Part 1 of 2 Progressive scenario

[mobey]

Sorry for the delay.....

Just not tech savy

[Arctickat]

Pericarditis as a result of Cardiosepsis causing the hyperglycemia and a febrile seizure...the temp is tympanic I assume? How is it or is it calibrated? I usually end up adding 2 degrees to a tympanic temp to get an equivalent core temp.

One day someone will actually post a pericarditis case...I know it.

[DartmouthDave]

Hello,

I would get her on the stretcher, monitor, get a line and put her on some o2.

I think the EKG is worrying. I would lean away from Pericarditis because their hasn't been a preceding illness (i.e. flu, ect). Also, it my understand that any ischemic changes rules out Pericarditis.

She had risk factors for CAD:

- Smoked 1/2 pack x 25 years

- Dyslipemia (taking Atrovastin)

- Lack of physical activity (watches TV)

- Hyperglycemia

- Age

She has the look and the symptoms: gray, unwell, and pain in her right elbow

The EKG shows Q-waves (I think), ST elevation in V1,2,3,4,5 and V6. ST depressions in II and III Plus, spike T-waves in a few locations

Also, the wide QRS morphology with spike 'T' waves could be caused by electrolytes which can minic an AMI, especially hyperkalemia / hypokalemiia.

Hyperkalemia can produce very odd looking EKG. Maybe, she has some renal inefficiency that has progressed?

Enough rambling.

I would:

1. Do a 12/15 lead EKG

2. Get bilateral BP's (as noted above)

3. Give her an antiemetic like Zofran IV or SL

4. Give small doses of Fentanyly for the arm pain (25mcg PRN)

5. Give NS 500

6. Watch her LOC for any changes

7. Give the N+V time to settle then give ASA PO

8. Transport to the local ED for some more assessments and labs (mainly lytes and BUN/Cr/Tn-I).

A stop here is a good idea before a long transfer.

I would like to know:

1. How long has she been feeling unwell?

2. Temp?

3. Why is she on Ropinirole? I looked it up and it is for Parkinson Disease and Restless Leg Syndrome.

4. Any rash?

5. Stiff neck? Still back or legs?

6. Splinter hemorrhages in the hands and feet?

7. Decreased voiding?

Cheers

I

Edited December 5, 2012 by DartmouthDave

[mobey]

Also, the wide QRS morphology with spike 'T' waves could be caused by electrolytes which can minic an AMI, especially hyperkalemia / hypokalemiia.

Hyperkalemia can produce very odd looking EKG. Maybe, she has some renal inefficiency that has progressed?

Enough rambling.

I would:

1. Do a 12/15 lead EKG 15 not available (i didn't do one... so you don't get one hahaha)

2. Get bilateral BP's (as noted above) They are equal

3. Give her an antiemetic like Zofran IV or SL 8mg PO in.

4. Give small doses of Fentanyly for the arm pain (25mcg PRN) We have a problem huston.... You cant get a IV!

5. Give NS 500 Done

6. Watch her LOC for any changes Getting lethargic, but easily roused. More fatigue then lethargy

7. Give the N+V time to settle then give ASA PO 160mg down the hatch

8. Transport to the local ED for some more assessments and labs (mainly lytes and BUN/Cr/Tn-I).

A stop here is a good idea before a long transfer.

I would like to know:

1. How long has she been feeling unwell? Just since the seizure

2. Temp? Normal

3. Why is she on Ropinirole? I looked it up and it is for Parkinson Disease and Restless Leg Syndrome. RLS

4. Any rash? Nope

5. Stiff neck? Still back or legs? Nope

6. Splinter hemorrhages in the hands and feet? Nope

7. Decreased voiding? Nope

Cheers

Anyone want to bypass local doc-in-a box?

Also: you have the option to transmit this to cardiologist and activate a thrombolytic protocol. You carry TNK. However, the cardiologists in this program are very busy working the cath lab while on call, and don't like to be bugged unless you are pretty sure.

the temp is tympanic I assume? How is it or is it calibrated?

Once a week I drop it on the ambulance floor and kick it against the wall.... If it still works, I consider it calibrated.

[island emt]

Kind of hard to give a thrombolytic until you get Venous access isn't it? If you can't get a peripheral line, then maybe an EJ, then it's time for IO, She's not going to be happy, but what can you do

Yes: I would bypass the doc in the box unless she has a sprained wrist. this lady is way beyond the capabilities of the local clinic.

If you have 12 lead capability , you also have 15 lead. just sayin!

[fakingpatience]

I would consider the 12 lead suspicious for at least a lateral wall MI. I would definitely bypass the local facility, if they are anything like the ones here all they'd do is yell at me for brining a pt who needs further care there and transfer her out. I agree with island EMT, time to go for an EJ in this lady and start considering an IO. I would transmit this EKG to the receiving facility, to me it's suspicious enough to "bother" them and see if they want us to begin TNK.

BTW how did she get the 500cc of NS if we don't have a line?

New set of vitals please

[DartmouthDave]

Hello,

I wonder about and IO and TNK? I am sure it is fine but I have never thought about it, until now.

So, we have a medical clinic and an ED 30 minutes away?

Cheers

[Arctickat]

I think the EKG is worrying. I would lean away from Pericarditis because their hasn't been a preceding illness (i.e. flu, ect). Also, it my understand that any ischemic changes rules out Pericarditis.

It's a running joke. I guess pericarditis for everything.

[DartmouthDave]

Hey Moby,

You better make the next scenario a paracarditis! =)

[mobey]

BTW how did she get the 500cc of NS if we don't have a line?

New set of vitals please

Great catch!

Typing without thinking...

OK, so we transmit to the city hospital & the Cardiologist Gives the consent for SQ lovenox, but says no to the IO.

Plavix 300mg PO.

He states he suspects large MI and orders to bypass to the cath lab.

New vitals: 148/88 HR 87. Resp rate 18, Spo2 97

An hour passes, we are now about 1hr from the cath lab. The patient is quite diaphoretic and c/o new midsternal crushing chest pain 7/10. She begins to vomit again.

BP 146/70 HR98