Case- Chest Pain

[Chrisclark]

You are dispatched from quarters for a Difficulty Breathing with chest pain call

Upon arrival you find BLS FD onscene and the Pt lying across the bed on his back with his knees drawn up slightly. He was found by his home healthcare nurse and has a history of prostate cancer. FD advises you that the Pt took 4 baby aspirin prior to arrival. Upon questioning the pt the pt states he has a tearing sensation in his back and no chest pain or difficulty breathing. upon assessment you find

CAAOX3 Skin- pale, cool, Dry HEENT- PERRL 0 JVD Trach- Midline Chest- BBS= Clear Abd- Soft and tenderx4 No distension slightly rigid Back- unremarkable Pelvis- Stable Ring Ext- PMSx4 ROM- Good No Neuro deficits noted O2 Sats- 94% Cap Refill- poor B/P- 84/42 HR- 150 RR- 22

Pt does not know what year it is or month, he states he does not want to go to the hospital. Upon telling him he will die without going to the hospital he agrees to go. He is place in tredelenburg and 2 large bore IVs are started in the truck and ran wide open, a 12 lead is performed - unremarkable- accucheck is WNL pt BP improves to 98/50 enroute to hospital.

In the ER his BP does not increase above 100 systolic despite 2 liters of fluid starting on the 3rd and trendelenburg

A CT scan is ordered what did it show?

[AnthonyM83]

Perforation of some kind....aortic? kidneys? reproductive system somewhere?

[Chrisclark]

close, not the aorta or the reproductive system,

no coment on the kidneys

[fiznat]

Like Anthony said, it sounds like some sort of perforation/dissection/aneurysm/etc. Without a mechanism of injury, pertinent finding, or history, I imagine it would be tough to determine exactly what vessel is causing the (assumed) bleed. Aorta would top my list. At this point though he is just hypotension with back pain. Could be a bleed, could be pericardial tamponade, could be muscular back pain and some other patholgy combined.

Not saying you did anything wrong, but what happened to permissive hypotension? 84/42 is a little low still, but I would have been extremely cautious with overloading this patient with fluid. This assumes we are in fact dealing with a bleed, but new PHTLS suggests that aggressive fluid loading in these patients can accelerate the hemmorage and dilute the remaining intravascular volume. Perfusion with blood made up of 1/2 NaCl is just as bad as hypoperfusion. Two IVs for sure, but perhaps not wide open.

So what did it turn out to be?

[OVeractiveBrain]

metastatic spinal cancer?

Dissecting descending anuerysm?

[AnthonyM83]

Where exactly in the back was it? Midline? Both sides? Close to flanks?

OPQRST?

SAMPLE??

[Chrisclark]

Ok this pt was not alert enough to give much info, ya'll got about as much as we did.

This Pt was suffering from kidney stones. The hypotension was a vasovagal reaction to the pain.

Also, we only gave him about a litter of fluid, the ER Doc continued the fluids and had the third back hung.

We thought he was an aortic dissection also, but the CT told otherwise.

[Dustdevil]

This Pt was suffering from kidney stones. The hypotension was a vasovagal reaction to the pain.

I know it's not as exciting as wide open bilateral large bore IVs, but this patient could have used a little "BS palliative care". Did that ever cross your mind?

Also, we only gave him about a litter of fluid...

[Chrisclark]

damn spell checker...

and he was presenting like an aortic dissection...

it would have been irresponsible to not have treated it as such

[Dustdevil]

and he was presenting like an aortic dissection...

it would have been irresponsible to not have treated it as such

Absolutely agreed. And good job on the assessment.

But aortic dissections need palliative care too.