Hot on the heels of the last case is another great case study, this one is from a reader named Baby Medic. I hope you enjoy it!
It is a busy Halloween night, when you and your EMT partner are dispatched to an outlying address in your service area for a 78 year old male complaining of dizziness.
After navigating a mess of rural farm roads, you arrive at a small house off a long dirt driveway. Out front you are met by the patient’s wife, who frantically directs you inside and down to the basement. There you find your patient, a noticeably larger man, sitting in a recliner with one hand on his chest. As your partner kneels down to obtain vitals, you ask him what is going on.
Onset: Chest pain started about 15 minutes ago, while watching TV
Provocation/Palliation: Nothing makes it better or worse
Quality: “Something is pushing on my chest”
Radiation: The pain is only localized retrosternal
Severity: 10 of 10
Timing: The pain is constant
Your partner briefly interrupts to say he cannot find a radial pulse. You continue with your history.
Medications: He can’t remember (you send his wife to find them)
Past Medical History: Extensive cardiac history, including CABG, HTN, and he was recently discharged from the hospital after carotid artery surgery
Last Ins/Outs: Normal dinner
Events: “Sitting in my chair, watching TV, got real dizzy and then the pain started.”
Your partner anxiously relays the patient’s vitals while he attaches the cardiac monitor.
Pulse: Could not palpate a radial pulse
RR: 24, labored; lungs clear and equal bilaterally
SaO2: Beeps and displays E34
A physical exam reveals no JVD, a soft, non-tender obese abdomen, and good pulse/sensory/motor in all extremities. The only remarkable feature is dusky, cool, diaphoretic skin.
An alarm sounds on the cardiac monitor as the initial rhythm strip is printed.
Your partner acquires a 12-Lead ECG while you interpret the rhythm strip.
What rhythm is present? Does the 12-Lead ECG help with your interpretation?
You’re 20 minutes from the nearest hospital and 45 minutes from a PCI capable facility. How would you treat this patient?