# Case study



## Muppet (Jun 16, 2015)

OK. Not "combat related" but will be a good review for some, good info for new guys.

Backround: An urban/suburban E.M.S. system in the northeast of the U.S., county run with a county medical and co medical directors that are both former paramedics, now emergency medical / special operations trained M.D.'s. System is run via single role A.L.S. organizations at the township level. Medical protocols are statewide based and progressive...for the most part.

Call: For a resp. distress.
Scene: Apartment complex for a 55 y/o female, apparent distress, is pale, and diaphoretic, apprehensive and when you get close to check pulse, no radial, weak carotid and is awake but lethargic.
V/S: B/P: 70P, HR: 130 and irregular, RR: 26 and labored, Lungs: rales but diminished, 12-lead: A-fib, rapid ventricular response with an obvious anterior wall M.I., some inferior elevation but under 1mm., an occasional P.V.C. 324 baby ASA given in field. Other treatments as well...

STEMI alert called. Transported to a PPCI capable hospital (bypassed a closer / farther PPCI is 5 mins. more away). Pt. remains awake. 12-lead and serial 12's show same and have both paramedic interpretation and transmitted to E.D. for attending M.D. review. M.D. agrees.

NOTE: Experienced medics and docs, please wait until new guys can give some answers here as I am sure you will know the answers...

QUESTIONS:
(1) What is a STEMI
(2): What do the rales represent?
(3): Why is the B/P low?
(4): Should CPAP be used or not used?
(5): If no I.V. access, what's the next step?
(6): Should you give Nitro?
(7): Why is the heart rate high?
(8): Do you treat heart rate?
(9): How do you treat low B/P?
(10): Does it make sense to place combi-pads in case of peri-arrest / sudden V-fib arrest?

@AKkeith. This is a good case for you brother, since your starting off. If you don't understand something here, ask. I will fill you all in on my treatment and it was accepted and complemented by the attending and cardiologist. Just figure it would be cool to post since it is kind of uncommon to see all at once w/o being dead...

M.


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## AKkeith (Jun 16, 2015)

1) No idea I'll google it. 
2) Not familiar with term.
3) Vessels are dilated probably due to shock. 
4) I'm not trained on it but my doc wants to go over it with me. 
5) Get an IV access. I wouldn't really want to do an IO on an awake patient. 
6) No BP is too low 
7) Shock
8) Oxygen. Better profusion may help slow the HR. 
9) Id do MAST Pants if lungs are clear. Also fluids. 
10) Not familiar with term peri-arrest. I'd place pads. 

These are my guesses. Id honestly call a life-flight.


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## 8654Maine (Jun 16, 2015)

AK, glad you're being honest.

I'd like to know not just the answers but the THOUGHT PROCESS behind them.  That is where true learning happens.

When I receive patients from EMS, I'm usually juggling a mixture of folks:  STEMI, CVA, several belly pains, more than a few nursing home seniors with dizziness,  lots of sniffles/ear pain/sore throats, several SI's, several drunks, & the spouse of someone very important.  And they all want my undivided attention at the same time.

If I have a question about a patient you bring in, it's usually gonna be critically important. 

If I get a blank look, it's not gonna bode well.

Understand the lingo.  Anticipate the questions.  This is what I do when I talk with my consultants.

We are all links in the chain of survival.

I'll always help those genuinely interested. 

I'll slam folks who become arrogant beyond their scope of practice.  Or piss off my nurses.


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## Marauder06 (Jun 16, 2015)

A case study from someone other than me?  Exxxxcelent.


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## policemedic (Jun 16, 2015)

Marauder06 said:


> A case study from someone other than me?  Exxxxcelent.



I suspect this one will be lacking the trademark tachypsychia we associate with the adventures of a particular intrepid SOF support officer....

By the way, don't you owe us another one?


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## Marauder06 (Jun 16, 2015)

I hate it when you people make me look up words.


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## medicchick (Jun 16, 2015)

AKkeith said:


> 1) No idea I'll google it.
> 2) Not familiar with term.
> 3) Vessels are dilated probably due to shock.
> 4) I'm not trained on it but my doc wants to go over it with me.
> ...



#2 means your #9 is out.  

http://www.easyauscultation.com/lung-sounds  Listen to them all and learn to tell what is what.  That along with learning the different rhythms on a monitor should be some of your best tools.  Drugs all depend on what you see and hear when it comes to cardiac events.  I used to have 12 lead flash cards my mentor would go over with me every time I did a ride.

I will now back out slowly and allow Muppet to resume his lesson.


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## x SF med (Jun 16, 2015)

Marauder06 said:


> A case study from someone other than me?  Exxxxcelent.



Yes, it is.... But,this one won't take months and years and decades to come to a conclusion.:blkeye::wall:


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## Muppet (Jun 17, 2015)

Update: no MI. Please pulmonary edema that resulted in myocardial ischemia, displaying the injury pattern that resembles the classic STEMI. Not sure of other outcomes. Will update when I get feed back from QA...

So. When we get this pt., we see that she is having an MI. The Afib is from what? No history of that. We assume that her left ventricle was shot to shit resulting in the pulmonary edema. I wonder if the pulmonary edema was due to the rate issue? She was in cardiogenic shock.

My plan, if I had more time: re contact medcomm. Consult on a fluid blous @ 250cc. Don't kill me. Ask the docs here. Many pt's with CHF are HYPOvolemic and the fluid bolus would increase myocardial contractility. That would be a doc consult. I also considered vasopressors and at this time, tritrating Dopamine is the plan of action but in 2 months, ALS protocols allow for push dose Epi.

Take a 10 cc saline flush, waste 1 cc, draw up 1 cc 1,10,000 Epi ( cardiac epi ) and that makes, Epi, 1,100,000. Give 1 cc over 2 mins to a b/p of 110 systolic. This was a cool as fuck call...

M.


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## AKkeith (Jun 17, 2015)

You must be a paramedic? 
EMT 3 in AK can't give epi to an awake patient. Obviously doc orders changes things, but my doc didn't add that into my expanded. 
Also you guys don't have predrawn 1 mg epi 1:10,000?


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## Muppet (Jun 17, 2015)

AKkeith said:


> You must be a paramedic?
> EMT 3 in AK can't give epi to an awake patient. Obviously doc orders changes things, but my doc didn't add that into my expanded.
> Also you guys don't have predrawn 1 mg epi 1:10,000?



Yes. Paramedic for almost 16 years. Yes. We have pre filled epi for arrests. I am talking about "push dose epi". Look it up bro. Instead of using a drip for a "pressor" or a med that is used to bring b/p up for awake but very unstable people, this method is used. It had been used in the hospital setting for years and finally making it to EMS. I am assuming an EMT 3 is similar to maybe an EMT I? Intermidiate?

M.


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## Ranger Psych (Jun 17, 2015)

EMT3 is best equated to splitting the difference between I and P for NREMT.  Once was said to me "EMT3's know WHAT to do, Paramedics know WHY"  ie 2nd/3rd order effects/causes, etc.


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## Muppet (Jun 17, 2015)

And. Ok. Thanks bro...

M.


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## TLDR20 (Jun 17, 2015)

AKkeith said:


> You must be a paramedic?
> EMT 3 in AK can't give epi to an awake patient. Obviously doc orders changes things, but my doc didn't add that into my expanded.
> Also you guys don't have predrawn 1 mg epi 1:10,000?



Epi is the ACLS protocol. If you are running ALS, you should be giving Epi.


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## medicchick (Jun 17, 2015)

Muppet said:


> Yes. Paramedic for almost 16 years. Yes. We have pre filled epi for arrests. I am talking about "push dose epi". Look it up bro. Instead of using a drip for a "pressor" or a med that is used to bring b/p up for awake but very unstable people, this method is used. It had been used in the hospital setting for years and finally making it to EMS. I am assuming an EMT 3 is similar to maybe an EMT I? Intermidiate?
> 
> M.


Alaska is a funky monkey with their own system.

http://dhss.alaska.gov/dph/Emergency/Pages/ems/training/default.aspx


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## AKkeith (Jun 17, 2015)

I will be taking an ACLS class later this month. Hopefully I will learn more about that then.


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## lushooter (Jun 17, 2015)

Ought to be a good refresher since I have the National Registry coming up in a few days. I am about to go to work, but I will come back tonight when I have some time to sit and really think this through a little more.


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## lushooter (Jun 17, 2015)

Alright, so I will admit to reviewing some old notes and stuff on a few since some of these terms were familiar, but not known with 100% certainty. However, I took this as a chance to learn something along the way. To answer the questions though...
1. All I could remember was the cardiac relation, but I didn't know. Verified answer: A bad MI. 
2. Fluid in the lungs. CHF/Pulmonary edema or something within that realm. 
3. Shock? Vessel dilation or just a weak heart possibly? 
4. I am not sure. From what I understand it could be helpful when the pt. has pulmonary edema, so my gut answer is yes. Verified: The indications in my book match pt. High RR, labored breathing, alert. I will stick with my yes after reading that, but if it is not right then I still learn something. 
5. Although I can't give an I.V. right now, I will take a stab at it anyway. The first thing that comes to mind is IO, but an IV sounds like the preferable of the 2 from the pt's perspective if possible. Try the other side to see if the IV can be started there. If the IV just isn't happening though, then IO is my guess. 
6. No, BP is definitely too low.
7. Shock, trying to compensate for the low BP.
8. I am not sure. Wouldn't slowing heart rate make it harder for the body to compensate for a low BP?
9. Not sure about that either. The only thing I can think of off the top of my head that would increase BP is epi. The epi would raise BP, but the pt is also tachycardic so I feel like that would rule out epi as an option, at least at my level. 
10. I am not sure what perri-arrest is, but I don't feel like it would be a bad idea. I would do it. 

If you have any more of these, I would love to look over them, even if through PM. I haven't thought this hard on a scenario ever.


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## lushooter (Jun 17, 2015)

If there is a connection between 8 & 9 treatments let me know. If there is a way to slow the heart rate and raise the BP, then I guess that would be the plan I'd try to pursue if I had the ability. That is over my head though, so I can really only speculate on treating those two.


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## policemedic (Jun 17, 2015)

AKkeith said:


> 5) Get an IV access. I wouldn't really want to do an IO on an awake patient.


 
Why not?  That sounds like a smart ass question, but it's not.



AKkeith said:


> EMT 3 in AK can't give epi to an awake patient.


 
What are your protocols for anaphylaxis...do they not include SC or IM epi, with an option for IV epi in cases refractory to other Rx?


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## Muppet (Jun 18, 2015)

I attempted 4 Iv sticks. No access including no EJ. I drilled her left tibia and gave 20mg Lidocaine for pain of IO. She tolerate it well. A crash line is a crash line.  Go watch the EZ IO videos from vida care. The bosses take it w/o pain relief to show it is ok...

M.


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## lushooter (Jun 18, 2015)

Never actually seen that done before on someone who was conscious. Not like what I expected, he took it real well.


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## AKkeith (Jun 18, 2015)

policemedic said:


> Why not?  That sounds like a smart ass question, but it's not.
> 
> 
> 
> What are your protocols for anaphylaxis...do they not include SC or IM epi, with an option for IV epi in cases refractory to other Rx?


I hadn't heard of or seen an IO given to a conscious patient, but I have now. 

I was replying to the topic of epi 1:10,000. 
We give epi 1:,1,000 IM for anaphylaxis, but we do not do IV.


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## TLDR20 (Jun 18, 2015)

Muppet said:


> I attempted 4 Iv sticks. No access including no EJ. I drilled her left tibia and gave 20mg Lidocaine for pain of IO. She tolerate it well. A crash line is a crash line.  Go watch the EZ IO videos from vida care. The bosses take it w/o pain relief to show it is ok...
> 
> M.



It is the flush that gets you, not the drill.


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