Crew dispatched to a non-emergent response on abdominal pain for a mid-40s female. On arrival to the scene, crew enters a private residence to a panicked family member yelling, “She’s in the laundry room!” The patient is lying in between the washer/dryer and the wall, and is actively vomiting; she states that she believes she is experiencing a case of “food poisoning”; family on scene state that the patient began to complain of acute onset mid-epigastric pain, vomiting, and dyspnea.
- GCS of 15
- Absent radial pulses
- Skin is ashen, moist, and cool
- Respirations appear rapid, shallow, and unlabored
- No obvious trauma noted
- BP: 76/40
- HR: 104/regular
- RR: 28
- Blood glucose: 204mg/dl
- SpO2: 91% on R/A
- Chronic back pain
- Kidney stones
You guessed it…This wouldn’t be an EKG case study without an EKG. This is what the crew finds:
Patient’s residence was fortunately approximately five minutes away from a fully staffed PCI center; crew initiated immediate transport, calling for additional man power as soon as they made contact with the patient.
- Oxygen via NRB @15LPM
- Large bore antecubital IV w/250ml NS bolus
- 324 ASA PO
- Withheld nitro due to hypotension
While moving the patient to the back of the ambulance, patient experiences a syncopal episode, and remains a GCS of 4 for remainder of transport, occasionally moaning to deep painful stimuli. RR drops to 4/BPM; no other significant changes to V/S; no changes noted to 12-lead.
- No RSI drugs available for induction; crew options to maintain BLS airway for transport.
- Initiates preoxygenation with a NC @15lpm; NPA placement due to trismus, and BVM ventilations started.
- Secondary IV access obtained.
On arrival to the ED, patient intubated, fluid boluses continued, and patient sent out to cath lab. Patient had a total of two stents placed, remained on a ventilator in ICU for two days, and was extubated on the third. After a total of a week in the ICU, patient was sent home in pre-incident condition.
If you and your crew were not in an urban setting and only five minutes away from a PCI center, what would you have done differently?
If the patient was not hypotensive, what is your department’s policy of nitroglycerin administration in the presence of an Inferior MI?
Are there any other diagnostic tests this crew could have run with the presence of STEMI in leads II, III, and AVF?