This was submitted to us by a friend of the podcast that works in an urban EMS setting.
You and your partner are dispatched to a private residence for a mid-60s male complaining difficulty breathing. A BLS engine and your commission arrive at the same time and find the patient standing outside of his residence waiting for you. The patient is hardly able to speak in one word sentences, and is gasping for breath. You rapidly move the patient to your stretcher and throw a NRB on him at 15lpm. The patient is sitting upright and immediately indicates that he needs more aggressive oxygen therapy. As you transition the patient to your commission, your partner is setting up your CPAP circuit as you are placing him on the monitor.
INITIAL 4-LEAD AND 12-LEAD
INITIAL VITAL SIGNS AND ASSESSMENT
- Patient is A/O x4
- Skin is pale (circumoral cyanosis noted), diaphoretic, and cool
- No obvious trauma noted
- BP: 180/140s
- HR: 110s/Regular
- SpO2: 85% on R/A
- RR: 52bpm/labored w/rales noted throughout
- Patient transitioned from NRB @15lpm to CPAP @10cmH2O
- Shows moderate amount of relief; RR down to mid-30s w/increased SpO2 to >96%
- Patient able to tolerate 324mg PO ASA
- 0.4mg SL Nitro spray while setting up CPAP and another 0.4mg SL Nitro spray immediately after acquiring 12-lead
- IV established
Transport initiated to the nearest PCI (approximately 10 minutes away from patient residence) center due to onset of pulmonary edema and ST depression noted. Two more sprays of 0.4mg SL Nitro given en route with no noticeable changes in VS or mentation. Patient remains agitated en route; 0.5mg IV lorazepam given with minor relief noted. While doing in depth assessment, you find that the patient is just had a cather placed to begin peritoneal dialysis next week; patient has a scar on his chest that you ascertain through yes or no questions was from a previous bypass. Due to significant respiratory distress and no access to the residence, you are unable to access medications.
Crew performed 15-lead due to extensive lateral and inferior depression on the initial 12-lead. 12 and 15 Lead EKGs transmitted to PCI. After arriving to the hospital, patient transferred to ED, where he was switched over to BiPAP and ED staff initiated nitro drip and IV furosemide.
- What would you have done differently?
- Would you have transported to a PCI?
- What other medications does your service consider for acute pulmonary edema?
- What do you see on the 12-lead? 15-lead?