p3medic Posted November 19, 2008 Author Posted November 19, 2008 Pt doesn't remember the last time she took her meds, the heroin was from a usual source. The patient is a fairly poor historian, does report a maternal hx of "cardiac" but unsure what. Mom is still alive. She takes the hydrocodone when she can get the script filled more for recreation than an actual injury. She was sitting in a chair eating a piece of watermelon when the pain began suddenly. The pain is in the anterior chest, does not radiate. Pain is not reproduceable.
p3medic Posted November 19, 2008 Author Posted November 19, 2008 It would be in the diff, but far down the list...if only that was her problem.
akflightmedic Posted November 19, 2008 Posted November 19, 2008 Is the pulse oximeter correct, not malfunctioning? Can you describe the pain more clearly, such as it is sharp, dull, pressure, talk to me man! Is it transient or constant? (Wondering if a VQ scan at the ER would aid in this diagnosis)
p3medic Posted November 19, 2008 Author Posted November 19, 2008 The pulse oximiter is reading correctly, good waveform corresponding with pts pulse. The patient can not describe the pain beyond it hurts "a lot", it was of sudden onset, 10/10 in severity. Her hr remains in the 50's, rr 18-20, spo2 100%, etco2 34mm Hg with good wave form. She is in obvious discomfort. The pain is constant, non radiating, not reproduceable. Pt does not appear short of breath.
Kiwiology Posted November 19, 2008 Posted November 19, 2008 Hmm ... if the ECG does not show any dysrhythmia or abnormalitiess beyond the bradycardia (which does not seem to be severely haemodynamicly compramising right now) I am going to look for a differential diagnosis. Since she was shooting up, what about a thrombus or embolus? Where abouts in the chest is the pain? Left, right, radiate etc OPQRST? Could she just be seeking drugs? Could this be an attempt to rip off our drugs? (Somebody hidden in a closet etc) I would want to either have myself or my partner have a look around the apartment and make sure there aint no junkies hiding under the bed with a blade or some shit like that.
zzyzx Posted November 19, 2008 Posted November 19, 2008 If I were to encounter a patient with hypotension, bradycardia, and chest pain, my first thought would be inferior MI with R-ventricular involvement. The fact that she doesn't have JVD and no ST elevation in the inferior leads does not rule this out, nor that she isn't having some other type of MI. I would transport, treat for cardiac chest pain, and try fluids. Is there anything else for us to do prehospital anyway, even if it turns out she's having a PE? But I'm sure you've got something else in mind. :wink:
p3medic Posted November 19, 2008 Author Posted November 19, 2008 The pain is substernal, onset was sudden while eating, non radiating. She is diaphoretic and visibly uncomfortable. Her hr is unchanged, weak radial pulse noted on R.
zzyzx Posted November 19, 2008 Posted November 19, 2008 "onset was sudden while eating," No problem then. Must just indigestion. Since it sounds like it's going to take a long time to get her down to the ambulance, let's start an IV before we put her on a flat and carry her down. Is her pulse weaker now than when we first felt it? What's her BP now? Transport to an ER with cath lab. Would be nice also to go somewhere that could also stitch up an aorta.
akflightmedic Posted November 19, 2008 Posted November 19, 2008 I considered a thoracic aneurysm then dismissed it, cant recall why now. However is it possible that she has indeed ruptured and the blood is vagaling the heart which is why the rate is staying low and steady? Or did she indeed take her meds and just doesnt remember so that is masking some of the signs? In the middle of poker with the fellas, will check back later.
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