EKG CASE STUDY #8: When Pragmatism Meets Idealism

This case study was donated to us by a close personal friend of the show. He works in an urban ALS service, and felt troubled that he wasn’t able to get more done for the patient before delivering him to the receiving PCI facility. His background before moving to the service he is currently working in was in a county ALS service where transport times to definitive care could be upwards of 30-60 minutes. So let’s dig in. 

HPI

You and your partner are dispatched to reports of an unconscious 65yom. First responders beat you to the scene and advise you that the patient was lying down on the couch “watching a football game”, when he experienced a sudden onset of midsternal, non-radiating chest “pressure” with accompanying general weakness and dizziness. The patient is lying shirtless on the couch and looks visibly anxious; he denies any type of medical history whatsoever, takes no prescription medications, and denies any drug allergies. Climbing over loose trinkets, leftover food, and garbage, the crew assesses that they are not going to be able to work in the residence. Crew rapidly removes patient from the residence to the back of their commission for a more thorough assessment.

INITIAL ASSESSMENT

Before leaving the residence, you note that:

  • Pt is a GCS of 15, but growing more and more tired by the minute
  • Absent radial pulses
  • Respirations appear within normal limits and non-labored
  • Skin is ashen, cool, and diaphoretic
  • No signs of trauma
  • Pupils are PERRL
  • L/S are clear/= in all fields w/= rise and fall
  • Abdomen is soft, non-tender, and non-pulsatile
  • Pt is tremoring c/o being extremely cold; while you try to suppress the patient’s movement with active warming with blankets, you begin to attempt to run some diagnostics

IMMEDIATE INTERVENTIONS

  • Oxygen therapy initiated
  • 324mg PO Aspirin
  • 18g IV initiated in the L AC w/250ml 0.09% NS bolus
  • Withheld nitroglycerin due to absence of radial pulses

FIRST 12-LEAD

Pt is continuing to tremor; first 12-lead obtained within five minutes of patient contact.

65YOM EKG #1 001

Nothing crazy. Right? 

SECOND 12-LEAD

65YOM EKG# 2 001

Better than the first, and doesn’t seem to be anything too alarming. The patient is telling you that his pain is intensifying, going into his jaw, and down his left arm.

THIRD 12-LEAD

65YOM EKG #3 001

Starting to see it? It gets better. You manage to warm up the patient enough to suppress the excessive tremors, and snap a fourth EKG.

FOURTH 12-LEAD

65yom EKG #4 001.jpg

12-lead faxed to closest PCI facility from the scene, and transport initiated. The patient’s BP has slightly improved to 80/42 with a 250ml 0.09% NS bolus, but the patient is starting to have episodes of bradycardia that are short-lived, dropping occasionally into the 20s and 30s, then returning back into the 50s. Just for kicks, he snapped a fifth 12-lead to see if he could get a cleaner picture. You grab the pads after obtaining your last 12-lead and place them on the patient.

FIFTH 12-LEAD

65yom EKG #5 001.jpg

DISCUSSION

So what’s the problem? You gave oxygen, aspirin, and fluids. You have a 12-lead that has definitive STEMI criteria. You can see the PCI center from the patient’s house. From patient contact to delivery to the PCI center was a total of 15 minutes. You have no other access to any other platelet aggregant inhibitors or fibrinolytics.

  • Would you have started pacing? 
  • Atropine? 
  • Percussion pacing
  • Would have delaying transport for a 15-lead or an extra line/bolus been worth it? 
  • What about pressors? 

Obviously, lengthier transport times allow time to perform additional interventions en route to the hospital, but in truly rhetorical fashion, is it worth delaying definitive care to investigate more? We live in the gray, and this is something we all must wrestle with.

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