Re: Syncope and hiccups

[Guest guest]

In a message dated 12/27/2000 3:57:33 PM Central Standard Time,

tonygarcia@... writes:

<

Physical exam + 12 lead + PulseOx

Good. Why?

gg

Re: [texasems-L] Syncope and hiccups

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[Guest guest]

Patient is 97% on room air, has been compliant with meds, and 12-lead shows

2.5 mm ST seg depression and Twave inversion in III and avF.

What now?

gg

[Guest guest]

Good. The right leads are OK but V2 & 3 are showing reciprocal changes.

There's no pain, however, just tightness and hiccups. Still need the NTG and

MS?

gg

[Guest guest]

Physical exam + 12 lead + PulseOx

[texasems-L] Syncope and hiccups

> Your 67 year old male patient has had a syncopal episode (no fall)

preceeded

> and followed by hiccups. Patient is now A & A & Ox3. No complaints of pain

but

> is somewhat dizzy, weak and borderline nausea. P 64, R 20 with

clear/equal

> BBS, BP 100/68. Takes a baby aspirin every other day, atenalol 25 mg

qd,

> terazocin 10 mg qd, and lisinopril 10 mg qd. Never had an episode like

this

> before. PMH of hypertension x 30 years. No allergies.

>

> Your team consists of an EMT-I and a Paramedic. What next?

>

> Gene Gandy

>

>

>

>

>

[Guest guest]

Also D-stick & O2 via NC unless high-flow is indicated by appearance

[texasems-L] Syncope and hiccups

> Your 67 year old male patient has had a syncopal episode (no fall)

preceeded

> and followed by hiccups. Patient is now A & A & Ox3. No complaints of pain

but

> is somewhat dizzy, weak and borderline nausea. P 64, R 20 with

clear/equal

> BBS, BP 100/68. Takes a baby aspirin every other day, atenalol 25 mg

qd,

> terazocin 10 mg qd, and lisinopril 10 mg qd. Never had an episode like

this

> before. PMH of hypertension x 30 years. No allergies.

>

> Your team consists of an EMT-I and a Paramedic. What next?

>

> Gene Gandy

>

>

>

>

>

[Guest guest]

Based on the PMH and 3 different BP meds, the pt vagaled down with the

hiccups. Pt gets O2 by mask, H & P, and a 12 lead EKG for arrhythmia.

Tony wrote:

> Physical exam + 12 lead + PulseOx

>

> [texasems-L] Syncope and hiccups

>

> > Your 67 year old male patient has had a syncopal episode (no fall)

> preceeded

> > and followed by hiccups. Patient is now A & A & Ox3. No complaints of pain

> but

> > is somewhat dizzy, weak and borderline nausea. P 64, R 20 with

> clear/equal

> > BBS, BP 100/68. Takes a baby aspirin every other day, atenalol 25 mg

> qd,

> > terazocin 10 mg qd, and lisinopril 10 mg qd. Never had an episode like

> this

> > before. PMH of hypertension x 30 years. No allergies.

> >

> > Your team consists of an EMT-I and a Paramedic. What next?

> >

> > Gene Gandy

> >

Steve Marshall EMT-P

s-marshall5@...

[Guest guest]

Physical exam because you should do one on every patient to a certain extent

and 12 lead because of age + syncope + cardiac HX

Re: [texasems-L] Syncope and hiccups

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> Content-Transfer-Encoding: 7bit

>

> >>

>

>

>

>

[Guest guest]

EKG 12 lead if available, physical exam, O2 nasal titrate to at least 95% FiO2

and pulse ox. Consider a saline lok.

Also check on patient's compliance in taking his meds. Consider medication side

effect (Ace inhibitor and Beta blocker) and transport. Recheck vitals signs

often.

Bernie Stafford EMTP

>>> wegandy@... 12/27/00 3:50:07 PM >>>

Your 67 year old male patient has had a syncopal episode (no fall) preceeded

and followed by hiccups. Patient is now A & A & Ox3. No complaints of pain but

is somewhat dizzy, weak and borderline nausea. P 64, R 20 with clear/equal

BBS, BP 100/68. Takes a baby aspirin every other day, atenalol 25 mg qd,

terazocin 10 mg qd, and lisinopril 10 mg qd. Never had an episode like this

before. PMH of hypertension x 30 years. No allergies.

Your team consists of an EMT-I and a Paramedic. What next?

Gene Gandy

[Guest guest]

continue O2, perform R side precordial leads (V4r/V5r/V6r - or just V4r) -

IF R sided AMI, USE CAUTION with NTG and MS but, with a fluid bolus to

increase preload, NTG OK as anti-ischemic

Re: [texasems-L] Syncope and hiccups

> Patient is 97% on room air, has been compliant with meds, and 12-lead

shows

> 2.5 mm ST seg depression and Twave inversion in III and avF.

>

> What now?

>

> gg

>

>

>

>

[Guest guest]

I agree, make sure it's NOT a Right sided MI. I would go ahead and give 160

mg ASA and continue the O2. I would seriously consider transport with lights

and sirens at this point. Something about time is muscle.....

Tony wrote:

> continue O2, perform R side precordial leads (V4r/V5r/V6r - or just V4r) -

> IF R sided AMI, USE CAUTION with NTG and MS but, with a fluid bolus to

> increase preload, NTG OK as anti-ischemic

>

> Re: [texasems-L] Syncope and hiccups

>

> > Patient is 97% on room air, has been compliant with meds, and 12-lead

> shows

> > 2.5 mm ST seg depression and Twave inversion in III and avF.

> >

> > What now?

> >

> > gg

> >

> >

> >

> >

>

--

Steve Marshall EMT-P

DFAB1 Quartz

s-marshall5@...

Ph. (972)995-2350

Pgr.(972)597-6921

[Guest guest]

From what you have described so far, there is presumptive evidence of

on-going ischemia and *possibly* an AMI. Is there any LVH or BBB? At this

point, with the info so far, I would give NTG prn titrated to BP and ECG,

start bilateral locks with at least one dbl lumen (just in case), and 2 mg

of MS to reduce pain/anxiety. Continue O2 and give 160-325mg of ASA if not

done already (MONA). Depending on the distance to the appropriate hosp (one

that can do both PTCA and Thrombolytics), transport via appropriate means.

tg

Re: [texasems-L] Syncope and hiccups

> Good. The right leads are OK but V2 & 3 are showing reciprocal changes.

> There's no pain, however, just tightness and hiccups. Still need the NTG

and

> MS?

>

> gg

>

>

>

>

[Guest guest]

Side note - I had a patient last weekend with a syncopal episode and HTN

history (no hiccups) with the following 12-lead changes:

new onset LBBB

net onset 1st degree block

2 mm elevation in v1

My conclusion was to treat as MI in progress with ASA and Nitro (and partner

agreed) as this would seem to point to a septal infarct affecting the AV

node.

Concurrence?

Mike

>

>Reply-To: egroups

>To: <egroups>

>Subject: Re: [texasems-L] Syncope and hiccups

>Date: Wed, 27 Dec 2000 23:27:22 -0600

>

>From what you have described so far, there is presumptive evidence of

>on-going ischemia and *possibly* an AMI. Is there any LVH or BBB? At this

>point, with the info so far, I would give NTG prn titrated to BP and ECG,

>start bilateral locks with at least one dbl lumen (just in case), and 2 mg

>of MS to reduce pain/anxiety. Continue O2 and give 160-325mg of ASA if not

>done already (MONA). Depending on the distance to the appropriate hosp (one

>that can do both PTCA and Thrombolytics), transport via appropriate means.

>

>tg

>

> Re: [texasems-L] Syncope and hiccups

>

>

> > Good. The right leads are OK but V2 & 3 are showing reciprocal changes.

> > There's no pain, however, just tightness and hiccups. Still need the

>NTG

>and

> > MS?

> >

> > gg

> >

> >

> >

> >

>

>

>

>

_________________________________________________________________

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[Guest guest]

R/O MI 1 baby aspirin , NGTsl and MS 2 mg IV push titrate, up to 10 mg or when

the tightness in his chest is gone. Recheck vital signs. Consider Thrombolytic

therapy or do the worksheet and immediate transport.

Bernie Stafford

>>> wegandy@... 12/27/00 5:29:22 PM >>>

Patient is 97% on room air, has been compliant with meds, and 12-lead shows

2.5 mm ST seg depression and Twave inversion in III and avF.

What now?

gg

[Guest guest]

Very good. He goes to the cath lab and gets rotorooted and stinted and lives

to eat chicken fried steak once again!!!

Thanks for participating.

GG

[Guest guest]

Interesting suggestion that we push MS until the tightness in the chest is

gone. I'm pretty neutral about that. Who thinks we should do that other

than Bernie, and why? Are there any studies that would show that we ought to

push MS in a case like this? What is the benefit of pushing it? What is the

detriment of NOT pushing it?

Gene

[Guest guest]

This may be zebras where there are only horses, but what about LVH with

impingment on the phrenic nerve, causing the hiccups?

" Leadership is action, not position "

Larry RN CFRN NREMTP

....and some other stuff

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[Guest guest]

MS reduces pain - pain causes catecholamine release - catecholamines

increase the workload on the heart and therefore oxygen demand. With a

myocardium that has evolving damage, MS is a good thing if there aren't any

other contraindications.

tg

Re: [texasems-L] Syncope and hiccups

> Interesting suggestion that we push MS until the tightness in the chest is

> gone. I'm pretty neutral about that. Who thinks we should do that other

> than Bernie, and why? Are there any studies that would show that we ought

to

> push MS in a case like this? What is the benefit of pushing it? What is

the

> detriment of NOT pushing it?

>

> Gene

>

>

>

[Guest guest]

Well, from a JCAHO stand point we are meeting their mandate to relieve a

patients pain, so this is good.

From the 'do no harm' stand point, assuming acceptible vitals, we are making

the patient feel better, which is doing not harm, thus this is good.

From a psychological stand point the patient is REALLY happy to no longer be

hurting, which should have the physiological effects of a> lowering their

BP, heart rate, and respiratory rate (I am late on this scenario so don't

know if that might be an issue, if their bp was low I might not want to do

this) as well as decreasing the workload on the heart (which is currently

deprived of oxygen/nutrients so decreasing its workload is good) and; b>

dilating the coronary arteries thus increasing blood flow (and thus oxygen

and nutrient flow) to the infarcted site.

I think that about covers they why it would be good as well as the why it

would be bad.

From my own personal experience with kidney stone pain (which I have been

told by a patient doesn't hold a candle to MI pain), I would NOT want to be

experiencing any pain of that magnitude for longer than I had to.

As for the, " They might become addicted to the Morphine, so we should

withold it " crowd, they have pretty much determined that patients in REAL

pain, don't become addicted from the stuff very quickly and if they do, they

are alive to get treatment.

Quick war story: Sitting in the ER one day when we get a phone call from a

local pharmacist who wants doctor authorization to refill a Morphine

prescription for a 92 year old cancer patient. The doctor doesn't hesitate

in giving authorization. Pharmacist asks, " But she got this prescription for

30 tablet (a 1-2 tablets tid for pain control) 5 days ago, I am worried that

she is becoming addicted. " Doctor looks at the phone and replies, " She is 92

years old. She has terminal cancer. She is in pain, or at least believes she

is. Who cares if she is becoming addicted?! " The moral of this story, " Make

the pain go away. Keep the patient alive for as long as you can, but make

the pain go away. " Does anyone on this list want to lay around in 10/10

chest pain (or 9/10, or 8/10, etc) for any longer than they have to? Do you

want your last minutes on earth being spent in screaming agony? If the

morphine won't cause an adverse physiologic action (IE: Death), GIVE IT!

Okay, the soap box is someone elses.

Webb, LP

FLW EMS, MO

_________________________________________________________________

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[Guest guest]

Sounds good to me. Phrenic nerve, diaphragm, LVH, all seem to go together,

don't they. Good thinking, Sir!

GG

[Guest guest]

In this case, as I recall, it was a " silent " MI, therefore little pain. So

is the MS really necessary? Any physicians care to weigh in on this? What

about beta-blockers?

gg

In a message dated 12/29/2000 8:38:29 Central Standard Time,

tonygarcia@... writes:

> Subj: Re: [texasems-L] Syncope and hiccups

>

>

> MS reduces pain - pain causes catecholamine release - catecholamines

> increase the workload on the heart and therefore oxygen demand. With a

> myocardium that has evolving damage, MS is a good thing if there aren't any

> other contraindications.

>

> tg

>

> Re: [texasems-L] Syncope and hiccups

>

>

> > Interesting suggestion that we push MS until the tightness in the chest is

> > gone. I'm pretty neutral about that. Who thinks we should do that other

> > than Bernie, and why? Are there any studies that would show that we ought

> to

> > push MS in a case like this? What is the benefit of pushing it? What is

> the

> > detriment of NOT pushing it?

> >

> > Gene

> >

> >

> >

[Guest guest]

Heartily agree with MW; however, the point of the original scenario was

syncope accompanied by hiccups in an otherwise painfree individual. The

point was to pick up that hiccups can go along with LVH and can signal an

ischemic event. Then we got off on MS. So, my question now is, ought the

patient with ST changes showing ischemia in II, III, and avF routinely get

the MS even if there's minimal or no chest pain, just chest discomfort?

Where there is pain involved, you get NO argument from me. I think MS is a

wonderful drug, as have thousands before me.

gg

a message dated 12/29/2000 9:54:34 Central Standard Time,

dfluffy01@... writes:

> Subj: Re: [texasems-L] Syncope and hiccups

> Date: 12/29/2000 9:54:34 Central Standard Time

> From: dfluffy01@... (M Webb)

> Reply-to: <A HREF= " mailto:egroups " >egroups</A>

> To: egroups

>

>

>

>

> Well, from a JCAHO stand point we are meeting their mandate to relieve a

> patients pain, so this is good.

>

> From the 'do no harm' stand point, assuming acceptible vitals, we are

> making

> the patient feel better, which is doing not harm, thus this is good.

>

> From a psychological stand point the patient is REALLY happy to no longer

> be

> hurting, which should have the physiological effects of a> lowering their

> BP, heart rate, and respiratory rate (I am late on this scenario so don't

> know if that might be an issue, if their bp was low I might not want to do

> this) as well as decreasing the workload on the heart (which is currently

> deprived of oxygen/nutrients so decreasing its workload is good) and; b>

> dilating the coronary arteries thus increasing blood flow (and thus oxygen

> and nutrient flow) to the infarcted site.

>

> I think that about covers they why it would be good as well as the why it

> would be bad.

>

> From my own personal experience with kidney stone pain (which I have been

> told by a patient doesn't hold a candle to MI pain), I would NOT want to be

> experiencing any pain of that magnitude for longer than I had to.

>

> As for the, " They might become addicted to the Morphine, so we should

> withold it " crowd, they have pretty much determined that patients in REAL

> pain, don't become addicted from the stuff very quickly and if they do,

> they

> are alive to get treatment.

>

> Quick war story: Sitting in the ER one day when we get a phone call from a

> local pharmacist who wants doctor authorization to refill a Morphine

> prescription for a 92 year old cancer patient. The doctor doesn't hesitate

> in giving authorization. Pharmacist asks, " But she got this prescription

> for

> 30 tablet (a 1-2 tablets tid for pain control) 5 days ago, I am worried

> that

> she is becoming addicted. " Doctor looks at the phone and replies, " She is

> 92

> years old. She has terminal cancer. She is in pain, or at least believes

> she

> is. Who cares if she is becoming addicted?! " The moral of this story, " Make

> the pain go away. Keep the patient alive for as long as you can, but make

> the pain go away. " Does anyone on this list want to lay around in 10/10

> chest pain (or 9/10, or 8/10, etc) for any longer than they have to? Do you

> want your last minutes on earth being spent in screaming agony? If the

> morphine won't cause an adverse physiologic action (IE: Death), GIVE IT!

>

> Okay, the soap box is someone elses.

> Webb, LP

> FLW EMS, MO

> _________________________________________________________________

> Get your FREE download of MSN Explorer at http://explorer.msn.com

>

>

>

>

>

>

>

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[Guest guest]

Well, Gene, I TOLD you I was coming into the scenario late! *grin*

Okay, so this guy has EKG changes in II, III, and avF, is experiencing

'chest discomfort' as opposed to 'chest pain', and has the hiccups. Okay, if

we assume that the patient is having an eschemic event (IE: a heart attack)

then we can simply fall back on the phrase, " All patients with chest pain

are met by MONA. " (Morphine, Oxygen, Nitroglycerine, Aspirin)

I would say that we would have to look at the level and quality of the

'discomfort'. Not only what the patient says it is, but what his general

appearance and vitals say it is. If he is clutching his chest and 'just

can't get comfortable', yeah, give the morphine. If he is sitting there

saying, " Nah, I'm fine. Can I have a sandwich? " , appears in no distress, and

rates the 'discomfort' as 1/10 or less, I don't think I would give the

morphine. Flip side, no matter what his/her appearence, if they rate the

'discomfort' as 10/10, give the morphine.

Then we would need to reassess the patients response after say 4mg of

Morphine. If the patient says the discomfort is less, then we are doing good

and should keep going until the pain is gone. If the patient says the

discomfort is worse, we need to STOP what we are doing and think of

something else. If the patient says there is no change we need to decide if

we want to continue with the therapy (the patient may just require MORE

Morphine to get the job done), change out treatment, or punt (call Medical

Direction and ask his/her opinion).

Okay, I am done. Have a Happy New Year all,

Webb, LP

FLW EMS, MO

_________________________________________________________________

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[Guest guest]

In a message dated 12/29/00 9:54:00 AM Central Standard Time,

dfluffy01@... writes:

> If the

> morphine won't cause an adverse physiologic action (IE: Death), GIVE IT!

>

>

Having had kidney stoneS and also being pregnant at the time..... GIVE THE

MEDS ASAP. They are a real bitch, no where near the pain of labor! Yes they

gave me big doses of Demoral and there was not problem with the baby

[Guest guest]

,

I had that same type of conversation with my grandmother's oncologist.

She was mets to the bones and brain at least and the doc was saying she

could live 10 years like this! I couldn't believe that statement, but the

doc had put her on hospice which is supposed to be terminal with 6 mos or

less to live. So, I'd asked for morphine titrated to comfort (before the

days of pt. pumps for pain meds). The doc said no, she may become addicted!

I lost it and explained that she may have missed this class in med school,

but my grandmother was 70 yo, terminal without a doubt, and she had no

reason to be in pain the last few days, months, years of her life! I

shouldn't have handled it the way I did, but Grandma did get the Morphine

and got it whenever she asked (or we asked for her!).

Sometimes you have to take care of those who took care of you!

Jana

Re: [texasems-L] Syncope and hiccups

> Well, from a JCAHO stand point we are meeting their mandate to relieve a

> patients pain, so this is good.

>

> From the 'do no harm' stand point, assuming acceptible vitals, we are

making

> the patient feel better, which is doing not harm, thus this is good.

>

> From a psychological stand point the patient is REALLY happy to no longer

be

> hurting, which should have the physiological effects of a> lowering their

> BP, heart rate, and respiratory rate (I am late on this scenario so don't

> know if that might be an issue, if their bp was low I might not want to do

> this) as well as decreasing the workload on the heart (which is currently

> deprived of oxygen/nutrients so decreasing its workload is good) and; b>

> dilating the coronary arteries thus increasing blood flow (and thus oxygen

> and nutrient flow) to the infarcted site.

>

> I think that about covers they why it would be good as well as the why it

> would be bad.

>

> From my own personal experience with kidney stone pain (which I have been

> told by a patient doesn't hold a candle to MI pain), I would NOT want to

be

> experiencing any pain of that magnitude for longer than I had to.

>

> As for the, " They might become addicted to the Morphine, so we should

> withold it " crowd, they have pretty much determined that patients in REAL

> pain, don't become addicted from the stuff very quickly and if they do,

they

> are alive to get treatment.

>

> Quick war story: Sitting in the ER one day when we get a phone call from a

> local pharmacist who wants doctor authorization to refill a Morphine

> prescription for a 92 year old cancer patient. The doctor doesn't hesitate

> in giving authorization. Pharmacist asks, " But she got this prescription

for

> 30 tablet (a 1-2 tablets tid for pain control) 5 days ago, I am worried

that

> she is becoming addicted. " Doctor looks at the phone and replies, " She is

92

> years old. She has terminal cancer. She is in pain, or at least believes

she

> is. Who cares if she is becoming addicted?! " The moral of this story,

" Make

> the pain go away. Keep the patient alive for as long as you can, but make

> the pain go away. " Does anyone on this list want to lay around in 10/10

> chest pain (or 9/10, or 8/10, etc) for any longer than they have to? Do

you

> want your last minutes on earth being spent in screaming agony? If the

> morphine won't cause an adverse physiologic action (IE: Death), GIVE IT!

>

> Okay, the soap box is someone elses.

> Webb, LP

> FLW EMS, MO

> _________________________________________________________________

> Get your FREE download of MSN Explorer at http://explorer.msn.com

>

>

>

>

>

_________________________________________________________