Case- Chest Pain

[OVeractiveBrain]

Hypotension + Vasodilation = reduced preload in a HYPOtensive patient = reduced starling forces leading to complete failure of the heart as a pump.

Hypotension + MS usually results in exacerbated hypotension. If some one is AMS as a result of the pathology (since im assuming this person is not normally altered, and presentation prior to the CT scan was highly suspect for an anuerism) and you give them anything to drop their pressure MORE, you are probably going to kill them. Thats why MS usually has an absolute systolic pressure of 90 and a risk benefit sys of 100 for ACS patients.

In this particular case, being that it was a tachycardic hypotensive "kidney stone," which i still do not believe is the only pathology, it might be a good idea. Given the presentation prehospitally, I would not go near morphine.

Dissections is the loss of blood volume between the intima and media of the arteries. Aka, youve already lost blood volume. Anneurysms that present tachycardic and hypotensive are massively weeping or burst already. Massive bleeding is not fixed by morphine. The vessels that are susecptable to dissection and aneurysm are those on the highest pressure system in the body. In an attempt to minorly fix the high pressure system on the vessels near to the heart you would most certainly compromise distal organ perfusion. MOrphine is great when they have an aneurism that has not ruptured, or is only slightly weeping and causing mesenteric irritation (blood + peritoneal organs can = pain). That is usually only after a CT scan.

I say I dont buy the diagnosis only because kidney stones, even in light of a "vagal response" should not be tachycardic and hypotensive. Now if you told me he has stage IV prostate cancer which has metastized to the spinal cord and brain (as i joked in my initial response) along with a kidney stone, i might agree.

[emt322632]

Any meds that could have caused the hypotension? Didn't get a med list with the presentation so I'm just curious.

[JakeEMTP]

Question,

So if we suspect a AAA in the field since it is virtually impossible be certain, would you treat with vasopressors such as epinephrine or norepinephrine? I thinking based on the patients presentation and vitals it is more Hypotension.

If we're thinking kidney stones, how about toradol?

I'm really just tossing this out there. I don't know for certain but trying to work it out in my mind ( what little of it there is left ). I could just as easily dismiss my theory, I'm just wondering what you guys and gals might think. I might be completely off my rocker here too, which is entirely possible.

[Ridryder 911]

Hypotension + Vasodilation = reduced preload in a HYPOtensive patient = reduced starling forces leading to complete failure of the heart as a pump.

Hypotension + MS usually results in exacerbated hypotension. If some one is AMS as a result of the pathology (since im assuming this person is not normally altered, and presentation prior to the CT scan was highly suspect for an anuerism) and you give them anything to drop their pressure MORE, you are probably going to kill them. Thats why MS usually has an absolute systolic pressure of 90 and a risk benefit sys of 100 for ACS patients. .

The main objective on a triple A is to allow permissive hypotension. In fact most practitioners prefer to allow and encourage hypotension > 70 & < 90 systolic in AAA. It is not unusual to establish Nipride IV med.'s & even NTG drips to permit deceased pressure on the anyeursm. It is our standard practice to administer M.S. to permit such hypotension, again to monitor closely but much rather have controlled hypotension than a pressure >100 systolic.

Vasopressors should be used very cautiously, and only to produce & maintain circulation level pressures for cerebral, coronary and renal perfusion. Again, increasing pressure may only execebrate the aneurysm.

Toradol IV is great for renal calculi, I have found it to be one of those med.'s to either work or not.

R/r 911

[JakeEMTP]

Thanks Ridryder. Great information, as usual.

[Dustdevil]

Yep, when was the last time you've seen anyone take a manual BP in an ER.

Several times today.

I say I dont buy the diagnosis only because kidney stones, even in light of a "vagal response" should not be tachycardic and hypotensive.

I can assure you that it happens. This case is almost identical to one I had in February, vital signs and all.

[chbare]

I have often seen renal calculi present with both tachycardia and hypotension. The problem with any pathology in the retroperitoneal cavity is the presentation of the pain. In some cases the pain masquerades as the pain we associate with a compromised AAA.

In any case, the ER was absolutely correct to obtain a CT, you will be able to look for both types of pathology.

Toradol is very effective in decreasing the pain associated with renal calculi. If we look at the action of the medication, we can see why. With renal calculi, we have spasm and inflammation of the ureter. Toradol has inflammation reducing and subsequent antispasm effects.

One thing to consider with Toradol however, is the fact that NSAIDS also have antiplatelet effects. In patients who may receive extracorporeal shock wave lithotripsy the risk of perinephric hemorrhage is much higher with NSAIDS on board. In addition, we need to screen people for/with pre-existing bleeding problems and the typical contraindications to NSAID use.

The following is an article on renal calculi diagnosis and management. It is a little dated, but the information is good in any event.

http://www.aafp.org/afp/20010401/1329.html

Take care,

chbare.

[fiznat]

Good case study. Atypical presentation and a nice little red herring thrown in the mix. I've learned something. :thumbright:

We should have an archive of these somewhere. ...If nothing else other than a stickey that has consolidated links to all of the (many!) quality case studies we've had.

[firefighter523]

Overactive, please look closely to my post, obviously if you give MS to a systolic pressure below 100 (thats being cautious) in any case out in the field you are wrong. I was only stating the physiology of MS on susceptible arteries. I don't think I have to explain to you, that surgery is the only option in AAA.

[ERDoc]

Hypotension + MS usually results in exacerbated hypotension. If some one is AMS as a result of the pathology (since im assuming this person is not normally altered, and presentation prior to the CT scan was highly suspect for an anuerism) and you give them anything to drop their pressure MORE, you are probably going to kill them. Thats why MS usually has an absolute systolic pressure of 90 and a risk benefit sys of 100 for ACS patients.

In this particular case, being that it was a tachycardic hypotensive "kidney stone," which i still do not believe is the only pathology, it might be a good idea. Given the presentation prehospitally, I would not go near morphine.

Dissections is the loss of blood volume between the intima and media of the arteries. Aka, youve already lost blood volume. Anneurysms that present tachycardic and hypotensive are massively weeping or burst already. Massive bleeding is not fixed by morphine. The vessels that are susecptable to dissection and aneurysm are those on the highest pressure system in the body. In an attempt to minorly fix the high pressure system on the vessels near to the heart you would most certainly compromise distal organ perfusion. MOrphine is great when they have an aneurism that has not ruptured, or is only slightly weeping and causing mesenteric irritation (blood + peritoneal organs can = pain). That is usually only after a CT scan.

I say I dont buy the diagnosis only because kidney stones, even in light of a "vagal response" should not be tachycardic and hypotensive. Now if you told me he has stage IV prostate cancer which has metastized to the spinal cord and brain (as i joked in my initial response) along with a kidney stone, i might agree.

Just to clarify a few things. The absolute systolic pressure for morphine is whatever the doctor feels like it is. It is a matter of how big your cajones are. I would agree that in this case I would probably not give it. Fentanyl might be a better choice.

When you have a pt with a suspected or confirmed disection the treatment is to decrease both the blood pressure and heart rate. The pulse acts like a hammer banging on the disection. You want to decrease how hard you hit the disection as well as how often you hit it. For this reason, morphine might not be the best option as you can produce a reflex tachycardia. This is why we give Nitroprusside (reduces BP) as well as esmolol (reduces BP and heart rate). You can reduce the BP enough to minimize the risk of worsening the disection and not compromise the other organ systems.

You generally do not have a large loss of blood volume from a disection. Yes there is blood between the layers of the vessel but it is not a large amount. The problems with disections is that they can cut off other important vessels coming off of the aorta such as the subclavians (produces stroke), coronaries (produces an MI), renals (produces renal failure) or mesenterics (bowel ischemia).

Aneurysms will become hypotensive and tachycardic when they rupture. Slow leaks will generally not cause any changes in vitals, but you might see an anemia depending on the rate of the leak.

Vasovagal episodes can produce vitals such as those that the pt had. A little more experience when you reach 3rd year will show you this.

This pt had a great story for dissection and should be treated as such until proven otherwise.