Guest guest Posted July 25, 2006 Report Share Posted July 25, 2006 Uncle Gene: What's the blood pressure? Heart rate? Other vitals? History? -Wes (probably an eager EMT) In a message dated 7/25/2006 10:35:15 PM Central Daylight Time, wegandy1938@... writes: Well, kids, Uncle Gene thinks it's time for a new puzzler. This one is for a free trip to Opdyke West, TX to enjoy the July weather. While this is for paramedics, knowledgeable, precocious, and eager EMTs are welcome to chime in. Your 58 year old male patient complains of chest pain which began approximately one hour prior to your arrival at his side. He relates that the pain is now 10 on a 10 scale, has not diminished since it started, and he is in great distress, with breathing difficulty, a look of panic in his eyes, ashen, moist skin, and he also complains of nausea. He begs you to help him. Your partner places the pulse oxymeter on him and begins to set up oxygen. The pulse ox reads 97%. He is placed on 12 lpm/NRB, and you have now placed the electrodes for your monitor on his chest. Unfortunately, your service has not yet purchased 12-lead monitors, so your monitor is designed to read leads I, II, and III. As your partner administers an aspirin to the patient, you watch the monitor in Lead II and see sinus rhythm with a high ST elevation. Switching to lead I, you note sinus rhythm with ST depression, and in Lead III you see marked ST segment elevation. Your partner now has an IV established in the left arm, and he asks you whether you want to hang NS or place a saline lock. All the while your patient is begging you to do something about his pain. Should you go with a saline lock or hang NS? Should you administer nitroglycerine? Morphine? Are there any other interventions you can do to help you decide those issues? If so, what? You are 12 minutes from a community hospital with a small ER and no cath lab and this is where your patient wants you to take him. You are 25 minutes from a large teaching hospital with a cath lab. What should your destination be and if you determine to go to the larger hospital, what do you tell your patient to get him to agree? Gene G. [Non-text portions of this message have been removed] Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 25, 2006 Report Share Posted July 25, 2006 I'm going with an inferior MI affecting the right coronary artery , as indicated by the ST elevations in leads II and III. The reciprocal change in lead I is also indicative of this form of MI. I'm going to go with the saline lock, due to his current blood pressure already being elevated. Holding off on the NTG for now. I'd encourage my patient to go to the teaching hospital because he needs a cath lab which the community hospital does not have. -Wes (eager EMT) In a message dated 7/25/2006 10:36:07 PM Central Daylight Time, wegandy1938@... writes: Well, kids, Uncle Gene thinks it's time for a new puzzler. This one is for a free trip to Opdyke West, TX to enjoy the July weather. While this is for paramedics, knowledgeable, precocious, and eager EMTs are welcome to chime in. Your 58 year old male patient complains of chest pain which began approximately one hour prior to your arrival at his side. He relates that the pain is now 10 on a 10 scale, has not diminished since it started, and he is in great distress, with breathing difficulty, a look of panic in his eyes, ashen, moist skin, and he also complains of nausea. He begs you to help him. Your partner places the pulse oxymeter on him and begins to set up oxygen. The pulse ox reads 97%. He is placed on 12 lpm/NRB, and you have now placed the electrodes for your monitor on his chest. Unfortunately, your service has not yet purchased 12-lead monitors, so your monitor is designed to read leads I, II, and III. As your partner administers an aspirin to the patient, you watch the monitor in Lead II and see sinus rhythm with a high ST elevation. Switching to lead I, you note sinus rhythm with ST depression, and in Lead III you see marked ST segment elevation. Your partner now has an IV established in the left arm, and he asks you whether you want to hang NS or place a saline lock. All the while your patient is begging you to do something about his pain. Should you go with a saline lock or hang NS? Should you administer nitroglycerine? Morphine? Are there any other interventions you can do to help you decide those issues? If so, what? You are 12 minutes from a community hospital with a small ER and no cath lab and this is where your patient wants you to take him. You are 25 minutes from a large teaching hospital with a cath lab. What should your destination be and if you determine to go to the larger hospital, what do you tell your patient to get him to agree? Gene G. [Non-text portions of this message have been removed] Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 25, 2006 Report Share Posted July 25, 2006 This looks like Right BBB. I would give no Nitro as peripheral return is already compromised, and will definitely give Morphine for the pain. Inform him that he needs to go to the hospital with cath lab. > > Well, kids, Uncle Gene thinks it's time for a new puzzler. This one is for > a free trip to Opdyke West, TX to enjoy the July weather. > > While this is for paramedics, knowledgeable, precocious, and eager EMTs are > welcome to chime in. > > Your 58 year old male patient complains of chest pain which began > approximately one hour prior to your arrival at his side. He relates that the pain is > now 10 on a 10 scale, has not diminished since it started, and he is in great > distress, with breathing difficulty, a look of panic in his eyes, ashen, moist > skin, and he also complains of nausea. He begs you to help him. > > Your partner places the pulse oxymeter on him and begins to set up oxygen. > The pulse ox reads 97%. He is placed on 12 lpm/NRB, and you have now placed > the electrodes for your monitor on his chest. Unfortunately, your service > has not yet purchased 12-lead monitors, so your monitor is designed to read > leads I, II, and III. As your partner administers an aspirin to the patient, you > watch the monitor in Lead II and see sinus rhythm with a high ST elevation. > Switching to lead I, you note sinus rhythm with ST depression, and in Lead > III you see marked ST segment elevation. > > Your partner now has an IV established in the left arm, and he asks you > whether you want to hang NS or place a saline lock. All the while your patient is > begging you to do something about his pain. > > Should you go with a saline lock or hang NS? Should you administer > nitroglycerine? Morphine? > > Are there any other interventions you can do to help you decide those issues? > If so, what? > > You are 12 minutes from a community hospital with a small ER and no cath lab > and this is where your patient wants you to take him. You are 25 minutes > from a large teaching hospital with a cath lab. What should your destination be > and if you determine to go to the larger hospital, what do you tell your > patient to get him to agree? > > Gene G. > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 26, 2006 Report Share Posted July 26, 2006 Hmm...sounds like he's got problems. A manual 12 lead, ASA PO, IV NS TKO, high flow O2, position of comfort and morphine. I would also strongly encourage him to go to the larger teaching hospital using any means possible (I don't play fair...wife, kids...etc). I would hold off on the Nitro until I got a good 12 lead and might still hold off then depending on the outcome of the 12 lead. Family history, previous history would be nice but he's still getting the same treatment either way. Vaughn EMT-P > > > > Well, kids, Uncle Gene thinks it's time for a new puzzler. This > one is for > > a free trip to Opdyke West, TX to enjoy the July weather. > > > > While this is for paramedics, knowledgeable, precocious, and eager > EMTs are > > welcome to chime in. > > > > Your 58 year old male patient complains of chest pain which began > > approximately one hour prior to your arrival at his side. He > relates that the pain is > > now 10 on a 10 scale, has not diminished since it started, and he is > in great > > distress, with breathing difficulty, a look of panic in his eyes, > ashen, moist > > skin, and he also complains of nausea. He begs you to help him. > > > > Your partner places the pulse oxymeter on him and begins to set up > oxygen. > > The pulse ox reads 97%. He is placed on 12 lpm/NRB, and you have > now placed > > the electrodes for your monitor on his chest. Unfortunately, your > service > > has not yet purchased 12-lead monitors, so your monitor is designed > to read > > leads I, II, and III. As your partner administers an aspirin to > the patient, you > > watch the monitor in Lead II and see sinus rhythm with a high ST > elevation. > > Switching to lead I, you note sinus rhythm with ST depression, and > in Lead > > III you see marked ST segment elevation. > > > > Your partner now has an IV established in the left arm, and he asks you > > whether you want to hang NS or place a saline lock. All the while > your patient is > > begging you to do something about his pain. > > > > Should you go with a saline lock or hang NS? Should you administer > > nitroglycerine? Morphine? > > > > Are there any other interventions you can do to help you decide > those issues? > > If so, what? > > > > You are 12 minutes from a community hospital with a small ER and no > cath lab > > and this is where your patient wants you to take him. You are 25 > minutes > > from a large teaching hospital with a cath lab. What should your > destination be > > and if you determine to go to the larger hospital, what do you tell > your > > patient to get him to agree? > > > > Gene G. > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 26, 2006 Report Share Posted July 26, 2006 Here is my 2 cents: High flow O2 IV NS @ TKO full set of vitals hit the road to the teaching hospital. Lung sounds position of comfort IF vital support Nitro with CAUTION if vitals support Mophine Not up on the whole move the leads around to get a pic of the rt side procedure. (got a LP12 with 12 lead cap) Damn technology Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 26, 2006 Report Share Posted July 26, 2006 Depending upon protocols for getting your patient to the closest facility. The explanation of where he may best be served would be something you would need to explain to him. I would start a line of NS at TKO. This is with the knowledge that if we are seeing those changes the patient could arrest at any time. Depending upon the vital signs ( which I did not see given) I would also administer some ntg. being prepared for the fact that this may or may not relieve the pain. Understanding that most ER docs want you to follow the full protocol (i.e. 3 nitg, ,patch with ntg, then ask for morphine .) I would give the first ntg. seeing if it would relieve the pain at all. If the first ntg. would not relieve the pain, I would request morphine 2mg with a 1 " of ntg paste. I would get the best possible history from this patient so that I could explain this to the receiving facility (regardless of where we are going) so that they get the full picture. Without the full picture they are still just guessing at what we are bringing in. By explaining what we have, how the patient is feeling, what has been done, what we are seeing is the only way to be assured that the patient will be well taken care of properly when you arrive at the facility. This may also help defend you position of taking the patient to the most appropriate hospital, not just the closest. wegandy1938@... wrote: Well, kids, Uncle Gene thinks it's time for a new puzzler. This one is for a free trip to Opdyke West, TX to enjoy the July weather. While this is for paramedics, knowledgeable, precocious, and eager EMTs are welcome to chime in. Your 58 year old male patient complains of chest pain which began approximately one hour prior to your arrival at his side. He relates that the pain is now 10 on a 10 scale, has not diminished since it started, and he is in great distress, with breathing difficulty, a look of panic in his eyes, ashen, moist skin, and he also complains of nausea. He begs you to help him. Your partner places the pulse oxymeter on him and begins to set up oxygen. The pulse ox reads 97%. He is placed on 12 lpm/NRB, and you have now placed the electrodes for your monitor on his chest. Unfortunately, your service has not yet purchased 12-lead monitors, so your monitor is designed to read leads I, II, and III. As your partner administers an aspirin to the patient, you watch the monitor in Lead II and see sinus rhythm with a high ST elevation. Switching to lead I, you note sinus rhythm with ST depression, and in Lead III you see marked ST segment elevation. Your partner now has an IV established in the left arm, and he asks you whether you want to hang NS or place a saline lock. All the while your patient is begging you to do something about his pain. Should you go with a saline lock or hang NS? Should you administer nitroglycerine? Morphine? Are there any other interventions you can do to help you decide those issues? If so, what? You are 12 minutes from a community hospital with a small ER and no cath lab and this is where your patient wants you to take him. You are 25 minutes from a large teaching hospital with a cath lab. What should your destination be and if you determine to go to the larger hospital, what do you tell your patient to get him to agree? Gene G. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 26, 2006 Report Share Posted July 26, 2006 Thought I'd put in my 2 cents just because. Seems like folks are leaning in the right direction, just a little off the mark. The Red lead should be placed on the right side at app the 5th intercostal space, read lead 3, and look for a marked ST elevation. This would be an Acute Right Ventricular MI. There could also be an accompanying Inferior MI. Treatment: high flow O2, IV NS @ TKO unless more needed for hypotention, NTG and Morphine should be used with caution because they can cause a BIG BP drop. Keep pacing in mind if necessary. By all means, this patient needs to go to the teaching hospital. Delay at the smaller facility could be disasterous. Well, there it is Gene. How did I do? LOL Joe T > > Well, kids, Uncle Gene thinks it's time for a new puzzler. This one is for > a free trip to Opdyke West, TX to enjoy the July weather. > > While this is for paramedics, knowledgeable, precocious, and eager EMTs are > welcome to chime in. > > Your 58 year old male patient complains of chest pain which began > approximately one hour prior to your arrival at his side. He relates that the pain is > now 10 on a 10 scale, has not diminished since it started, and he is in great > distress, with breathing difficulty, a look of panic in his eyes, ashen, moist > skin, and he also complains of nausea. He begs you to help him. > > Your partner places the pulse oxymeter on him and begins to set up oxygen. > The pulse ox reads 97%. He is placed on 12 lpm/NRB, and you have now placed > the electrodes for your monitor on his chest. Unfortunately, your service > has not yet purchased 12-lead monitors, so your monitor is designed to read > leads I, II, and III. As your partner administers an aspirin to the patient, you > watch the monitor in Lead II and see sinus rhythm with a high ST elevation. > Switching to lead I, you note sinus rhythm with ST depression, and in Lead > III you see marked ST segment elevation. > > Your partner now has an IV established in the left arm, and he asks you > whether you want to hang NS or place a saline lock. All the while your patient is > begging you to do something about his pain. > > Should you go with a saline lock or hang NS? Should you administer > nitroglycerine? Morphine? > > Are there any other interventions you can do to help you decide those issues? > If so, what? > > You are 12 minutes from a community hospital with a small ER and no cath lab > and this is where your patient wants you to take him. You are 25 minutes > from a large teaching hospital with a cath lab. What should your destination be > and if you determine to go to the larger hospital, what do you tell your > patient to get him to agree? > > Gene G. > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 26, 2006 Report Share Posted July 26, 2006 > This guy is having an inferior/RVI. So he's going to be preload dependent, > and if we don't recognize that and give NTG without the ability to correct a > sudden drop in CO and BP, we'll do great harm to this patient. That's okay, I'll just give him Epi to keep his pressure up... it's a pressor, right? <ducking and running for cover> Mike Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 26, 2006 Report Share Posted July 26, 2006 Remind me that I don't want to have an MI the next time I am up there visiting y'all Mike......hopefully your better half would know better!!! LOL > > That's okay, I'll just give him Epi to keep his pressure up... it's a > pressor, right? > > <ducking and running for cover> > > Mike > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 26, 2006 Report Share Posted July 26, 2006 Multilead ECG, MCLs to include Right MCL4. Oxygen, etc. RVI - Fluid bolus to maintain BP, NTG & Morphine cautiously. Quote Link to comment Share on other sites More sharing options...
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