Riblett Posted May 6, 2010 Posted May 6, 2010 Lets have some fun. This was my patient yesterday morning. I have attached an EKG and will give you some information to start. You get to ask questions and I'll provide assessment information as we go... Some background: You are a paramedic working at a small clinic and have two very new LPNs with you. You are the only clinician. It is 08:05 and the physician for the day is running late, but your first patient has already arrived. They will arrive in about another 15-20 minutes. You, as the paramedic, can act entirely within your scope at the clinic for the purposes of this scenario. You have all ALS drugs and cardiac monitoring. If you want a transport unit, you have to call for it and they will arrive in about 7-8 minutes. An eleven year old male is brought in by his father. The child is in obvious pain, very anxious, but is completely awake and oriented. His father states that he has been complaining of chest pain since late last night. Father states that he has observed what he believes to be intermittent respiratory distress. You direct one of the LPNs to acquire a 12 lead. See attached image. The other LPN gets the following vital signs: BP 104/73 HR 70 RR 22 %SPO2 97. What would you like to do? What would you like to know?
HellsBells Posted May 6, 2010 Posted May 6, 2010 Looks like the ST elevation is nearly global, so perhaps pericarditis is the culprit. Any increase in SOB when he lies back, as opposed to sitting? Temp? What does auscaltation of the chest reveal? Perhaps a chest x-ray is in order? Med Hx? Allergies? Meds? Oh, and for the moment lets also put the kid on a nasal cannula @ 4LPM and gain IV access, get a BGL and draw blood.
jonas salk Posted May 6, 2010 Posted May 6, 2010 Has the kid been ill recently? What is the quality of the pain, what provokes/palliates it? Does it change on palpation? What does the kids chest look like? Any previous cardiac history? What does the kid look like? What is his ethnic background? Is he a sedentary kid? or an active kid? What's his family cardiac history like?
Just Plain Ruff Posted May 6, 2010 Posted May 6, 2010 (edited) Lets have some fun. This was my patient yesterday morning. I have attached an EKG and will give you some information to start. You get to ask questions and I'll provide assessment information as we go... Some background: You are a paramedic working at a small clinic and have two very new LPNs with you. You are the only clinician. It is 08:05 and the physician for the day is running late, but your first patient has already arrived. They will arrive in about another 15-20 minutes. You, as the paramedic, can act entirely within your scope at the clinic for the purposes of this scenario. You have all ALS drugs and cardiac monitoring. If you want a transport unit, you have to call for it and they will arrive in about 7-8 minutes. An eleven year old male is brought in by his father. The child is in obvious pain, very anxious, but is completely awake and oriented. His father states that he has been complaining of chest pain since late last night. Father states that he has observed what he believes to be intermittent respiratory distress. You direct one of the LPNs to acquire a 12 lead. See attached image. The other LPN gets the following vital signs: BP 104/73 HR 70 RR 22 %SPO2 97. What would you like to do? What would you like to know? No offense to the LPN's out there but Lead placement????? Was it right? Assuming it was Pericarditis until ruled out. But what about the peaked t-waves - possible overload of Potassium? Maybe too many red bulls or he got into grandma's pills? I'd do another 12 lead just to verify. Edited May 6, 2010 by Ruffems
Dominion300 Posted May 6, 2010 Posted May 6, 2010 Looks pericarditis, as ruff said until it's ruled out. Establish IV access, O2, continuous monitoring, do all your normal assessments and call for a transport to ER. I'd also try to get the doc on the line to let them know what you got, maybe they can get in or will have further orders for you.
FL_Medic Posted May 7, 2010 Posted May 7, 2010 12-lead ECGs are not recommended for paramedics to do... because we will see much more than there really is most of the time. Pericarditis is possible, is he sick, febrile, positional pain? Early repolarization is very likely in the young patients. They will almost always present with a degree of ST-elevation. Large QRS complexes in precordial leads indicate LVH in adults, but I think this may be benign in kids. The width of the QRS complexes is of concern. Usually depolarization is much faster the younger you are.
Riblett Posted May 7, 2010 Author Posted May 7, 2010 (edited) Great replies. You oversee the lead placement yourself and you take a second one just for good measure. It is identical to the first one. There is no cardiac history in the family that the father is aware of, but the paternal grandfather has HTN and IDDM. The father denies any recent illness, not even a cold. The child rates the pain as 9 of 10 on the pain scale. No exacerbation with positioning, but the child flinches when you press down on the sternum. The child has no medical history except for ADHD, for which he has been taking lower dose Adderall for 3 years. He has no allergies. He doesn't really understand when you ask him to describe the pain other than the fact that "it hurts." You can draw blood, but you gotta tell me which tests you want. Finger stick BGL is 86 and he skipped breakfast this morning because he was feeling bad. You can't take an x-ray, despite having the radiology department in the clinic. The radiology tech doesn't arrive until 9 and the physician usually shoots any emergency x-rays if she isn't there. Visualization of the chest is unremarkable. Lung sounds are clear and equal bilaterally. Auscultation of the chest reveals normal heart tones, clear S1/S2, no murmurs, rubs, or gallops. Pulsus paradoxus not present. What do we think is going on here? Is there anything else you want to ask the father about? Any other tests you want to run? Edited May 7, 2010 by Riblett
DartmouthDave Posted May 7, 2010 Posted May 7, 2010 Great replies. You oversee the lead placement yourself and you take a second one just for good measure. It is identical to the first one. There is no cardiac history in the family that the father is aware of, but the paternal grandfather has HTN and IDDM. The father denies any recent illness, not even a cold. The child rates the pain as 9 of 10 on the pain scale. No exacerbation with positioning, but the child flinches when you press down on the sternum. The child has no medical history except for ADHD, for which he has been taking lower dose Adderall for 3 years. He has no allergies. He doesn't really understand when you ask him to describe the pain other than the fact that "it hurts." You can draw blood, but you gotta tell me which tests you want. Finger stick BGL is 86 and he skipped breakfast this morning because he was feeling bad. You can't take an x-ray, despite having the radiology department in the clinic. The radiology tech doesn't arrive until 9 and the physician usually shoots any emergency x-rays if she isn't there. Visualization of the chest is unremarkable. Lung sounds are clear and equal bilaterally. Auscultation of the chest reveals normal heart tones, clear S1/S2, no murmurs, rubs, or gallops. Pulsus paradoxus not present. What do we think is going on here? Is there anything else you want to ask the father about? Any other tests you want to run? Hello, I like Jonas Salk questions: What dose the kid look like? Tall, thin --> Marfan Syndrome ?Disection? What is his ethnic background? Balck --> Sicke Cell Crisis?? I would ask the father: -->Any distant medical history when he was younger? Kawasaki Disease? (I only ask because there was a child in the ED awhile back that had cardiac issues due to childhood KD) -->Any auto-immune diseases? -->Any SCD in the family? I would ask the patient: -->PO Intake; any energy drinks? I would reassess the patient and look for: -->Any rashes? Also, I would crack a CPS. And look up ADHD med......I am not family with it. Any dose changes? Labs and Investigation: I CXR would be nice. So, I guess we have to wait for the tech or the Dr. Lab.....I would go with CBC, Lytes, Tn, Urine + Serum Tox and BUN/Cr At a bit of a loss. Ped Cardiac isn't my strong point. Cheers
daniel h Posted May 10, 2010 Posted May 10, 2010 (edited) Eh, Basic question... Does the pain radiate anywhere? What does V4R show? Posterior V7,V8,V9 show any depression, Elevation? LBBB new for this PT?, ACS maybe, With Timeline, Transmural Infarct maybe, Myocarditis... Maybe. Cardiac packet labs. CPk-MB^, Troponin^, BUN/Creatine^, Potassium^, WBC^? Syncopal episodes? Febrile? Pupils equal/reactive? H/A? Tinnitus? Blurred vision? Paresthesia? Any HX of AMS in recent hours? I disagree with FL_Medic on Paramedics interpreting 12 Leads. If you, Or your Medics have issues with 12 Leads in your area, Then maybe y'all should reevaluate your curriculum. Why would you even consider not doing a 12 Lead with a 3,4,5 lead showing ectopy? ECG Interpretation in the field is huge in our area with our Medical Directors and receiving facilities. And yes... I said diagnose and treat for the people about to jump all over that. Maybe we just have good training, And know what were doing? Don't mean to sound arrogant. Edited May 10, 2010 by daniel h 2
DartmouthDave Posted May 10, 2010 Posted May 10, 2010 Eh, Basic question... Does the pain radiate anywhere? What does V4R show? Posterior V7,V8,V9 show any depression, Elevation? LBBB new for this PT?, ACS maybe, With Timeline, Transmural Infarct maybe, Myocarditis... Maybe. Cardiac packet labs. CPk-MB^, Troponin^, BUN/Creatine^, Potassium^, WBC^? Syncopal episodes? Febrile? Pupils equal/reactive? H/A? Tinnitus? Blurred vision? Paresthesia? Any HX of AMS in recent hours? I disagree with FL_Medic on Paramedics interpreting 12 Leads. If you, Or your Medics have issues with 12 Leads in your area, Then maybe y'all should reevaluate your curriculum. Why would you even consider not doing a 12 Lead with a 3,4,5 lead showing ectopy? ECG Interpretation in the field is huge in our area with our Medical Directors and receiving facilities. And yes... I said diagnose and treat for the people about to jump all over that. Maybe we just have good training, And know what were doing? Don't mean to sound arrogant. Hello, DH, I agree that 12-lead EKG are an important part of any progressive EMS system. STEMI alerts. Baseline EKG. ACS care starts upon arrival of EMS. Wonderful stuff. However, FL Medic position has validity as well. There is a great deal more to 12-leads than what is covered academically for paramedics (other medical professionals as well) or seen clinically by medics in the field on a regular basis. This 12 year-old falls in to this category. I am sure when the EP arrives they will be calling in or talking to an expert on this one. One last thing. What is AMS..... Pupils equal/reactive? H/A? Tinnitus? Blurred vision? Paresthesia? Nice.......thinking about EKG changes due to a SAH..... Cheers...
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