fakingpatience Posted December 6, 2012 Posted December 6, 2012 Repeat 12 lead, repeat d-stick. What is her mental status now? I'm not sure about the PO zofran you gave earlier, I know with IV zofran you could repeat a dose at this point, so since we don't have a line I'd do 0.4mg IM. Cautiously begin giving the pt nitro SL 1 pill q5mins as so long as pressure holds. Consider a narcotic pain medication IM. I'd also have the IO kit sitting out next to pt, incase she deteriorates and I need venous access. Oh, and I'd put the "oh sh*t" pads on her, just in case.
island emt Posted December 7, 2012 Posted December 7, 2012 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 At this point you have a pt that is heading down the path of no return and it's not going to get better soon. She is starting to circle the drain and you have no IV access. It's time to think a little outside the box here. Did you look at her feet & lower legs?? There are several good veins there that can usually be found even when you've had no luck on the hands & arms. Me : Would have gone to the EJ as a direct route , but it's all how comfortable you are with finding the landmarks. You really need to be careful with the nitro, looks to be rt sided from what little we've gotten from the ECG strip. Like Patience said pads on and be ready. Diesel bolus might be her only option at this point on your journey
Arctickat Posted December 7, 2012 Posted December 7, 2012 You've got time, why hasn't anyone asked for a right side 12 lead?
triemal04 Posted December 7, 2012 Posted December 7, 2012 At first glance this would appear to be an MI or otherwise cardiac related...but...some other things there too. She has had a prior hemmorhagic CVA...while it was 12 years ago this is still something to be thinking about. Add in that this was her first seizure in 12 years and her disorder was caused by the CVA in the first place...worth keeping in mind. If she is getting less responsive/lethargic and continueing to do so, very concerning. Repeat neuro exams, especially with a 2.5 hour transport are mandatory. The 12lead looks both like an acute MI, and a little like one that's been ongoing for awhile. With the recent seizure and her history I'd be a little leery about the plavix and lovenox. Not saying I wouldn't, but a conversation with the cardiologist would be in order with my concerns expressly laid out. The tnk is definetly out. Far as the access issue...if you can't find a peripheral vein then she get's an IO. Right away. You can try lidocaine (which is less than effective that I've seen) along with some IM fentanyl and versed, but she still get's it early. The other option, which will depend on how well you know the local doctor and what his capabilities are, is that it might be worth calling and asking if he'd be willing to start either an IJ or subclavian before you continue towards the city. If it's something he's good at it won't add much time, and with this being a high risk patient for both cardiac and neuro issues (or something else), a long transport, and the potential use of anticoagulants and/or thrombolytics, it'd be worth having. Continue with repeat 12 leads (or 18 but since you said that's out...), repeat neuro exams and aggresively treat the nausea with your anti-emetic of choice. If the lethargy continues to progress or the vommitting becomes severe...carefully intubate.
mobey Posted December 7, 2012 Author Posted December 7, 2012 At this point you have a pt that is heading down the path of no return and it's not going to get better soon. She is starting to circle the drain and you have no IV access. It's time to think a little outside the box here. Did you look at her feet & lower legs?? There are several good veins there that can usually be found even when you've had no luck on the hands & arms. Me : Would have gone to the EJ as a direct route , but it's all how comfortable you are with finding the landmarks. You really need to be careful with the nitro, looks to be rt sided from what little we've gotten from the ECG strip. Like Patience said pads on and be ready. Diesel bolus might be her only option at this point on your journey Nitro is supplied at 0.4mg spray. Oh yes.... the feel/legs/upper arms etc were all tried. 9 times in fact! There is no chance at IV unless you go EJ. I would love to post a 15/18 lead for ya'll, but I just didn't do one. I am not posting a fake scenario so I don't wanna make crap up. So before I wrap this up, are we spraying the nitro without a line?
fakingpatience Posted December 7, 2012 Posted December 7, 2012 Oh, we haven't looked/ tried an EJ yet? Absolutely, at this point get the EJ before any further medication
island emt Posted December 7, 2012 Posted December 7, 2012 Oh yes.... the feel/legs/upper arms etc were all tried. 9 times in fact! There is no chance at IV unless you go EJ. So before I wrap this up, are we spraying the nitro without a line? Then EJ it is as I mentioned back on page 2. In hindsight, What was the reason for zero success in peripheral IV access? With her BP it wouldn't appear to be vascular shunting from the periphery. Just going off track a little here: Do you have a Rad 57 by chance or a LP 15 with CO capability? As far as the nitro spray: I'm still very leery of giving it without a 15 lead to check for rt side involvement & definatly not until venous access is established. Too easy for things to go to hell in a handbasket here . You've got time, why hasn't anyone asked for a right side 12 lead? I asked for one a long time ago Trevor. he didn't do one
DartmouthDave Posted December 7, 2012 Posted December 7, 2012 (edited) Hello, IV access is needed. Depending on your protocols go for a femoral line or an EJ. Then, if you need it, an I.O. The question that needs to be answered is: Is the I.O. ok for the cath lab? I assume it is...but I am not sure. Also, I would like to roll thinghs back a little. I assume this case study is in rural Alberta. You need to get to the cath lab. But, there is nothing wrong is stopping at a local Emergency department first. They could put in a central line (maybe they have U/S), run a quick set of labs. Take a look at the heart with the u/s to see what is going on. A quick u/s can help with some of the DDx that can mimic a AMI. Such as pericarditis with an effusion, atypical balloning, CNS bleeding, LV aneurysm from an old MI and a number of other that i can not recall right now. Second, with a line, she can be managed better during the transfer. She has had ASA,Plavix and PO Zofran. Some NTG IV would be nice. Also, if their isn't too much delay a Head CT to make sure all is well. I have seen enough STEMI to know standard medical management (ASA,Plavix,IV NTG, Heparin or Lovenox)can have patients's pain free and somewhat stable for the trip to the cath lab. A little more on CNS bleeds being a STEMI mimic. I have seen SAH/CVA cause ST elevations. Usually, their isn't pump failure and cornary blood flow is uneffected. In some cases, the CNS bleeding caused a stunned myocardium (Dilated Cardiomyopathy). The tell tale sign in these cases is a HYPOTENSIVE neuro patient. This is big trouble. Recently, in the local ED, there was a fit 30 year-old women with a ST elevations and a Grade IV SAH. Her pressure was in the 70's despite an incresed in ICP. As for the seizure. Maybe here Dilantin level is low or their is a medabolic cause. I must admit that the seizure is worrysome. But, if here LOC is good (14-15/15) with no abnormal finding (weakness) I would be more reassured. She is hypertensive. She has a histroy of HTN. I would expect her BP to be much higer if their was a CNS bleed or clot. So, if here LOC is good I would: 1. Get a line of some type 2. Zofran IV 3. NTG IV 4. Fentanyl IV Cheers Edited December 7, 2012 by DartmouthDave
mobey Posted December 8, 2012 Author Posted December 8, 2012 Thx for the participation guys. Here is what I did No EJ/IO 2xSprays nitro with IO close by. If she dropped her pressure, I would have placed it. Serial 12 leads q 20-30min, with no changes. Enter the cath lab: IV is attempted 8 more times (literally)... all Fail Right femoral - Fail Left fomoral - successful Peripheral vascuilar disease diagnosis charted Heart circulation visualized = 100% LAD occlusion Stent placed, circulation restored. Pt given 50mcg Fentanyl for pain Anterior wall motion absent. EF calculated at 26% Not candidate for ventricular assist device d/t peripheral vascular disease. Pt refuses DNR= Sent home 4 days later Standby for scenario #2
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