Is this a cardiac patient or not?

[emtannie]

As some of you are aware, I am just starting my first practicum of the paramedic program I am in. The purpose of this practicum is to start thinking like a medic, not an EMT, and become proficient in assessment, history-taking, and differential diagnosis, learning to integrate paramedic skills and scope of practice.

I had a call the other night, and I would like some opinions on it. I hope I can explain it well enough.

We were called to an 85yo male, complaining of abdominal pain causing shortness of breath.

We arrive on scene, and he is in his recliner, alert and oriented, no obvious distress, good skin color. Note he has a urinaery catheter bag at his feet, and tube coming from under his bathrobe. (also note a good collection of Playboy and Penthouse magazines under the end table next to him - good on ya, old guy!).

Guy is deaf as a stone, so I have to yell (even though both his hearing aids are in) to get any information.

He is complaining of abdoninal pain he describes as pressure, like gas "if I could just fart, I would feel better" kind of discomfort. He says that it feels like it is pushing upwards, and that makes him short of breath, especially when he lays down.

He says this started 2 days ago, and was bad the night before, and he considered calling 911, but hoped it would just go away.

On assessment:

HEENT: skin pink, warm, dry, pupils ERL, patient does not appear dehydrated

Neck: no JVD noted

Chest: note bruising common to elderly, especially those on warfarin, no sternal scar, no medication patches. Denies chest pain or discomfort. Lung sounds have fine crackles in all lobes, and patient says he had pneumonia 2 months earlier, and still gets a bit of a cough

Abdomen: distended, quite rigid, no bowel sounds noted (am thinking possible bowel obstruction at this point). Patient says discomfort is across entire abdomen, but at one point, when asked to point to the pain, he points to just above umbilicus. No pulsating masses..

Pelvis: urinary catheter, urine in collection bag is dark, like tea, about 200mL. Patient stated he had had a BM earlier in the day, but smaller than usual, no diarrhea or pain during BM.

Legs: significant pedal edema, pitting, bruises, difficult to find pedal pulses, good motor function and sensation

Arms: strong radial pulses, movement, and sensation, same type of bruises as on legs and chest

Back: unremarkable

Initial Vitals:

HR 60, strong, irregular (patient states irregular HR is normal for him)

BP 170/100

resps 22

SpO2 95% on room air

Temp: 36.5C

BGL: 5.8mmol

Hx:

No known allergies

Meds: metoprolol, nitro patch (only wears for 8 hrs/day), lasix, flomax, diazepam, warfarin, prednisone

MI 3 years ago, had 3 stents put in

prostate cancer - hence the urinary cath

denies CVA, diabetes, HTN, any other medical issues

eating normally, no decreased level of consciousness, can recall all events

Because of the SOB, and at one point when I was trying to get information, he pointed above his umbilicus, I ran a 3 lead.... Rate was irregular, between 60 - 130, with several PVC`s (4 -5 per minute). I did a 12 lead, which showed elevation in V2, V3, V4 and depression in V5 and V6.

So, I showed it to my preceptor, and say my gut tells me this is an old cardiac issue, not acute, and that we are still dealing with a GI issue, not a cardiac issue, but I want her opinion on it. She looks at it, shows it to the other medic, and we discuss back and forth for a minute.... my argument is that he is pink, warm, dry, good SpO2, no cardiac complaints except the SOB, and is it possible that the 12 lead could be showing prior injury, not acute onset? But, I question my preceptor - should we be treating the cardiac findings as well, with ASA and nitro? I don't want to treat based on monitor findings only, when his symptoms appear non-cardiac....

They agree, and we transmit the 12 lead to the hospital (gotta love bluetooth technology) and call the ER doc. He says give ASA and nitro, and treat as cardiac until we get to hospital.

So, we draw blood tubes, give the ASA and nitro, continue O2 via nasal cannula, continue monitor, and transport....

There was no change in patient condition, so I still think it was GI, but we never got back to the hospital so I could follow up....

It was good to see that my preceptors were as stumped as I was..... I was completely convinced it was a total GI issue, until I got the 12 lead.... but then when I saw the ST elevation, then I thought "Whoa, do we have more going on here?" And yet the only cardiac symptoms were the shortness of breath, and irregular heartbeat, neither of which were acute onset.

The one ER nurse said she remembered him from a prior visit, where he had the same symptoms, and he was admitted, given doses of Lasix, and returned home within a couple days.

So….. my questions are:

- is it possible for a 12 lead to have ST elevation or depression that is from prior damage, not acute onset?

- Would you have treated as a cardiac patient, or a GI patient, and why?

I am hoping to be able to follow up on this guy my next tour – the ER docs where I work are pretty good about discussing cases so you can learn from them.

[Bieber]

This sounds like a complicated case, and to be honest I would have stayed on the safe side and gone down the cardiac route as well, and I'll tell you why. To my knowledge, the most common chronic EKG changes following an MI is chronic Q waves. Now cardiology is one of those subjects where you can go as deep as you want into it, and I'm sure there are some real cardio wizards out there who could probably tear that simplistic argument apart, but that's my understanding.

Secondly, it's true that an MI is NOT the most common cause for ST elevation, but there's some factors that we in the prehospital arena have to consider. First, what is this guy's baseline EKG? We don't know. We don't know if this is what his EKG always looks like or if this is truly new ST elevation; because of that, in the absence of the patient saying he always has that on his EKG, we have to assume it's new onset until proven otherwise. The second thing you ought to think about is his age, and how that can alter the presentation of an MI. To be honest, you make a better case for this being an atypical MI than for it to be a GI issue. When was his last BM? Has he had GI issues before? Any dark, tarry stool or bloody vomit? Recent fever, cough, nausea/vomiting, diarrhea? Are those PVCs a known issue? If not, you'd better assume they're acute, even despite his age, and the most common cause of PVCs is myocardial irritability, which is more consistent with an MI than a GI issue. Did they go away with O2?

Now, am I convinced that this is definitely an MI over anything else? No. With a recent history of pneumonia, there's a ton of possible diagnoses and you're unlikely to make a definitive diagnosis in the field; he could have developed pericarditis (though to my understanding the EKG generally presents with a different morphology of the ST segment than in MI and the elevation is diffuse except for V1 and also I believe AVL). You said his rhythm was irregular? History of a-fib? You also say his abdomen was distended, was that per the patient's own assessment? And you mentioned you palpated for any pulsatile masses, did you also have a listen? I've heard from a physician that the more effective way of assessing for an abdominal aorta is to actually listen for audible bruits over the aorta. Is the dark colored urine new for him?

Anyway, I'm not trying to knock you, but as you can see this is a complicated patient. I don't know if you can make a definitive diagnosis in the field, but I wouldn't feel comfortable ruling out an MI in the presence of ST changes, dyspnea, and abdominal pain.

Great case, let us know if you find out any more about it.

[fiznat]

First let me complement you on your thorough and diligent assessment. A lot of people never realize that the "paramedic assessment" is *much* more about diligence than it is about diagnosis.

As far as your questions:

-is it possible for a 12 lead to have ST elevation or depression that is from prior damage, not acute onset?

No. ST elevation means the condition is acute. With rare exception (like in the days following a CABG), there is no such thing as "old ST elevation." Keep your STEMI mimickers in mind (LBBB, BER, LVH, pacers, etc etc etc), but real ST elevation is something to be considered as cardiac injury. Depression can be a number of things, but "cardiac depression" is caused by ischemia or is a reflective change from injury. Consider it an acute problem.

-Would you have treated as a cardiac patient, or a GI patient, and why?

Whats the difference? What does a "cardiac" patient get that a GI patient does not? If you are worried about a AAA or some sort of GI bleed I would imagine you might be concerned about ASA (and I would too), but it seems you did the right thing by passing that decision on to on-line medical control. NTG as well. Other than that, both GI and cardiac patients get IV/Monitor/O2 and continued reassessment.

Don't forget that this patient may have both a GI problem and a cardiac problem. It is not necessarily one or the other. You can't rule out cardiac because he has problems in his belly. Take heart, though. Our job is largely the same. Prepare for something worse to happen, consult on any meds you might want to give (if any), and reassess, reassess, reassess.

[HERBIE1]

All good advice so far. It seems there is some type of cardiac issue going on. Could be the primary problem, or secondary to something else. I would not rule out a AAA yet either. Pulsating masses are a late sign, and not always present when a person first starts to dissect. You noted fine crackles in the bases, so barring a pneumonia, I would say this person may also be in failure. This person has clotting issues so that complicates everything- whether it be a AAA, a bleed, or an infarct.

Tough call, but I agree that dropping a NTG and ASA is not going to harm the person or really exacerbate whatever their problem is. The downside/risk is negligible, IMHO. I would be curious to see what the DX ends up being. My guess is there will be multiple things going on with this PT.

Good H&P- sounds like you covered all your bases.

[mobey]

Thx for posting!

I concur with the others.

The ASA was a gimme due to ECG changes, and the lack of side effects (Risk vs benefit).

I as well would have tried at least 2 Nitro, then move to Morphine for pain control.

That way all bases are covered.

BTW: Would love to see the ECG if you can swing it

[1EMT-P]

Given this patient's history & physical it appears that there are multiple things going on with him. ACS, A-Fib, also a possible Bowel Obstruction & CHF. I would have treated him with O2, IV, Monitor. I also would have given him ASA & Nitro.

[Happiness]

Here is a call that reminds me sort of like Annies, had it 2 days ago,

Go to helipad and pick up pt with Chest pain will be arriving in 20 min.

55 yr old male. History of a heart defect that was detected 10 years ago and has had a pigs valuve replacement. They discovered this defect when he had the heart attack.

Pt. talking if full sentences no SOB, BP 134/78, pulse 60, regular,(no artery on left arm due to heart surgery),color a bit flushed, Blood sugar 5.8, Resps 16 regual. No chest pain = expansion. No numbness and tingly, but did state his hands felt tingly just befor he fainted. His hearing also just before fainting he said was like yelling in a culvert. = grips, eyes = and reactive, abdom soft and no guarding x4, no abdom pain. He feels alittle fatuiged but has been sleeping well, No swelling in lower extremities and has been compliant with his med, and Im sorry I cant remember what the are. He was on heart meds and bp meds. He had just gotten over the flu a week ago.

Pt has had a full breakfast and is logging truck driver. He states that he has had periods of fatuge during the morning hrs after climbing in and out of truck. At noon felt dizzy and fainted. He was out for just seconds. At 12:45 same feeling but did not faint. First aid attendent did great job in his vitals and they were recorded every 15 mins, and were consistant. Only thing he noted was that once in awhile he would go pale. (he did not do this in front of me) When we got to the hospital they did an ECG (i didnt see it) my partner looked at it and since we have very little experience in it all we can really tell is something looks wrong. He saw something and had a little discussion with the nurse, shrug his sholders and said it could be anything.

When I looked at this pt I would have said he was a fairly healthy looking fellow for his age, freindly and polite. had no complaints what so ever.

4 hrs later he was on a medivac to an off island hospital (i didnt do that transfer so I dont have all the details)with a doctor and a crew. The next day we were told that he had a disected aorta. Now I do not know if this gentleman died or made it to surgery, but I am sure we will find out later. It always amazes me how medical emergency's can change like a flip of a coin. And thank god he didnt have chest pain as he had a perscription for Nitro and in our protocol it involves ASA. I didnt give him any.

[DwayneEMTP]

...I as well would have tried at least 2 Nitro, then move to Morphine for pain control.

That way all bases are covered.

I didn't see a reference for pain, but perhaps I missed it? I do see where the pt specifically denied chest pain or discomfort though.

Also Afib is pretty much a given here as he's 85 AND on Warfarin so the rate is not concerning, neither the high nor the low.

I agree that the ASA was a no brainer, (though I believe it's value in the face of Warfarin is questionable, it's likelyhood of detriment is small) based on 12 lead findings alone, even if that's all that you had, but it wasn't. You also had the DOB (difficulty of breathing) and crackles, both pointing to pulmonary fluid, and fluid often pointing to retarded cardiac function?

One thing I did notice is that his B/P was pretty high considering he's on a beta blocker, metoprolol, which I've found to work pretty well. (Not terribly so, but work with me I'm going for the zebra here!) I wonder if it's possible that he haden't taken it like he was supposed to, which is very common in my experience for beta blockers, and if he didn't take that, then perhaps he's chosen not, or forgotten, to take his other meds, like Lasix, and his nitro patch? (pulmonary edema exacerbation, possible arterial constriction allowing a cardiac thrombus to cause your ST changes?)

Most everyplace I've worked the protocol for Nitro in cardiac pts is 0.4 mg SL q 3-5 mins until pain relieved, or some such. Would you have given the nitro based on the 12 lead changes alone? (forget Dr.s orders) I would have given it to this patient for the crackles in the hopes that it would battle some of the fluid, but I'm not sure that I would have for the BP or cardiac issue. I'm curious on your thoughts here, as well as the others that delivered Nitro to this patient. Would you simply have pushed two or three doses? How would you know when to stop? How would you verify effectiveness of treatment?

And as the others have said, pretty certainly a cardiac event, but not just because of the ECG changes. Everything else about this guy screams a heart ready to go, at least that's my thought.

I'm looking for your thoughts, as it's more than likely all of the above is simply me talking out of my ass as I have touched 5 seriously ill pts in the last 4 months. I'm going to need to go back to basic school soon...

Great call, and giant cast iron ovaries evident in posting it.

Dwayne

Edited February 3, 2011 by DwayneEMTP

[mobey]

I didn't see a reference for pain, but perhaps I missed it? I do see where the pt specifically denied chest pain or discomfort though.

The Pt was complaining of Abd pain. I only believe 5% of what people tell me about thier pain when dealing with ACS as there are far too many variables such as referred pain, silent MI, the way cardiac pain is deciphered by the brain varies too much. That is why I rely on my entire clinical picture (not saying you dont of course). If it looks cardiac, but the pt is complaining of back/abd/pleural pain, I will definatly try Nitro.

As a side note, pain "Above the umbilicus" I call epigastric.

Note: Warfarin inhibits Vitamin K dependant clotting factors. ASA/Plavix inhibit Platelet aggregation.

Working on different parts of the clotting cascade, I am unaware of any debate on witholding ASA with Coumadin use.

Not too sure if you're talking to me anymore, but I will answer

Most everyplace I've worked the protocol for Nitro in cardiac pts is 0.4 mg SL q 3-5 mins until pain relieved, or some such. Would you have given the nitro based on the 12 lead changes alone?

I would give the Nitro based on the global picture.

This scenario reads cardiac (as you mentioned). The Nitro as given by me, is on a trial basis.

If epigastric pain relieved and SOB subsides... Cardiac

If there is no effect on epigastric pain...... GI.

I have no concrete reason to stop at 2 sprays of Nitro before going to MS. In my mind, if there is no change after 2 sprays, and I am not sure of this even being Cardiac, moving to Morphine seems right.

By choosing morphine, I am not moving away from Cardiac treatment totally. Just trying a different avenue.

[ERDoc]

Don't be lulled into a false sense of security. This could very well be an MI. There was a study in Annals of Emergency Medicine in 2002 that showed that only 53% of people presenting to the ER had chest pain. Studies have also shown that cardiac pain can be relieved by a GI cocktail (I beleive it was something like 10% of people with MIs had relief with a GI cocktail, can't find the study right now). As for using nitro to decide of something is cardiac or not, another study (Henrickson CA et al. "Chest pain relieved by nitroglycerin does not predict active coronary artery disease." Ann Intern Me;d, 2003 Dec 16: 139: 979-86) showed that nitro has a sensitivity of 35% and specificity of 59%.

Cardiac disease is the great imitator.