Chest pains

[trauma1534]

Here is yet another call that I had recently, try this one out. Tell me if you think this is cardiac related... if not what do you think.... also what is your tx plan for this patient????

You are dispatched to a 21 year old male patient having chest pains, pain down BOTH arms, difficulty breathing and nausea.

Upon arrival, you find a healthy looking 21 year old male, down on the ground beside of his car in the yard, vomiting and crying from pain. Family reports to you that he has no medical history... no allergies... has been otherwise health, fresh out of marine boot camp. Upon assessment you see no signs of trauma. When you ask patient what is going on, he states that his chest feels like something is setting on it, both arms are radiating with pain. He also states that he is having problems catching his breath. On a pain scale of 0-5, he says it is a 4. Vitals are as follows: Resp. rate: 36, Pulse: 120, B/P 210/114. Lungs: clear bilateral, no JVD, no Treachea Deviation, PERL. You load him into the truck on the stretcher. In the back of the truck, he now tells you that the pain is getting worst, but is feeling different. The chest pain is now a sharp stabbing pain, radiating to us LUQ.

What are you thinking... what is your plan of action? I will then tell you what I did and what the diagnosis was from the ER doctor.

Have fun!

 

[daemonicusxx]

You said BLS providers, but i want a strip. O2, IV. not sure what it is though, i guess diesel therapy would work too.

 

[ndilley]

tough one...well first things first, O2 is a must. another set of vitals, consider nitro, if not cardiac would help with b/p, even though bls; might hook up to a monitor (if avaliable) just to see anything completely abnormal...
also thinking possible pancreatitis b/c of LUQ pain... and of course when all else fails consume copious amounts of fuel and run L&S to hospital

 

[Jon]

I can't really say weather or not it was cardiac until I've seen an EKG, preferably a 12-lead.

Sounds like the kid has something going on, but don't know what - he needs to go to the hospital is for sure.

Jon

 

[Chimpie]

Was he smoking "anything" or taking any drugs?

I didn't think they came home after boot camp. Where was he serving prior to coming home?

(okay, I've been watching too much House lately)

 

[Jon]

Ok . I thought you were just asking "cardiac or non-cardiac"

here is my full answer (on 7 hours of sleep in 72 hours ).

I'm thinking apendicitis is a possibility - often happens to young, otherwise healthy folk.

Also, could be fractures or bruising from "something" at boot camp (Hazing can still be part of military life, and the guy JUST got through boot camp)


Treatment - transport in a position of comfort, higfh-flow O2 and Class III to the closest ED. If transport will be greater than 5 minutes, consider an ALS intercept for both the cardiac monitor, and possibly pharacological analgesia.

Jon

 

[emtbuff]

I would agree with the others with the High flow O2, and diesel therapy. And depending on if I could determine cause I would alert the hospital to consider having the chopper crew come in.

It could be either something internal like the appendix or pancrease. Or it could be trauma of some sort.

For those that are ALS I would start a line, nitro, an analgesic, and a strip.

 

[AnthonyM83]

I'd be thinking appendix or as Jon said, broke something. Something floating around in there (shrapnel?) poking at stuff.

O2, position of comfort, calm & soothing voice.

What's diesel therapy? Pedal to the metal?

 

[ndilley]

hey trauma when you going to post what the doc said??? the suspense is killing me h34r:

 

[TTLWHKR]

Originally posted by MedicStudentJon@Nov 26 2005, 07:27 AM
Appendicitis

:blink: Left Upper Quadrant
Maybe RUQ, mid naval, possible even LLQ..


Cx Pn. LUQ. Gets worse when sitting, possibly laying.

Broken rib, punctured lung, partial pneumothorax, pleurisy, descending colon obstruction, kidney stones, internal bleeding from a fall, ulcer, pancreatitis, Splenic injury or rupture, Aneurysm, renal failure, Diverticulitis ?

People who have lost a fair amount of blood internally, weather into the abdomen, or bowels often complain of pain in the chest, neck, and arms from lack of perfusion. As the body is trying to compensate for the loss of fluids, electrolytes, and cells.


The normal stuff.. He's a too hypertensive for a young, fit male. ECG, IV 120xhr, 3xASA, 2xNstat, no pain management. If you get rid of the pain, how will the er doc be able to determine what is causing it, if it is a soft tissue injury? Pn on inspiration/expiration? pnt tenderness?
Since it's LUQ, I'd want to know if he's ingested anything unusual, or what he has eaten in the past 48 hours. I.e. fish, peanuts, clams, anything with bones or bone fragments, last BM, any blood? check for bowel sounds. Any problems urinating, color, etc. Could the pain be in his back, and just feels like the chest, i.e. kidney stones. Febrile? Abdominal tenderness, rigidity, distension?

 

[bravofoxtrot]

Taking another shot in the dark, possibly a pulmonary embolism? But with that BP it doesn't really sound like that either.

I really would not go with appendicitis, but I wouldn't rule it out either. Appendicitis is usually umbilicus to RLQ. LLQ pain usually goes with diverticulitis.

Give O2, get a strip on him. (Even if it's only Lead II.) Diesel.

 

[bravofoxtrot]

BTW, was he coughing up anything?

Could be cardiac, maybe even an MI, but for his age and shape I doubt it. Who knows, could be a genetic problem with his heart. Some family history enroute might reveal something. That LUQ pain could just be associated pain from the rest of the chest.

 

[MedicPrincess]

High Flow O2, get'em to the ER.

I am going for Pancreatitis or Gall Bladder.

 

[CaptainPanic]

OK, Im going to ignore everyone elses answeres and take a stab at it... so here goes, WEEEEEEEEEEEEEEE!!!

OK I have 21 y/o male c/c of pain in his chest bilaterally and pain raidiating down his arms. He his vomiting and appears nauseated. (This is my initial asessment)

You said his V/S were as follows:
BP: 210/114
Pulse: 120
R/R: 36
Lungs: clear bilateral, no JVD, no Treachea Deviation, PERL
He has pain in his LUQ (Left Upper Quadrant).
Also other V/S I need to make a better asessment:
Pulse Ox (I know this doesnt say a whole lot - but it does tell me if hes getting enough oxygen saturation.)
Skin: Is the skin normal, is it abnormal? (tell me cold, hot, dry, moist, clammy, pale, cyanosis,etc)
Pupils: are his pupils equal and reactive? (This might tell me if the kid is on some sort of drugs that the family doesnt know about - crack-cocaine use has a side effect of nuasea) h34r:


Im going to use SAMPLE and OPQRST to find my Hx.
S- Severity: You used the 0-5 scale, pt said it was rated as 4
A- Allergies: He has no known allergies
M- Medications: You never said if he was on any type of medication. Please give me this info.
P- Pertinent Medical Hx: You said the family said he has been otherwise healthy.
L- Last Oral Intake: What was the last thing he took by mouth (food, meds, liquids)
E- Events leading to illness: What was he doing before the onset? Was he doing strenous activity such as basketball, running, mowing lawn??? Please give us this info.

Now for my OPQRST
O- Onset: What was the onset- what caused it, when did it happen??
P- Provokes: What makes it worse? (Now that hes lying down on the stretcher and is c/o his pain becoming stabbing, Im going raise him to semi-fowlers/fowlers position, maybe even lay him on his left side if he is still nauseated. I'll be prepared suction at this point)
Q- Quality: What type of hurt is it? (Pt said stabbing after we got him in the truck)
R- Radiate: The pt said that he had pain radiating down both arms in the initial assessment, now after loading in the truck, he said it radiates to LUQ.
S- Severity - Pt said it is now a stabbing pain. In the initial assessment he rated at 4 (0-5) scale, I want to know if it is worse now.
T- Time: What time was it when it started?

Now for the rest of my asessment:
Im going to palpate his abdomen, focusing on his LUQ looking for tenderness, distension, pain upon palpation, also is the pt guarding his abdomen?

With his pain becoming worse and a high BP for his age Im going to contact Med Control to get the OK to administer NTG sublingually to bring his BP down. I will also administer 02 via NRB @ 15lpms - if unable to handle the NRB I will use cannuala at 4lpms.

This is a load and go. With his pain progressively getting worse and depending on what the ETA is to the nearest hospital is I may request for ALS intercept.

At the ER Id like to see fluids via IV and a cardiac workup just to be on the safe-side, given the pulse and BP. According to my texts, stabbing pain in the LUQ could mean Liver, spleen, kidney, stomach, colon, pancreas. With the nausea, Im going to lean towards stomach/colon/kidney problems.

Now whats the Dx Doc????

-CP

 

[TTLWHKR]

Originally posted by CaptainPanic@Nov 28 2005, 10:19 AM
OK, Im going to ignore everyone elses answeres and take a stab at it... so here goes, WEEEEEEEEEEEEEEE!!!

OK I have 21 y/o male c/c of pain in his chest bilaterally and pain raidiating down his arms. He his vomiting and appears nauseated. (This is my initial asessment)

You said his V/S were as follows:
BP: 210/114
Pulse: 120
R/R: 36
Lungs: clear bilateral, no JVD, no Treachea Deviation, PERL
He has pain in his LUQ (Left Upper Quadrant).
Also other V/S I need to make a better asessment:
Pulse Ox (I know this doesnt say a whole lot - but it does tell me if hes getting enough oxygen saturation.)
Skin: Is the skin normal, is it abnormal? (tell me cold, hot, dry, moist, clammy, pale, cyanosis,etc)
Pupils: are his pupils equal and reactive? (This might tell me if the kid is on some sort of drugs that the family doesnt know about - crack-cocaine use has a side effect of nuasea) h34r:


Im going to use SAMPLE and OPQRST to find my Hx.
S- Severity: You used the 0-5 scale, pt said it was rated as 4
A- Allergies: He has no known allergies
M- Medications: You never said if he was on any type of medication. Please give me this info.
P- Pertinent Medical Hx: You said the family said he has been otherwise healthy.
L- Last Oral Intake: What was the last thing he took by mouth (food, meds, liquids)
E- Events leading to illness: What was he doing before the onset? Was he doing strenous activity such as basketball, running, mowing lawn??? Please give us this info.

Now for my OPQRST
O- Onset: What was the onset- what caused it, when did it happen??
P- Provokes: What makes it worse? (Now that hes lying down on the stretcher and is c/o his pain becoming stabbing, Im going raise him to semi-fowlers/fowlers position, maybe even lay him on his left side if he is still nauseated. I'll be prepared suction at this point)
Q- Quality: What type of hurt is it? (Pt said stabbing after we got him in the truck)
R- Radiate: The pt said that he had pain radiating down both arms in the initial assessment, now after loading in the truck, he said it radiates to LUQ.
S- Severity - Pt said it is now a stabbing pain. In the initial assessment he rated at 4 (0-5) scale, I want to know if it is worse now.
T- Time: What time was it when it started?

Now for the rest of my asessment:
Im going to palpate his abdomen, focusing on his LUQ looking for tenderness, distension, pain upon palpation, also is the pt guarding his abdomen?

With his pain becoming worse and a high BP for his age Im going to contact Med Control to get the OK to administer NTG sublingually to bring his BP down. I will also administer 02 via NRB @ 15lpms - if unable to handle the NRB I will use cannuala at 4lpms.

This is a load and go. With his pain progressively getting worse and depending on what the ETA is to the nearest hospital is I may request for ALS intercept.

At the ER Id like to see fluids via IV and a cardiac workup just to be on the safe-side, given the pulse and BP. According to my texts, stabbing pain in the LUQ could mean Liver, spleen, kidney, stomach, colon, pancreas. With the nausea, Im going to lean towards stomach/colon/kidney problems.

Now whats the Dx Doc????

-CP

Know what would suck?


If he didn't come back with the answer to our pondering... :blink:

 

[bravofoxtrot]

That would...watch, he probably won't come back now.

 

[squid]

I guess I would treat him for pain because those symptoms might all be secondary to really intense pain -- saw a guy like that once with stomach ulcers. Of course, we were a couple hours from the hospital, not 5 minutes, so that might make a difference.

 

[CaptainPanic]

Great now that I did that entire speel, he aint gonna come back-

I guess someone else could step in and make up some stuff so we can finish the scenario at least----- perhaps do a role-playing thread. :lol:

 

[squid]

Ow! Ow! Owwwwwwwww!

Huh, I think my acting's better IRL than here.

 

[TTLWHKR]

Originally posted by squid@Nov 29 2005, 06:26 PM
Ow! Ow! Owwwwwwwww!

Huh, I think my acting's better IRL than here.

Hits squid with a rolled up newspaper.

Someone email him...