This is part 2 of a multi-part series examining a 68-year-old male patient who presented with a chief complaint of "chest tightness" and an abnormal ECG. You may want to review the initial description of the patient here. We're going to save the dissection of the ECG's for the next post and continue on with his case presentation for now…
You start by administering 324mg of aspirin PO, chewed well. Recognizing that the patient is in rapid atrial fibrillation at about 127 bpm and that his elevated heart-rate could be contributing to his symptoms, you start to draw up a loading-dose of diltiazem to slowly bring his rate under control. However, before you can administer the medication, you notice a change on the monitor and shoot a 12-lead.
For good measure you shoot an ECG with posterior leads V7-V9 as well (Note: Whenever I print a posterior ECG I do so at 2x gain).
Aside from an obvious decrease in the patient's heart rate, his vitals are unchanged. You question him closely about his symptoms and they are still exactly the same. He is still experiencing chest discomfort that he rates as a 6 out of 10, absolutely no different from when he first presented. "Well maybe it wasn't the a-fib giving him symptoms…" you think.
You administer 0.4mg of nitro SL, reassess his pain as being mildly reduced to a 5/10, and run another 12-lead.
You administer a second dose of 0.4mg nitro SL, reassess his pain as being 3/10, and run another 12-lead (not shown).
You administer a third dose of 0.4mg nitro SL and the patient tells you that his pain is nearly gone. "Nearly, not entirely?" you ask, and he admits that there is still a little discomfort that he would rate as a 1/10. You print yet another 12-lead.
The patient seems to be responding well to nitro but unfortunately at this point you've reached your ceiling, not due to some arbitrary number of doses but rather the patient's BP. You would keep going but his pressure is now 94/52 mmHg and it is not within your protocols, comfort level, or training to take him any lower. His skin is still warm, pink and dry, pulse is strong, and the patient looks great and in-fact feels much better. He's even questioning why he called the ambulance in the first place and looks forward to getting home to catch a football game later that evening.
You are less than 10 minutes from arriving at the local PCI-capable hospital and about to call report to the ED, this patient not being a candidate for direct transport to the cath lab under regional protocols.
What are your next considerations in the care of this patient?
How are you going to frame the case in your report and hand-off to the ED staff?
At the moment the patient looks absolutely wonderful. Are you still worried in spite of his excellent symptomatic response to treatment?