a CVA so I was having a hard time making a decision on what to do (also why she didn't get CP meds early in the call).

So what would you do? I'll post what I did later! Thanks! Would appreciate any suggestions on how to handle this kind of call and deal with a potential MI vs a CVA.

Feel free to ask for more info sorry but you're looking through an interns eyes =)

[defib_wizard]

Impressive description. You've painted a pretty good description of your assessment. But I do have some questions about her loc.

How does she respond? you say slow but a&o is her speech slurred as in a cva or is she sedated from a possible accidental OD of morphine and lorazepam.

Based on what you have said I would like to obtain a blood glucose. And would consider some iv narcan and reassess her loc.

( One of the worst OD's I ever had was a 75 yof that took 100 percocet we still had to intubate her after 4mg narcan ( she started breathing on her own but didn't wake up) It took 6 more to extubate her at the hospital and a narcan drip)

[jwraider]

Blood sugar 116 (sorry that was important)

Her pupils are PERL at about 3mm and RR was at 18-20. She also said the symptoms started 6 hours ago and got progressively worse.

She only talks when you ask her a question although she does moan and groan some. Her answers always take a few seconds to start and she speaks very softly and slowly. She could either be in alot of pain and very tired or maybe she is actually having a neurological event. All her answers are correct just not elaborate. For example in response to "where does it hurt?" she can say "chest" but if you asked for something more complex like "what medications are you on?" or "can you tell me what happened?" she just won't say anything. I don't know if her speach was slurred it was hard to tell... "Slow" is the best way I can describe it.

Sorry I forgot something: She has a foley which I discovered en route and the urine is a mild yellow color. (I don't know why someone who can use a walker has a foley)

Her daughter was making the case that her LOC was different but seemed to be reffering to energy level more than anything.

[Timmy]

Fluid intake and output? Temp? Skin Turgor?

[ERDoc]

UTIs in the elderly can present in many unusual ways including weakness and mental status changes. However, with the chest symptoms we need to look at more serious things. One thing that you need to think about in someone with chest discomfort with neuro symptoms is dissection. Pneumonia can also present in in similar fashion.

[spenac]

These are the fun ones. The chest pain, the stroke symptoms, the possible overdose, which to treat first what fun. Then as mentioned this could be related to some infection. Really need an accurate temperature on her as well. Was urine cloudy?

Close to the hospital might just do all the prep work such as 2 large bore IV's and a blood draw. Oxygen.

Further out you might have to decide which way to start treating her understanding that treatments for one thing could cause more harm in the other. Such as treating the cardiac could make the stroke worse if she has a bleed. In my part time job 90 miles from the hospital we run into having to make the hard choice on patients that have multiple events happening.

Sure glad you guys didn't walk her to the ambulance.

[jwraider]

"Sure glad you guys didn't walk her to the ambulance." Local FD did that last week with a COPD'er diaphoretic and talking in 1 word sentances but thats another story.

"Fluid intake and output? Temp? Skin Turgor?"

There was about 1/2 liter of normal looking yellow urine in the foley bag. UTI could be possible she is on a med "macro" which could be macrobid.... My fault for not knowing that for sure I had someone else copy down the drug names and read them to me and don't remember the exact name.

I don't know her fluid intake and turgor was normal. Didn't have a way to take a temp but her skin temp felt normal.

"someone with chest discomfort with neuro symptoms is dissection" I got a BP in both arms but a few minutes apart. I was taught to look for a difference which could suggest a AAA etc... any idea if doing them more than a few minutes apart counts? BP was similair in both arms.

So you guys are considering the MI, CVA and also a possible infection which I see there are some signs for thanks. This is what I did:

I had the EMT go code2 to Kaiser knowing I could divert to the other facilty if I identified a STEMI (on scene 12 lead was negative). I decided that since the symptoms started 6 hours ago this wasn't a "hot stroke".

I got an 18 in her left AC and continued to ask her questions which is when I established the order of symptoms and that she might of had this kind of CP before. I did not give her ASA because I could not rule out a head bleed. After much debate I gave her nitro because my understanding is you don't want to make ICP worse with nitro (cerebral blood vessels dilating) but I didn't see any signs (pupils PERL, pulse pressure normal... now I'm sure that's not enough but that's what I went on).

The nitro had a positive effect and she felt better. She actually was able to smile for me and once in the ER bed she seemed slightly more alert.

When I got to Kaiser I spent 5 minutes arguing with the nurse about the PTs Kaiser number and "why is she on a NRB I'm going to take it off"......... 3-4 mins later the PT is in bed complaining of shortness of breath with a RA sat of 88%. They put her on 2 whole liters and started listening finally. Nice to know about the SOB but would havebeen nice to give a report and get in bed first.

So my impression is cardiac since the nitro helped and there was a SOB factor discovered. What do you guys think? Any tips?

Thanks for the replies!!

[spenac]

Biggest advice is try and learn something from every patient whether serious or complete BS. That way you will always keep improving rather than stagnating like sadly so many do.

[crotchitymedic1986]

You didnt mention why the patient is on two narcotics. The most likely scenario is granny was high. I would have started with some Narcan and see if LOC improved. But the main lesson to be learned here is that all old people need to be transported. I cant tell you the number of times i have seen medics leave elderly people at home that have had a single syncopal episode. I am sorry, i dont care if you are 98 or 18 it is not normal to lose consciousness. My general rule is that i transport everyone under age 5 and over age 70, regardless of complaint.

[Arizonaffcep]

You didnt mention why the patient is on two narcotics. The most likely scenario is granny was high. I would have started with some Narcan and see if LOC improved. But the main lesson to be learned here is that all old people need to be transported. I cant tell you the number of times i have seen medics leave elderly people at home that have had a single syncopal episode. I am sorry, i dont care if you are 98 or 18 it is not normal to lose consciousness. My general rule is that i transport everyone under age 5 and over age 70, regardless of complaint.

Sure it is, if you have narcolepssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssss

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