ASA and NTG or no?

[ERDoc]

First: Always treat the patient, not the machines.

No, just no. The machines provide important information about the pt, that the pt cannot provide. Treat the pt and the machines as appropriate.

[scubanurse]

Sometimes people may be asymptomatic but their EKG is telling me otherwise, should I ignore ST elevation or extremely peaked t-waves? How about multifocal pvc's the patient is oblivious to?

[triemal04]

That's LVH, not a STEMI.

Most likely anyway, based of the crappy 12lead. There are some things that are odd about your exam, and good for picking up on those and following up, but you probably should have dug further, and gotten a better 12-lead.

I don't see a problem with withholding ASA; I'd expect him to be on a blood thinner right now anyway.

I'm not sure why a c-collar was placed.

How did you present this patient at the hospital?

[mikeymedic1984]

HMMMM , YOU have a patient that is A&Ox 3, 4, 5 , 6 -- whatever you measure, and they have a glucose of 12 ----- do you give D50, or do you think that possibly because the glucometer and strips are kept in an ambulance where the factory prescribed temperatures are not maintained, that the glucometer could be wrong. Technology is a great thing, but it should be used to CONFIRM what you think the diagnosis is. not used to give you a diagnosis. I know this is crazy to all you new medics, but this is why youall give NTG to people with chest pain that have just been in an MVC and hit the steering wheel and have chest pain. Dont practice cook=book medicine, use your brain.

[triemal04]

And if you're to stupid to determine how to correlate what you find during your history and physical exam with what you find by using all dem dang ol' purty toys then you are correct, you should ignore what "machines" tell you.

In fact at that point you should ignore what you find on your h&p and find a different line of work all together.

Because you aren't smart enough to be a paramedic.

It's unfortunate that some people are allowed to continue even when that's the case.

Edited December 13, 2014 by triemal04

[ERDoc]

There are examples for both sides, as has been pointed out by Scuba and Mikey. We can sit here and go around on this merry-go-round AGAIN or just drop it and get back to worthwhile discussion.

[systemet]

Re: the above; it's a gestalt, you take all available information, formulate a list of DDx, and find a working diagnosis. It's not treat the X, not the Y. It's treat both.

Okay, I am humbly submitting myself for review - not humiliation or ridicule, but some good, constructive criticism.

This is a great attitude, so we should keep this discussion constructive.

A cervical collar was placed. The patient resisted being placed on a long backboard and was not forced.

I think there are two questions here: (1) Was SMR indicated? and (2) How should SMR be performed?

On one hand, you have a ground level fall in a 58 year old man. He's moving all four limbs without gross motor weakness. There's no obvious deformity to the c-spine. On the other hand, it's not clear how alert he is, and whether he would be able to report any paresthesia or sensory deficits that he might be experiencing.

For c-spine rule-out, the first question is whether there's a potential mechanism., I would submit that a ground level fall in a 58 year old, probably isn't. But this is a matter of debate, and how you interpret this probably dependings on practice in your area. If you do feel that a potential mechanism exists, then, as indicated by ErDoc who's much smarter than me, then SMR is mandated.

As to how SMR should be performed, I think the best choice would be to place the patient supine, with a C-collar on, and instructions not to move their head. If he is hypoxic, and becomes distressed while supine, they he could be placed semi-Fowlers, with the same.

If he needs to be spinalled, and can't follow instructions, then you have to decide if he can tolerate being supine. If he can, a scoop or long board might be in order.

Based on the history of falls and likely history of syncope, a Lead II ECG was obtained. Initially, Lead II indicated a sinus rhythm with tri-gemini PVCs. The patient did not appear hypoxic, but he was placed on high-flow oxygen via mask. PVCs seemed to resolve. Patient's ECG converted to A-Fib at a rate of 50-100.

My opinion, and it's just that, is that none of the ECGs attached show a.fib. I didn't see this patient, but my opinion is that I'd be unlike to placed oxygen on someone who didn't appear hypoxic, just because they have a few PVCs, and I can't get an SpO2.

The question here is, are these PVCs acute or chronic? I don't see anything here that really pushes towards acute hypoxia as a cause. It seems more likely that this is a chronic exam finding for this patient.

A twelve-lead ECG was obtained. The initial twelve-lead indicated 2-3 mm elevation in V1 and V2 with reciprocal changes in V5, V6. After about ten minutes, a second twelve-lead was obtained. The second twelve lead indicated continued elevation with the return of the PVCs.

So, as others have mentioned, your ECG has a lot of artifact. Reading through it, and making my best attempt to fill in the gaps, I see a sinus rhythm with probable LAFB, with frequent PVCs (probably from high on the posterior wall of the RV), and Q waves with some very modest ST elevation in V1, V2 (and maybe V3, V4). There's also voltage criteria for LVH.

I think this represents prior cardiac disease that either the patient is unaware of, or the staff are unaware of. It may or may not have been seen by a healthcare worker before (you'd need old ECGs for comparison). As this ST elevation is modest (much < 25% of the preceding Q wave), I'd suggest it's probably persistent elevation from an old infarction, versus a new acute event. Serial ECGs and troponins will be necessary to know for sure. In any case, there's no criteria for diagnosing STEMI in a background of LVH. I'm sure there's cardiologist who can do it, but I don't think it's an EMS thing.

I don't see the lateral ST depression, and just want to point out that you really don't see reciprocal ST depression in V5-V6. Especially not to anterior elevation, which typically only produces reciprocal change inferiorly in the presence of lateral involvement. If it is there, another possibility is LV strain, but like I said, I don't see it.

Like I said, I feel like I missed something. Did I? What would you do differently?

I don't think I would have put on oxygen, or attempted SMR. My primary concern here would probably be the risk of traumatic brain injury from the impact, especially if the patient is anticoagulated, and I expect they would get wound closure and maybe a CT.

Then there's the question of whether there was a medical reason for the injury. It's unclear from the history whether this was a true syncopal event. If there has been a progressive functional decline, sepsis and medical change/interaction have to be high up the list of differentials. It's possible he's NSTEMI'd, or having a TIA/CVA, but I don't think there's anything definitive in the story here.

Just opinions from another paramedic.

Edited December 16, 2014 by systemet

[mikeymedic1984]

There is a study out there somewhere that highlights the increased mortality rate of elderly patients with ground level falls; I will see if I can dig it up. But basically, as you age, your brain shrinks, leaving more room in your skull to bleed into. Therefore, elderly patients with a brain bleed may not show signs and symptoms for hours/days after their fall (and since it is only a ground level fall with a minor contusion/laceration on their head, and there are no signs or symptoms of anything worse, we (EMS) fail to transport, or the ER fails to scan them, and discharges them home).

I wouldn't say you did anything wrong, if anything you overthought what you had, which may have steered you away from the most probably diagnosis (CVA/TIA or brain injury from the falls), which isnt necessarily a bad thing, I would rather you "THINK" about all possibilities (not necessarily ACT on all possibilities), rather than always assume the obvious; as long as you are not providing dangerous or unneeded treatments for the most unlikely cause versus the most obvious cause, there is nothing wrong with overthinking.

You had too much artifact in your 12 lead to use for any diagnosis. Lots of elderly people have horrible looking EKGs every day of their life. Not to say that trigeminy or PVCs shouldn't grab your attention, but in the elderly who are asymptomatic of an acute cardiac event, and have a cardiac history, I wouldn't be reaching for the drug box immediately. We can argue about the use of a spine board, I probably would not have done it, but after four days of multiple falls, I can not fault you for doing it (until such time that we have x-ray/ct scanners on the ambulance).

IF YOU DID ANYTHING WRONG, IT WOULD BE WHAT YOU DIDN'T MENTION:

Hopefully you transported this patient to a Stroke Certified Hospital or a Trauma Center where a Neuro-Surgeon was available. If you transported this patient to "PODUNK COUNTY GENERAL HOSPITAL" with no neuro capabilities, that would have been a huge mistake. The reason I say this is that you noted the patient was released from the ER that same day for hypoxia after multiple days of falls/syncopal episodes (multiple falls/syncopal episodes in an elderly patient in a short span of time should have at least got him a 24hour Observation admission ---- not a good sign that this hospital discharged him --- unless the family refused to let him be admitted and sent him back to the NH); I am guessing you transported back to that same ER ??????

[scubanurse]

What's SMR? This is what I found when I googled SMR medical abbreviation :

SMR

Abbreviation for:
senior medical resident
severe mental retardation
sexual maturity rating
standard metabolic rate
standardised morbidity ratio
standardised mortality ratio, see there
streptomycin resistant
submucosal resection

None of those fit in this scenario though.

Edited December 16, 2014 by scubanurse

[ERDoc]

I wouldn't consider 58y/o as elderly (but I may be biased since my 40th birthday is less than a year away). Although the meds are not listed, it is possible that he is on Plavix, et al, given the stroke history. The staff states he is a little "disoriented", so can we truly clear his c-spine clinically? I guess it depends on our personal exam. I don't see a need for a stroke or trauma center. This is something that can easily be worked up in most ERs, although I question the one the pt was originally at. To answer the OPs original questions, I do not think nitro is indicated and I would hold aspirin until the head CT is clear.