Daisys Dilema

[vquintessence]

Just a little stream of consciousness but...

Regarding the 12 lead: Any abnormalities in the PRI (ex: prolonged, elevated or depressed)? What is the amplitude of the QRS's in the precordial leads (ex: evidence of LVH?). Is there any manifestation of a bundle blockage (ex: rSr leads v1 w/ S wave lead I?). Any indications of electrolyte derangement (ex: peaked t-waves, widened qrs, etc)? Sorry, I'm just trying to get a more specific description than anteroseptal STE to rule in&out the mimics.

Well, barring any profound neurological presentations, denial of presence of toxins and an unremarkable physical exam...

Letting my cart lead the donkey, I'd like to meekly suggest Brugadas syndrome? I know an elderly female doesn't exactly fit the demographic norm... but what we do know is:

Nana was working in the heat, which possibly triggered the event/syndrome (a run of VT making the pt feel the described general thoracic discomfort); the run then self terminated, resulting in her syncope and "looking dead" to her husband temporarily. The ECG findings could arguably help strengthen this train of thought?

It is a shot in the dark, but I also like to run with the scissors pointed outwards and nothing else is coming to mind.

 

[Sam Adams]

= radials? / brachials? / femorals?

 

[zzyzx]

I didn't know zebras lived in New Zealand.

A thoracic aneurysm could irritate the vagal nerve and cause the bradycardia. But is that too easy as well?:wacko:

 

[Smash]

Spontaneous coronary artery dissection? I seem to recall that a certain Dr Smith having such a beast. Mostly happens in women although not necessarily this demographic. She may have increased shear forces bending over her flowers, precipitating dissection, giving her the sickness of muchness.
Or it may be that I had 4 hours ofsleep and shouldn't be allowed near a keyboard, much less a patient.

 

[jjesusfreak01]

ParathinkIam Brad (thats my name) thinks she vagaled out when pulling weeks, causing depressed breathing which strangely led to cardiac ischemia (angina like effects). Recommend oxygen therapy (probably a nasal canula will be fine) and a quick trip to see a person with MD written after their name on a door somewhere. If arterial dissection can be reasonably ruled out, ASA and GTN might be on the menu.

 

[Outbac1]

Aspirin and one litre of fluid are administered

New vital signs
BP 90 systolic
HR 70
Pain is still heay 7/10

No reciprocal changes on the 12 lead and no, this is not an MI do you think Brown would post something that easy?

Not really but the initial presentation leads one this way. My initial tx started with a bolus. Now that she has had one her HR is up but B/P is not up a lot. It was a hot day and she was working outside. Dehydration is a possibility leading to electrolyte imbalance. The voltarn (not familiar with this so googled it) can add K . So what did her Ts look like? Peaked? How about dehydration signs? Turgor? Furry tongue? Any hx of renal failure?
An aneurysm could also explain the fluid loss, pain presentation, and lack of increased B/P after 1 liter as well. Perhaps she has both?
If dehydrated and peaked Ts more fluid is needed. But she shouldn't be overloaded on just ns. It is just adding Na. methinks a more balanced solution would be better (ringers/hartmans). Potassium toxicity would call for 0.5 - 1.0 g of calcium chloride.
Continued transport to Dr. Brown and comrades is still in order.

 

[MrBrown]

= radials? / brachials? / femorals?

Radial and brachial are palpable and irregular, no femoral pulse is palpable but given her blood pressure is it a suprise?

I didn't know zebras lived in New Zealand.

A thoracic aneurysm could irritate the vagal nerve and cause the bradycardia. But is that too easy as well?:wacko:

No but we have a healthy heard of Browns. An aneurysm should not be ruled out at this stage.

Spontaneous coronary artery dissection?

Or it may be that I had 4 hours ofsleep and shouldn't be allowed near a keyboard, much less a patient.

Nah its not that. Now, bend over so Brown can stick this ketofol in your bum and you can get some sleep.

ParathinkIam Brad (thats my name) thinks she vagaled out when pulling weeks, causing depressed breathing which strangely led to cardiac ischemia (angina like effects).

At least you admit being a Parathinktheyare, thats the first step mate

At this stage no morphine or GTN because of her blood pressure if we can get it a bit higher maybe one tab of nitro but then again GTN really has no role in STEMI or so Brown thinks. Brown thinks perhaps we could try maybe a mg or two of morphine if her pressure stays where it is.

So what did her Ts look like? Peaked? How about dehydration signs? Turgor? Furry tongue? Any hx of renal failure?
An aneurysm could also explain the fluid loss, pain presentation, and lack of increased B/P after 1 liter as well. Perhaps she has both?

Continued transport to Dr. Brown and comrades is still in order.

No signs of hyperkalemia and the patient does not appear to be dehydrated.

 

[usafmedic45]

no femoral pulse is palpable but given her blood pressure is it a suprise?

Actually, yeah, that would be a big one in my book since you're probably going to lose your radials and brachials first before you lose your femoral pulses. Given that bit of information, I'm guessing this is an aortic dissection with compression of the coronary arteries. What's her diastolic pressure? If she's sporting a narrowed pulse pressure, I would be concerned for cardiac tamponade as well.

 

[CAOX3]

Oh that little bugger the Katipo got her.

Im guessing myocarditis is causing the ST elevation and not an MI.

Now I want a case of FOUR LOKO as my prize.

 

[usafmedic45]

You could see those EKG changes with pericarditis, but I would not expect someone to drop their pressure so dramatically from it (not to mention that the pain is often relieved to a great extent by positioning and it's not normally a "crushing" pain but rather pleuritic in nature) unless they had a very large effusion with it and even then you don't normally go from no real symptoms to death door without warning.

In myocarditis, usually you have a stabbing or tearing chest pain. The EKG changes are also generally fairly characteristic and are often described as "saddle-shaped" as they are in pericarditis as well. The lack of T wave inversion in the non-elevated leads also makes me think this is not myocarditis. The only thing that makes me even put myocarditis on the DDx list is the history of recent joint pain which might suggest a recent viral infection.

 

[CAOX3]

You could see those EKG changes with pericarditis, but I would not expect someone to drop their pressure so dramatically from it (not to mention that the pain is often relieved to a great extent by positioning and it's not normally a "crushing" pain but rather pleuritic in nature) unless they had a very large effusion with it and even then you don't normally go from no real symptoms to death door without warning.

In myocarditis, usually you have a stabbing or tearing chest pain. The EKG changes are also generally fairly characteristic and are often described as "saddle-shaped" as they are in pericarditis as well. The lack of T wave inversion in the non-elevated leads also makes me think this is not myocarditis. The only thing that makes me even put myocarditis on the DDx list is the history of recent joint pain which might suggest a recent viral infection.

I was basing it on the joint pain and complete system shut down, I was going with snake bite but I remembered from sleeping on my Zoology book every M, W, F for three months that New Zealand has no native poisonous snakes.

It was a stertch but can I still get my prize.

 

[Veneficus]

11 complications of an MI

1. Contractile dysfunction
2. Arrhythmia
3. Myocardial rupture Not often seen, but usually seen in females, over 60, with no prior history of MI, history of hypertension, and no evidence of left ventricular hypertrophy.(mitral or aortic murmers) Most often seen in Anterior transmural infarcts. (STEMI) 90% to the free wall, 10% to the ventricular septum.
4. Pericarditis
5. Septal dysfunction
6. Infarct extension
7. Infarct expansion
8. Mural thrombus
9. Ventricular aneurysm
10. Papilary muscle dysfunction
11. Progressive late heart failure

Why oh why do they spend so much time on cardiology in paramedic education?

 

[MrBrown]

All prizes have been curtailed due to the neeed for Brown to increase financial resillance. Diapers and baby food are expensive!

 

[usafmedic45]

All prizes have been curtailed due to the neeed for Brown to increase financial resillance. Diapers and baby food are expensive!

I'll settle for you catching me one of those Kiwi birds you all have down there and overnighting it.

 

[MrBrown]

I'll settle for you catching me one of those Kiwi birds you all have down there and overnighting it.

The Department of Conseration and Ministry of Agriculture & Fisheries might have a problem with that. Brown will get you a T shirt.

 

[usafmedic45]

The Department of Conseration and Ministry of Agriculture & Fisheries might have a problem with that. Brown will get you a T shirt.

I'll accept a t-shirt. If you make it two (one for me and one for the fiancee) we can reciprocate and send you two back. Sort of like cultural t-shirt exchange. LOL

 

[CAOX3]

1. Contractile dysfunction
2. Arrhythmia
3. Myocardial rupture Not often seen, but usually seen in females, over 60, with no prior history of MI, history of hypertension, and no evidence of left ventricular hypertrophy.(mitral or aortic murmers) Most often seen in Anterior transmural infarcts. (STEMI) 90% to the free wall, 10% to the ventricular septum.
4. Pericarditis
5. Septal dysfunction
6. Infarct extension
7. Infarct expansion
8. Mural thrombus
9. Ventricular aneurysm
10. Papilary muscle dysfunction
11. Progressive late heart failure

Why oh why do they spend so much time on cardiology in paramedic education?

Listen rupture is so boring compared to the story of that little buggie thing taken a chunk out of youin the woods.

But from now on all almost doctors are disqualified, stop collecting all the the dam prizes, show off. Insert smiley face but I couldn't because my phone sucks

And I'm going back to verizon to get stupid phone in the bag like magnum pi had, screw this technology.

Congratulations on the baby Brown.

 

[Aidey]

No reciprocal changes on the 12 lead and no, this is not an MI do you think Brown would post something that easy?

1. Contractile dysfunction
2. Arrhythmia
3. Myocardial rupture Not often seen, but usually seen in females, over 60, with no prior history of MI, history of hypertension, and no evidence of left ventricular hypertrophy.(mitral or aortic murmers) Most often seen in Anterior transmural infarcts. (STEMI) 90% to the free wall, 10% to the ventricular septum.
etc......

I'm calling foul. It can't be a complication of an MI when you said it wasn't an MI, unless it is a spontaneous rupture not associated with an MI.

 

[Veneficus]

Listen rupture is so boring compared to the story of that little buggie thing taken a chunk out of youin the woods.

But from now on all almost doctors are disqualified, stop collecting all the the dam prizes, show off. Insert smiley face but I couldn't because my phone sucks

And I'm going back to verizon to get stupid phone in the bag like magnum pi had, screw this technology.

Congratulations on the baby Brown.

I don't want the prize, I tried to toss you guys some clues a few pages back and have been kind enogh to answer several scenarios in PM so others could have a chance.

But you guys were getting farther and farther away.

I find it very disheartening that so much time in paramedic class is dedicated to cardiology instead of something much more complicated like trauma.

I know that the complications of MI are very rarely ever even mentioned, much less tested in paramedic school despite EMS using their ability to make a difference in MIs as the centerpiece of ALS value.

 

[Veneficus]

I'm calling foul. It can't be a complication of an MI when you said it wasn't an MI, unless it is a spontaneous rupture not associated with an MI.

It is secondary to the MI.

like DIC can be secondary to sepsis.

(I keep trying to tell you guys that you need thicker physio and patho books, it is not sufficently covered all in the paramedic texts.)

What happens when you start filling this patient up with fluid and giving her ASA?