Arctickat Posted May 19, 2013 Posted May 19, 2013 So, I was called earlier to transport a 75 year old female to the CCU 150 miles away for investigation of Acute Coronary Syndrome. History is that she had sudden onset back pain between shoulder blades 24 hours prior. Throbbing in nature like she's being repeatedly stabbed but then resolved a short time later. She went to the doc who assessed her and sent her back home. Today at noon she had the same pain, 10/10 radiating to jaw and left arm. She went to the ED and their assesment included a Right arm BP 157/82 Left arm BP 132/76. Heart rate NSR at 60, Sats 95% on 3l, Lungs clear and equal, abd is soft and nontender. 12 lead shows inverted T waves in V1 - V3, 1mm S-T depression. Lab values, including trops are normal. Sorry, no picture of the ECG. Chest X-ray was unremarkable. No other diagnostic imaging was available. Upon my arrival she was on a heparin infusion at 1000 units per hour. Stat meds include Nitro, ASA, Enoxiparin, and Heparin. PmHx is Hypertension and diet controlled diabetes. as well as a family cardiac history. Our doc consulted with the cardiologist who decided the treatment plan I assessed the client who was now pain free. BP was similar to that noted above. Pulses were equal at wrists and feet and we began transport...but I have this nagging feeling.
Aussieaid Posted May 19, 2013 Posted May 19, 2013 Hmmm, nagging like a potential aortic dissection? Nitro good...ASA and heparin not so good.
ERDoc Posted May 19, 2013 Posted May 19, 2013 I agree that this is a little concerning. Chest xray is good at picking up about 80% of dissections but that is a big miss rate for something so important and a lot of times the findings are subtle and I would guess only visible with a retrospectroscope.
ChaseZ Posted May 20, 2013 Posted May 20, 2013 (edited) I am surprised they loaded Lovenox along with a Heparin drip. Good luck if it is a dissecting aneurysm. I think a Tridil Drip would have been beneficial until further diagnostics could be obtained. Edited May 20, 2013 by ChaseZ
HarryM Posted May 20, 2013 Posted May 20, 2013 (edited) Did they do a chest CT or MRI at ED? Edited May 20, 2013 by HarryM
Arctickat Posted May 20, 2013 Author Posted May 20, 2013 Did they do a chest CT or MRI at ED? Ahem... Chest X-ray was unremarkable. No other diagnostic imaging was available.
HarryM Posted May 20, 2013 Posted May 20, 2013 Ahem... Chest X-ray was unremarkable. No other diagnostic imaging was available. Ah right. Missed that. Not sure what your clinical guidelines are but if you are suspecting a dissection/aneurysm then the best thing to do enroute would be to keep HR under 60 and BP between 100-120 to reduce aortic wall stress. So maybe a beta-blocker and an anti-hypertensive. But otherwise you are a bit stuck unless you want to query the diagnosis with the D doctor.
Arctickat Posted May 20, 2013 Author Posted May 20, 2013 Unfortunately we don't have access to beta blockers in our scope...I've been trying to get Metoprolol, but it's a tough sell. What I did do was verify the blood pressure manually on both arms, called the receiving cardiologist to discuss my concerns, and got permission to d/c the heparin infusion. He told me that he wasn't aware from the doctors referral that the pain was described in such a manner, or that the BP was that different. Even though our local doc also suspected the DTA, she ruled it out when the chest X-ray appeared normal. I've asked for a followup diagnosis from the receiving facility so we can determine what actually happened.
systemet Posted May 20, 2013 Posted May 20, 2013 (edited) Certainly a possibility, but unequal bilateral B/Ps are a fairly insensitive / nonspecific finding. The patient's not particularly hypertensive, and the CXR is "clear". The heparin can be reversed with protamine at the receiving facility, if necessary. The lovenox seems like a poor choice if the risk of dissection is appreciated. I think you did the right thing here. Labetalol is probably a better option over metoprolol, if you're going to give something. There's a link to one registry here showing that pulse deficits were only found in ~ 15-20% of patients with dissection: http://jama.jamanetwork.com/article.aspx?articleid=192401 Hagen et al. The International Registry of Acute Aortic Dissection (IRAD)New Insights Into an Old Disease. JAMA. 2000;283(7):897-903. doi:10.1001/jama.283.7.897 Edited May 20, 2013 by systemet
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