Call from hell - difficulty breathing

[theotherphil]

I had a call to a regular diabetic who was hypoglyceamic and unresponsive, BM <2mmol/l. He was typical hypoglyceamic presentation and very clammy. Normally fit and well with no notable history. All vitals were within normal limits so we treat with O2, Glucagon IM and dextrose gel. He came round pretty quickly but the diaphoresis continued and he looked ghastly. He denied any pain but I wasn't happy. The guy I was working with looked quizically when I asked him the grab the monitor. I did a 12 lead and noticed ST elev in II, III and aVf with reciprocal changes in I and aVl....the patient was having a silent inferior MI! The patient is a regular hypo and we usually treat at home and leave him - I'm so glad I did that 12 lead. Treat with O2, Aspirin 300mg and GTN. Faxed the ECG to coronary care who arranged for the guy to go straight to the cath labs for Angioplasty.

[fiznat]

Didnt anyone else think CHF from the story? Transient SOB, increasing on laying down (typical of pulm. edema), elevated diastolic BP, rales can easially sound like rhonchi, normothermic, and a compensatory tachychardia which eventually gets out of control...

I donno... As I must I preface everything I say in this forum with the acknowledgement that I am still a medic student (almost done though), but I find it hard to justify the adenosine in this case. Even though the guy's rate was 170, I still have a hard time believing that this was a rate-related problem. By your own admission you said you thought it was a PE... so why treat the rate? I feel like I would have tried to focus on his breathing instead... I was thinking more along the lines of diuretics, nitro, and beta II agonists... I'm a student though, so-- anyone agree?

[stretcher monkey]

Silent MI's are sneaky and you need to look for it to find it. Recently went to 60+ YO male who was complaining of 'feeling dizzy' and nothing else (definately no pain). He just didn't look 'right'. Sure enough the 12-lead revealed an inferiolateral MI. Our guidelines state that the patient has to have 'typical' cardiac-type pain to receive pre-hospital thrombolysis or direct refferal to cath labs for primary angioplasty, so he was taken to the ED where the doc's agreed and he was sent to cath labs.

[OVeractiveBrain]

Always get a twelve lead, and make it count. The 12 lead is invaluable and takes only about 30 seconds - a minute to get. YOur partner can be setting them up while you do everything else. My viewpoint is that if you are an ALS crew, and youre going to the hospital with ALS established, your patient warrants a 12lead. That would be any Diff Breather, any Fatigure, any AMS, CP, or whatever else have you. Performing an appropriate 12 lead would have tipped you off to the MI. Ive taken 12 leads of guys in Vtach at 220-240 and had no difficulty reading the 12-lead, so rate should not be a deterrent. Usually, it is electrode placement, moving ambulance or electrcal disturbance ("No Cell Phones Allowed").

The 12-lead would have also fixed the SVT vs Physiologic Tachycardia. If it were a reentrant rhythm, P waves would be absent, regardless of the rate. If you were going to go after rate, it should have been a bit sooner, thouh I can see waiting until he goes over 150 and shows some signs of instability before trying to treat it. WIthout any slowing of the rhythm with 6mg, I would be concerned with, and hesitant to give any more.

The fact that he was having problems for the past several nights does seem to indicate something along teh lines of CHF. However, for him to code on you right then and there is a bit rare for a 60 yo CHFer without any real difficulty breathing. Pneumonia was where I was going as well, and PE seems pretty attractive given the painful inspiration. Then again, an MI has that same sign. Im pretty sure he had a silent MI that CAUSED the Pulmonary Edema, not the edema that caused the MI or the code. Whats worse is the guy had a language barrier, so getting a good history is rough as it is. You have to go with more of the signs and symptoms than the story.

Bottom line, DO A 12 LEAD EVERY PATIENT EVERY TIME

-OveractiveBrain