Old dude can`t breathe

[mobey]

92 y/o male resp distress

Mildly hypertensive, HR 112, Sp02 on room air 82%. Temp normal RR44

Pt presented to lodge staff at 0330 with sudden onset difficulty breathing. Pt first sat in a chair, then layed on floor while awaiting EMS.

We arrive 20min later to find him with peripheral cyanosis, cold extremeties, no diaphoresis.

No peripheral edema. No chest pain, no neuro deficits.

History of Htn is all I got.

Meds = zylopram, senokot, furosemide, coumadin, vit d3, Apo-Cal.

Pt is Alert although clearly tired.

Wheezes audible in the room. Apicies are very musical indeed! Bases are near silent, but faint wheese heared at end of expiratory phase.

Tx: Immediatly 5mg Ventolin, 500mcg Atrovent.

8mg Dexamethasone.

Load into ambulance.

I.V. initiated 4 lead = A-Fib.

Sidestream EtC02 = 31 Shark fin shaped waveform

No change in presentation. Sp02 now 91% on nebulizer. Resps now at 36

Start 2nd neb identicle to above and capture 12 lead.

Infuse 2gm MgS04

ASA 160mg

Upon arrival at hospital, pt sitting up talking full sentences. Slight tachypnea, mild wheezes in bases, clear apicies. No complaints

OK... Check out the 12 lead hope the quality is OK.

[Yarbo]

?pulmonary embolism - evident by sudden onset & high resps? - maybe has PVD & BBB.

[Kiwiology]

?pulmonary embolism - evident by sudden onset & high resps? - maybe has PVD & BBB.

We need a couple of things to seriously consider a PE

1. History of coagulopathy or risk factors for such e.g. smoking, HTN, AF, diabetes, recent pregnancy or venous structural defect (varicose veins in the calf most common)

2. Chest pain that worsens significantly with inspiration

3. Patients with a PE very often have a degree of being shut down and are hypothermic

His history reads more like congestive cardiac failure but I don't see any evidence of an acute exacerbation here

Hmm, he scoffs down coumadin but I don't see AF in his ECG so to me this sounds more like a respiratory problem

Edited November 14, 2011 by kiwimedic

[Yarbo]

My next possible route for this one could be Cardiac asthma d/t CHF w/ evident with shark fin, wheezing, & showing improvement with a neb tx. Anymore subjective findings?

Edited November 14, 2011 by Yarbo

[ERDoc]

Never underestimate a PE. There are textbook symptoms, but no one follows them. Severity of the symptoms depends on size and location. I've had 2 recent 'holy crap batman' moments in the last few weeks involving PEs. The first guy presented with dyspnea when walking up a flight of steps for the last 2 days, no other risk factors or symptoms (chest pain, etc). The workup with unremarkable and we were thinking something viral. We got him up to walk him and he dropped his sats from 98 to 91 without becoming short of breath. I threw on the CT and found multiple peripheral PEs in the right lung. Two days later another guy with no risk factor comes in with some upper abd pain and tenderness. We scanned his belly and in the upper cuts they could see multiple b/l PEs.

As for the OP, they guy must have some history of clot, he's on coumadin. I wouldn't call that 12 lead normal either.

[systemet]

A couple of points regarding the 12-lead:

* The lateral leads are showing downsloping ST-segments and T-wave inversion, this is probably LV strain

* The axis is borderline for LAD;

* While this does meet the common voltage criteria for LVH (i.e. S wave in V1/V2 + R wave in V5/V6 > 35 mm), the R wave in aVL is sitting right at 12 mm (>12 is considered suspicious for LVH). Obviously LVH is better identified with echo.

* Not sure whether I see a.fib either, it's a little hard to tell from the tracing.

I would probably still fax this, although I think the ST changes are secondary to LVH. I wouldn't expect to get orders to thrombolyse this, but I'd let someone with MD after their name decide.

I don't think there are ECG changes to support a PE -- starting with the caveat that the ECG is pretty insensitive here. If I was going to see something, I'd expect to see a rightward or right axis, +/- RBBB, right strain, RAA (collectively suspicious for RVH).

Any follow-up on the patient? Any point-of-care testing available?

[ERDoc]

What is the most common EKG finding in the setting of a PE?

[Yarbo]

What is the most common EKG finding in the setting of a PE?

non-specific st segment & t changes?

[systemet]

What is the most common EKG finding in the setting of a PE?

My guess, in order:

1. sinus tachycardia

2. new-onset a.fib

3. changes related to previous disease

10. Right heart strain

80. The much debated S1Q3T3 pattern.

How did I do?

* I wasn't trying to suggest that the presence of left heart strain in any way rules out a PE. I'm aware that the sensitivity and specificity of the ECG for PE is very low.

* I'm not presuming to lecture an ER physician on subtleties of ECG interpretation. I'm sort of stupid but not that stupid

* How would you feel if a crew faxed you this ECG, and asked about the STs? My opinion as a paramedic, which is worth exactly that, is that you probably wouldn't give me orders for TNK? Do you agree?

Edited November 15, 2011 by systemet

[ERDoc]

Systemet, don't think I was trying to pick on you. There are a lot of times in EMS when you see a pt with X pathology but never know about it because you are unable to get followup. You usually are able to get followup on the sickest cases so you start to develop a biased view of a disease process based on your experience. We even do it as doctors, that is why cases like the ones I posted above are humbling. The difference is that in the hospital we get to know the dx and can be humbled. I don't remember if either one of them were brought in by EMS but if they were I can guarantee you that the crew never thought about them again. Had I not know about the PEs, I probably would never have thought about them again either.

You are correct, depending on the study you read, sinus tach is the most common finding, but it is not 100%. The most useful thing an EKG is for in someone with a PE is making sure there is not something else going on. As for the TNK (or any other lytic), it's not indicated in this case. I won't get into the interpretation of the EKG in case someone else wants to do that, but I will say there is no STEMI, so lytics are not indicated.