DartmouthDave Posted March 2, 2010 Posted March 2, 2010 (edited) Hello, Here is an interesting case that I was involved with the other day. I would like to just work with the pre-hospital side of things for now. Then deal with the hospital side of things and a transfer. Case Presentation: A 52 year-old male calls 911 complaining of shoulder and neck pain after seeing his Chiropractor. Initially, a BLS ambulance is dispatched. On arrivial the BLS crew notes that the patient is plae and soaked in a cold sweat. He is very anxious and in obvious distress. Physical Exam: Physical exam finds that the patient is anxious, tachy (120's), hypertensive (220/114), and tachypenea (30's). SpO2 = 95%. His lungs are clear. Skin is pale and soaked in cold sweat. No JVD. Beeds of sweat run down the patient's face. Pulses strong and regular x 4. No N+V. No GU issues. He describes the pain as 'numbness' in his shoulder and right arm and scores it as 9/10. He also states that his chest feels tight. Like a band squeezing him. In addition, the patient had had similar episodes over the past two weeks. However, the pain was quite mild in comparison. Nothing in particular caused the pain and it just 'Went away on its own.' History: Past medical history is obtained from his mother and sister (who are quite anxious). They state that he has a long history of neck and should pain which he see a Chiropractor frequently. They add that the Chiropractor didn't do aggressive manipulation of the patient's neck. He also has a history of HTN, Anxiety, Depression, Dyslipemia and Cancer (...not sure what type...but treatment was effective...). He also quite smoking 15 years ago. His only drug allergey is to Ativan. Currently, he takes Ramipril 10mg PO OD, Immovaine 15mg PO QHS, Lipitor 40mg PO QD, and Advil PRN, Tyl PRN, and Tyl#3 PRN for pain. Family History: Noteworthy family history includes a father who die of a MI a 50. A family history of depression and suicides. Current Situation.......... The BLS calls fro ALS and insert a #20 IV in the patients left hand (...a hard start...) and place the patient on nasal canulas at 3 lpm. ALS arrives shortly. Total scene time has been 10 minutes so far. They hospital is 15 minutes away. They have a good ED, ICU, CCU but no ango. ALS has 12-lead EKG, CPAP, TNK and ALS medications. Thank you....... Edited March 2, 2010 by DartmouthDave
HERBIE1 Posted March 2, 2010 Posted March 2, 2010 (edited) I'd be leaning towards an exacerbation of his chronic musculoskeletal issues, but given his age and history, I'd work him up as a cardiac case. I'd look at the 12 lead and proceed from there. Edited March 2, 2010 by HERBIE1
Happiness Posted March 2, 2010 Posted March 2, 2010 Even though you are saying there was no aggressive manipulation of the neck Im going to lean toward a Stroke. There has been alot of research lately of pts. haveing strokes after a visit to the crack doctor and it can be from passive or agressive manipulation. http://www.cmaj.ca/cgi/content/full/166/6/794
HERBIE1 Posted March 3, 2010 Posted March 3, 2010 Even though you are saying there was no aggressive manipulation of the neck Im going to lean toward a Stroke. There has been alot of research lately of pts. haveing strokes after a visit to the crack doctor and it can be from passive or agressive manipulation. http://www.cmaj.ca/c.../full/166/6/794 I KNEW there was a reason I never went to a chiropractor!
DartmouthDave Posted March 3, 2010 Author Posted March 3, 2010 Hello, Ok, we are thinking about MSK pain, CVA and a AMI. So, ALS arrives, and dose an assessment. The patient is alert and orientated (GCS 15) with no deficits found. His pupils respond to light. Additional findings are the same as the BLS crew. They also place the patient on the monitor and do a 12-lead EKG (see attached....this is not the original...sorry). So, what other interventions are we thinking of here? Thank you....
Levi Posted March 3, 2010 Posted March 3, 2010 Hello, Ok, we are thinking about MSK pain, CVA and a AMI. So, ALS arrives, and dose an assessment. The patient is alert and orientated (GCS 15) with no deficits found. His pupils respond to light. Additional findings are the same as the BLS crew. They also place the patient on the monitor and do a 12-lead EKG (see attached....this is not the original...sorry). So, what other interventions are we thinking of here? Thank you.... Sorry, did you forget to attach the ECG or do I just not know how to find it? Without one I would chalk this up probably to an acute coronary syndrome. The BP is a bit concerning. I would consider lowering that a bit because this sounds like the BP could acutely be causing some end organ damage here. Once you head down the ACS pathway you will be giving nitroglycerin and morphine which should help. Was a neuro exam done? Any focal findings? Any cranial nerve problems? There isn't much that makes me think this is a CVA at the moment, but I'd still do a good exam to make sure there are no findings.
Siffaliss Posted March 3, 2010 Posted March 3, 2010 (edited) What was the onset of the neck and shoulder pain? Did a headache accompany the other s/s? If so, was it described as sudden onset and "worst ever"? I'd like to see the 12 lead too How did the vitals progress? Did the BP vary from arm to arm? Did he end up bradycardic? Any decrease in LOC over time with EMS? Sounds like a good one for several differentials. My pharmacological interventions would depend on the 12 lead ... more info now please Edited March 3, 2010 by Siffaliss
DartmouthDave Posted March 3, 2010 Author Posted March 3, 2010 (edited) Hello, Sorry about that I was having issues with uploading the image. It seems that it has to be less than 3.7K. So, I need to upgrade my membership and get better at this. CNS: A/O x 3 and no focal findings No H/A, photophobia CVS: The BP is the same in both arms (200/110) Tachy Cold Sweats EKG-----> Inverted T-wave in V1, V2, V3 No 'q' waves, normal axis, and good 'r' wave progression. The crew gave SL NTG x 3 and ASA. Started a 2nd IV and transported. The BP wasn't lowered by the NTG. Cheers Edited March 3, 2010 by DartmouthDave
Just Plain Ruff Posted March 3, 2010 Posted March 3, 2010 Hello, Here is an interesting case that I was involved with the other day. I would like to just work with the pre-hospital side of things for now. Then deal with the hospital side of things and a transfer. Case Presentation: A 52 year-old male calls 911 complaining of shoulder and neck pain after seeing his Chiropractor. Initially, a BLS ambulance is dispatched. On arrivial the BLS crew notes that the patient is plae and soaked in a cold sweat. He is very anxious and in obvious distress. Physical Exam: Physical exam finds that the patient is anxious, tachy (120's), hypertensive (220/114), and tachypenea (30's). SpO2 = 95%. His lungs are clear. Skin is pale and soaked in cold sweat. No JVD. Beeds of sweat run down the patient's face. Pulses strong and regular x 4. No N+V. No GU issues. He describes the pain as 'numbness' in his shoulder and right arm and scores it as 9/10. He also states that his chest feels tight. Like a band squeezing him. In addition, the patient had had similar episodes over the past two weeks. However, the pain was quite mild in comparison. Nothing in particular caused the pain and it just 'Went away on its own.' History: Past medical history is obtained from his mother and sister (who are quite anxious). They state that he has a long history of neck and should pain which he see a Chiropractor frequently. They add that the Chiropractor didn't do aggressive manipulation of the patient's neck. He also has a history of HTN, Anxiety, Depression, Dyslipemia and Cancer (...not sure what type...but treatment was effective...). He also quite smoking 15 years ago. His only drug allergey is to Ativan. Currently, he takes Ramipril 10mg PO OD, Immovaine 15mg PO QHS, Lipitor 40mg PO QD, and Advil PRN, Tyl PRN, and Tyl#3 PRN for pain. Family History: Noteworthy family history includes a father who die of a MI a 50. A family history of depression and suicides. Current Situation.......... The BLS calls fro ALS and insert a #20 IV in the patients left hand (...a hard start...) and place the patient on nasal canulas at 3 lpm. ALS arrives shortly. Total scene time has been 10 minutes so far. They hospital is 15 minutes away. They have a good ED, ICU, CCU but no ango. ALS has 12-lead EKG, CPAP, TNK and ALS medications. Thank you....... I'm thinking something was torn or ruptured in the manipulation of this patients neck. I'd not be messing around on scene with this guy. Do we have some sort of Carotid aneurysm or arterial problem under the shoulder area. Did the chiro manipulate and do something to the nerve? I would be quick to initially blame the manipulation but I'm suspecting this might be something more ominous or not. hmmmmm who k nows.
JPINFV Posted March 4, 2010 Posted March 4, 2010 Even though you are saying there was no aggressive manipulation of the neck Im going to lean toward a Stroke. There has been alot of research lately of pts. haveing strokes after a visit to the crack doctor and it can be from passive or agressive manipulation. http://www.cmaj.ca/cgi/content/full/166/6/794 Yep, bone cracking (high velocity-low amplitude (HVLA) in osteopathic manipulation) has been known to cause dissecting aneurysms, however when the procedure is done correctly the complication rates are extremely low.
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