EKG Case Study #14: Mid-70s Male C/O Acute Weakness and Diarrhea

You and your partner work for an urban ALS system. At approximately 2300, you are dispatched to a choking with an unresponsive party. As you arrive on scene, a BLS engine crew member alerts you to the fact that they have a mid-70s male in full cardiorespiratory arrest just outside of a downstairs bathroom. Family members advise that the patient starting to feel “ill” around 2100, complaining of a sudden onset of weakness followed by an acute onset of diarrhea around 2230. They also relay that they heard the patient “struggling” in the bathroom and becoming notably dyspneic. You note frothy sputum around the corners of the mouth. As your crew initiates chest compressions and an OPA/NRB combo due to local CCR protocols, you find a med list and history that reveals: A-fib, HTN, COPD, CHF. Patient’s family also state that the patient has a history of DVTs, PEs, and has had three cardiac stents placed. Your partner places the defib pads on the patient and you take a look at your initial rhythm.

INITIAL RHYTHM

8137bddb-0b32-4e44-8884-812cbb3e9672-original

PULSE CHECK

  • Due to potential respiratory etiology of arrest, crew bypasses local CCR protocols and assumes standard ACLS procedures, placing OPA and ventilating patient approximately 8-10bpm.
  • Chest compressions continued
  • IO established in L tibial tuberosity
  • First round of 1.0mg 1: 10,000 Epi IO
  • Crew recognizes PEA and no defib delivered

PULSE CHECK

  • Patient remains in PEA
  • Chest compressions resumed
  • IO fluids hung with pressure bag placed wide open
  • EtCO2 line placed and measured at 12mmHg
  • BGL assessed and noted to be 92mg/dl
  • No obvious signs of trauma noted; no forms of ETOH use or illicit drug use noted; patient is not on any known opioids

PULSE CHECK

  • Patient remains in PEA
  • Second round of 1.0mg 1: 10,000 Epi IO
  • Chest compressions resumed
  • Patient vigorously suctioned due to foaming secretions; intubated with first pass success with channeled blade video laryngoscope and bougie stylette
  • EtCO2 improves to 22mmHg

PULSE CHECK

  • Patient remains in PEA
  • Chest compressions resumed
  • Secondary IV access obtained with fluids hung wide open with pressure bag; approx. 750ml have been infused thus far
  • 50meq Sodium Bicarbonate IO
  • EtCO2: 20mmHg

PULSE CHECK

  • Patient remains in PEA
  • Chest compressions resumed
  • Third round of 1.0mg 1: 10, 000 Epi IO
  • EtCO2: 23mmHg
  • Crew begins to approach family about the fact that ten minutes of resuscitation have taken place with no gross changes and initiates conversation about end of life decisions; family states that the patient has no known end of life arrangements in place, and request that despite no gross changes, patient be transported regardless of ROSC.

PULSE CHECK

  • Patient remains in PEA
  • Chest compressions resumed
  • Approximately 1.2L of 0.9% NS have been infused at this time
  • Crew gathers backboard and other packaging equipment, but stop long enough to note that the EtCO2 has risen to 67mmHg from the low 20s
  • Confirmed ROSC noted at this time

ROSC 12-LEAD

67692a19-9ddd-41d6-b589-53b2f80466ab-original

  • BP: 102/48
  • EtCO2: 49mmHg
  • HR: 116
  • Pupils are dilated and unresponsive
  • Patient remains GCS of 3
  • What do you see on the 12-lead?
  • Crew initiates transport to local PCI center approx. 10 minutes away from residence; approximately five minutes into transport, patient arrests a second time.
  • Chest compressions initiated again.

PULSE CHECK

  • Patient is found in PEA
  • Chest compressions resumed
  • Fourth round of 1: 10,000 Epi IO
  • EtCO2: 25mmHg; towards end of cycle of CPR, crew notes another spike in EtCO2 to 56mmHg
  • Crew confirms that they have ROSC again

SECOND ROSC 12-LEAD

2fc58b6e-d12a-498e-a0e0-15e380b86ded-original

  • BP: 74/42
  • HR: 88
  • EtCO2: 52mmHg
  • Patient continues to ventilate without difficulty
  • What do you see on the 12-lead?
  • Approximately 2.5L of 0.9NS have been infused at this time
  • Crew initiates norepinephrine drip at 2mcg/min per crew’s protocol

ED HANDOFF

  • Patient codes a third time
  • Ongoing resuscitation in the ED lasts for another 30 minutes with no ROSC
  • Patient found have to have pulmonary embolus and pronounced in the ED

DISCUSSION

  • What would you have done differently?
  • Do you think that there is a place for thrombolytics in routine care for post arrest patients from possible thromboembolism?
  • What do you think the role of prehospital ultrasound is?

EKG Case Study #13: 45YOM with Abdominal Pain

You and your partner work in an urban ALS service and are called to a report of a seizure. En route to the scene, dispatch advises you that the call has been upgraded from a seizure to a cardiac arrest. When you arrive on scene, FD personnel tell you that they have been on scene for approximately three minutes, have completed one cycle of CPR and have delivered one defibrillation via AED. The patient’s family has a significant language barrier making history gathering significantly more difficult. To the best of the crew’s ability, they deciphered that the patient has been experiencing abdominal discomfort and weakness for approximately the last 24 hours, and that the patient has no know medical history, medications, or allergies. The FD has already placed an OPA and a NRB mask per local cardiocerebral resuscitation (CCR) protocols. You switch the pads over from the AED to your monitor, and this is what you find…

INITIAL RHYTHM

ECS13 Initial Rhythm 001ECS D1 001

  • 2nd defibrillation at 360 Joules
  • Chest compressions resumed immediately for another two minute cycle
  • IO established in the L Tibia
  • 1.0mg Epi 1: 10,000 IO
  • 250ml 0.09% NS Bolus initiated

PULSE CHECK

ECS13 D2 001

  • 3rd defibrillation at 360 Joules
  • Chest compressions resumed immediately for another two minute cycle
  • 300mg Amiodarone IO
  • Advanced airway placement preparation
  • Explored H/Ts
    • Blood glucose assessed and found to be 96mg/dl
    • No signs of illicit/prescribed drug abuse, ETOH consumption, or trauma noted

PULSE CHECK

ECS D3 001

  • 4th defibrillation at 360 Joules
  • Chest compressions resumed immediately for another two minute cycle
  • 1.0mg Epi 1: 10,000 IO administered
  • 250ml 0.09% NS Bolus administered
  • Unsuccessful ETI attempt
    • OPA replaced and BVM ventilation initiated

PULSE CHECK

  • Reveals bradycardic PEA (rate of 40s- not pictured)
  • Chest compressions resumed immediately for another two minute cycle
  • Supraglottic airway placed
    • Confirmed with an EtCO2 of 34
    • L/S confirmed; absent epigastric sounds
    • Tube fogging noted
    • Chest rise and fall noted
  • Secondary large bore IV access placed in the L Antecubital
  • Third 250ml 0.09% NS bolus initiated with no presence of pulmonary edema

PULSE CHECK

  • Reveals bradycardic PEA (rate of 40s- not pictured)
  • Chest compressions resumed immediately for another two minute cycle
  • 1.0mg Epi 1: 10,000 IO administered
  • Fourth 250ml 0.09% NS bolus initiated with no presence of pulmonary edema
  • Crew began to start contemplating transport decision; due to significant language barrier, crew opted to initiate transport due to inability to properly communicate with family; receiving hospital has access to interpretation lines.
  • While packaging patient for transport, crew notes a significant spike in EtCO2 from the mid-30s to 72mmHg
  • Crew confirms newly gained presence of carotid/femoral pulse

12-LEAD #1

ECS13- 12 lead 1 001

  • Crew initiates transport to the closest PCI facility approximately 10-15 minutes away
  • BP: 118/70
  • HR: 76
  • Patient remains a GCS of 3
  • SpO2: 96%
  • EtCO2: 68mmHg

12-LEAD #2

ECS13 12 Lead 2 001

  • Five minutes after initial EKG, crew notes a significant reduction in heart rate
  • BP: 134/72
  • HR: 44
  • SpO2: 97%
  • EtCO2: 40mmHg
  • Patient remains a GCS of 3
  • Cold packs placed in the groin, neck, and axilla

12-LEAD #3

ECS13 12 Lead 3 001

  • Crew notes a significant drop in EtCO2 from 40mmHg to 24mmHg while pulling into ambulance bay.
  • BP: 68/40
  • HR: 50
  • SpO2: 96%
  • EtCO2: 24mmHg
  • Administered 0.5mg IV Atropine
  • Initiates TCP gaining capture at 125mA at a rate of 70
  • Levophed initiated at2mcg/min
  • Patient remains a GCS of 3
  • Crew delivers patient to the ED

FOLLOW UP

  • ED staff continue levophed infusion titrating to a total of 20mcg/min
  • TCP continued
  • Patient transferred to cath lab, with stents placed
  • Patient maintains pulse post cath lab and transferred to Cardiac ICU

DISCUSSION

  • What would you have done differently?
  • Would your care changed if you were further away from definitive care?
  • Do you agree with the crew’s decision to transport due to ineffective family communication?
  • What are your department’s policies on ETI v. SGA usage in cardiac arrest? Impending arrest?

EKG Case Study #12: 55YOM Found Unresponsive

You are dispatched to an unresponsive party at a private residence; a BLS engine crew and your unit arrive at the same time. As you are moving your equipment into the house, you see the engine crew dragging the patient from a back bedroom to an open space in the living room. The engine captain tells you that the patient was “agonally breathing” in the back bedroom. As you make your way to the patient, you note that he is now pulseless, apneic, and unresponsive with no obvious signs of trauma or indicators of drug usage in the home. Chest compressions are initiated and an OPA and NRB @15lpm of oxygen is initiated due to local CCR protocols. The patient’s wife tells you that she woke up to the patient “snoring” and being “unable to wake him up” around 0400; she states that he was last seen normal around 2300 the evening before.

INITIAL RHYTHM

EKG Case Study #12- 55YOM Initial Rhythm 001

Chest compressions continued until defibrillator charged.

EKG Case Study #12- 55YOM 1st Defib 001

  • First defibrillation at 360 Joules
  • Chest compressions immediately resumed
  • 16g IV placed in the Left AC
  • 1.0mg of 1:10,000 Epinephrine IV
  • Blood glucose check results in 76mg/dl
  • 0.09% NS hung and 500ml bolus initiated
  • First two minute cycle completed

PULSE CHECK

EKG Case Study #12- 55YOM 2nd Defib 001

  • Patient remains in V-fib; second defibrillation at 360 Joules delivered
  • Chest compressions immediately resumed
  • 300mg IVP Amiodarone administered
  • Preparation for ETT set up
  • Second two minute cycle completed

PULSE CHECK

EKG Case Study #12- 55YOM 3rd Defib 001

  • Patient remains in V-fib; third defibrillation at 360 Joules delivered
  • Chest Compressions immediately resumed
  • 1.0mg Epinephrine 1:10,000 administered
  • Secondary access established with Left-sided Proximal Tibial IO
  • Second 500ml bolus of 0.09%NS initiated
  • Third two minute cycle completed

OVER THE NEXT TEN MINUTES…

  • Patient intubated with first pass success
    • Crew used channeled blade video laryngoscope with bougie stylette
    • Is video laryngoscopy changing the way we approach airway management in OHCA?
    • What is your departments first line airway? ETT? SGA?
  • Waveform capnography placed revealing EtCO2 values consistently in the mid-40s
  • Five pulse checks performed revealing bradycardic PEA in the 40s
  • Two more rounds of IV 1.0mg Epinephrine 1:10,000 administered
  • Exploring H/Ts
    • Patient has a previous history of renal cancer and HTN
    • He takes no medications
    • No prior complaint of illness recently
    • No access to opioids or previous ETOH/drug abuse noted
  • Crew contemplating transport decision due to quality capnography readings with CPR, and then…

PULSE CHECK

EKG Case Study #12- 55YOM 4th Defib 001

  • Presents with pulseless V-Tach; fourth defibrillation at 360 Joules
  • Chest compressions resumed immediately
  • 150mg IVP Amiodarone administered
  • Ninth two minute cycle completed

PULSE CHECK

EKG Case Study #12- 55YOM ROSC 12-Lead #1 001

  • Patient has a strong radial/carotid pulse
  • BP: 186/132
  • HR: 48bpm/irregular
  • EtCO2: 45
  • SpO2: 98%/intubated and being ventilated via BVM @15lpm at rate of 10bpm
  • Patient carried to stretcher and transport initiated to nearest PCI facility that is approximately 15 minutes away

SECOND 12-LEAD

EKG Case Study #12- 55YOM ROSC 12-Lead #2

  • EtCO2 dropping from 45 into the low 20s with no change in ventilatory pattern
  • Cold packs placed in the groin, axillary regions
  • Patient remains GCS of 3
  • Other vital signs remain similar to last check approximately 3 minutes prior
  • EtCO2 drops again from the low 20s to 18; pulse reassessed tube position and pulses; absent carotid pulses noted
  • CPR initiated again for one cycle; presented with bradycardic PEA
  • 1.0mg IV Epinephrine 1:10,000 administered
  • Two minute cycle completed

PULSE CHECK

EKG Case Study #12- 55YOM ROSC 12-Lead #3 001

  • Patient regains strong/irregular/slow carotid and radial pulses
  • What’s your interpretation?
  • BP: 164/96
  • HR: 24bpm; slow/irregular
  • EtCO2: 75
  • SpO2: 99%/intubated and being ventilated w/BVM @15lpm at a rate of 10bpm
  • Considered atropine and TCP but withheld due to compensatory BP

FOURTH 12-LEAD

EKG Case Study #12- 55YOM ROSC 12-Lead #4 001

  • Rate rapidly improves without pharmacological or electrical assistance
  • Vital signs outside of heart rate stay within similar ranges
  • Crew arrives at PCI facility and care is transferred to receiving ED staff

AFTER DELIVERY

  • Patient sustains ROSC after delivery
  • Patient’s vital signs begin to rapidly decompensate in resus bay
    • BP: 34/20
    • HR: 20
    • EtCO2: 24
  • ED initiates TCP; administer 0.5mg IV Atropine
  • Art Line established with 1L bolus of 0.09NS started
  • Initiates levophed and dopamine infusions
  • Vital signs stabilized in ED and sent upstairs to ICU

 

 

EKG Case Study #11: Mid-40s Male C/O Weakness

This run was submitted to us by a friend of the podcast; this friend works in an urban EMS service. 

You and your partner are dispatched to an illness at a private residence for a mid-40s male that states he has been feeling weak off an on all day. He had just gotten back from work that day, when he grew weaker and decided to lie down on the couch. After about 30 minutes, the weakness grew worse still and he became nauseated. The patient is actively vomiting when you walk into the room. The patient tells you that he doesn’t know of any medical problems that he has been diagnosed with, and denies taking any prescription medications or having medication allergies.

INITIAL ASSESSMENT

  • Patient is a GCS of 15 w/no neurological deficit noted
  • Skin is ashen, cool, and diaphoretic
  • Weak/regular/slow radial pulses detected
  • Respirations appear eupneic, pain free, and quiet w/clear and = L/S noted throughout
  • No obvious indicators or trauma noted

INITIAL VITAL SIGNS

  • BP: 104/62
  • HR: 52/regular
  • SpO2: 96% on R/A
  • RR: 20bpm
  • Blood Glucose: 136mg/dl

I won’t insult the intelligence of you guys, anymore. After all, this is an EKG blog. Your partner turns on the monitor, and you can only imagine what you can find.

INITIAL 4-LEAD AND 12-LEAD

EKG Case Study #11 4-Lead 001

EKG Case Study #11 001.jpg

What part of the heart is affected? Is this patient a candidate for a right-sided 12 lead

TREATMENT

Crew immediately administered 324mg PO Aspirin, and had no access to any other types of platelet aggregant inhibitors or anticoagulants. Patient was loaded on the stretcher, and transport was initiated to closest PCI (about 10 minutes away). Successful large bore IV access gained and 250ml 0.09% NS bolus initiated due to borderline blood pressure. Patient received 4.0mg ondansetron and three rounds of 0.4mg SL nitroglycerin with a blood pressure of 168/100 on delivery to the ED physician. No other 12-leads were provided and no other interventions were done. Follow up with the ED physician reveals that the patient had an 80% LAD occlusion and a 100% Circumflex occlusion. The patient had three stents placed, and was sent home after a short ICU stay.

DISCUSSION

  • This crew did not give oxygen to the patient; no complaint of dyspnea or distress was noted. What are your thoughts on whithholding O2 to the STEMI patient that is not in distress?
  • What would you have done differently?
  • What are your thoughts on fluid therapy in the presence of STEMI?
  • Would your care have changed if you were in a rural setting?

EKG Case Study #10: Mid-60s Male with Pulmonary Edema

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

EKG Case Study #10- Inferior Lead View 001

EKG Case Study #10- First 12 Lead 001

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

INITIAL TREATMENT

  • 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.

15-LEAD

EKG Case Study #10- 15 Lead 001

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.

DISCUSSION

  • 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?

 

EKG Case Study #9: The Crashing DNR Patient

This was submitted to us by a friend of the show. A run I’m sure a lot of you have had, but with the understanding that there are multiple ways to manage this type of patient. 

You and your partner are working for an urban ALS service, when you are dispatched to an unresponsive patient on the outskirts of town. A BLS engine with four EMTs is on scene as you arrive, and state that they found the patient in the back bathroom. The patient, an approximately 85yof, is slumped over to the left side on the toilet. She is covered in vomit, and is only responding to firm painful stimuli. The patient’s daughter states that the patient has a Do Not Resuscitate order, but is unable to find the paperwork; she also reports that the patient was last seen acting normal (a GCS of 13 due to late stage Alzheimer Dementia) around 15 minutes prior to calling 911 (approximately 25 minutes ago now). No recent illnesses or trauma were reported; the patient’s daughter just felt like “something was wrong”, and went to check on the patient. The BLS crew has her on a NRB mask when you arrive.

INITIAL ASSESSMENT

  • GCS of 4; only moans to painful stimuli
  • Respiration appears bradypneic and shallow; ranging between 6-10bpm
  • Skin is cool, pale, and moist
  • Absent radial pulses, weak carotid pulses in the 60s noted and regular
  • No indicators of trauma present
  • Unable to assess pupillary response due to cataracts
  • L/S are diminished due to shallow respiration; clear/= throughout

INITIAL VITAL SIGNS

  • Unable to obtain B/P even with automatic cuff
    • Absent radial pulses; weak carotid
  • HR: Starting to brady down into the 50s/regular
  • Respiration starting to slow down to the 2-6bpm range
  • BGL: 149
  • 75% on R/A
  • EtCO2: 9mmHg

MEDICAL HISTORY

  • End stage Alzheimer Dementia
  • Hypothyroidism

MEDICATIONS

  • Patient takes no medications beyond daily vitamins

ALLERGIES

  • NKDA

DIAGNOSTICS AND TREATMENT

Due to the confined working conditions, crew opted to remove patient from scene to back of commission to begin to treatment.

  • Initial intact gag reflex noted; NPA placed
  • Assisted ventilation with a BVM
  • Bilateral large bore IV access initiated with 0.09% NS hung via pressure bags
    • 500ml bolus initiated with no change to V/S

85yof DNR Initial Rhythm 001

85yof 12-lead #2 001

This is what the crew sees originally. STEMI? Any other diagnostics you would run? 

Transport initiated to the closest hospital that is 15-20 minutes away (which is consequently a PCI/Stroke Center) after approximately a 10-15 minutes scene time. Patient’s daughter was not able to obtain a hard copy of the patient’s DNR order prior to transport. The patient is rapidly decompensating, and has gone from agonal respiration to apnea. NPA was exchanged for an OPA. EtCO2, which started off at 9mmHg, has now dropped to 5mmHg. Marked bradycardia ranging between the 30-40s has now started. Crew is still unable to palpate radial pulses, and is unable to detect a blood pressure via automatic cuff; weak carotid pulses are still present.

85yof DNR 12-lead #3 001

After this printout, crew places pads on the patient and initiates transcutaneous pacing.

85yof Pacing Initiated 001

Transcutaneous pacing initiated at a rate of 60bpm and 10mA; titrated up 40mA and still not obtaining mechanical capture. While first crew member is increasing the mA of the pacing, they are preparing to initiate a Levophed drip due to the marked hypotension. Lead medic calls report to the receiving hospital; as the medic is calling report, they notice a drop in EtCO2 from 5mmHg to 0mmHg. The patient is now in full cardiorespiratory arrest. 

The crew does not have a hard copy of the DNR order, but makes a request to medical control to withhold any further BLS/ALS intervention due to adamant family request. Permission is granted to withhold any further intervention.

85yof Pacing Terminated 001

DISCUSSION

  • What would you do differently?
  • When you have an actively dying DNR patient in front of you, how aggressive is your treatment?
  • Removing the DNR aspect, what are your thoughts on going straight to TCP instead of Atropine in this instance?
    • In the presence of an MI?
  • Would you have worked the patient as a full arrest instead of calling medical control?

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.

EKG CASE STUDY #7: 60YOM C/O Chest Pain and Dyspnea

This study was donated to us from a friend working in a nearby rural EMS service, and is a treasure trove of conversation topics. Let’s get started. 

HPI

You and your partner are called to a private residence out in the county for a 60YOM complaining of chest. As you arrive on scene, you see the patient seated in his recliner looking obviously distressed and anxious. The patient tells you that he finished his dinner approximately an hour ago and went to sit down and watch t.v. afterwards. While at rest, the patient began to develop significant chest “pressure” that begins to travel down his left arm. As the pain worsens, he decides to call 911.

INITIAL ASSESSMENT

  • Patient is a GCS of 15 with no noted neurological deficits noted
  • Skin is pale, cool, and profusely diaphoretic
  • Weak/regular radial pulses noted
  • No obvious signs of trauma noted
  • Resp rate appears elevated and mildly dyspneic
    • L/S are clear/= throughout

VITAL SIGNS

  • B/P: 124/74
  • HR: 64/regular
  • RR: 20
  • SpO2: 97% on R/A

INITIAL RHYTHM STRIP AND 12-LEAD

EKG Case Study #7 5-Lead

EKG Case Study #7- 1st 12 Lead 001

Upon seeing the first 12-lead, you call for first responders to make your scene for extra personnel to drive you to the hospital. You are approximately 10 minutes away from a community hospital that has no cardiac capabilities, and are about 45 minutes away from a PCI facility. It’s raining outside and no  helicopter will meet you for transport; this is your patient.

INITIAL TREATMENT

  • 324mg PO ASA
  • 18g Saline Lock established in the R forearm
  • 0.4mg SL nitroglycerin
    • Patient states that initial 8/10 pain improves to 5/10
  • 180mg PO Ticagrelor (a platelet aggregation inhibitor) per local protocol
  • Oxygen via NC @4lpm
  • 12-Lead transmitted to receiving hospital; receiving hospital notified about patient and ETA
  • Transport initiated
  • 0.09% NS hung; initial 250ml bolus due to obvious signs of poor perfusion and nitroglycerin administration with a borderline B/P
  • B/P reassessed: 124/74; no gross changes in RR, HR, or SpO2%
  • 0.4mg SL nitroglycerin
    • Patient states that 5/10 pain improves to 3/10
  • Secondary IV access obtain with a 20g in the L AC
  • 0.4mg SL nitroglycerin
    • Patient states that 3/10 pain improves to 2/10

DURING TRANSPORT

The patient states that the relief he was getting from the SL nitro is beginning to dissipate and now his pain waxes and wanes, but is beginning to feel worse than it did before he called 911.

  • Nitroglycerin drip initiated @5.0mcg/min

Crew elects to due a 15-lead due to initial inferior involvement in the initial 12-lead

15-LEAD FINDINGS

EKG Case Study #7- 15 Lead 001

  • Is there any posterior involvement? 
  • Right-sided involvement? 
  • What are the dangers of giving nitroglycerin with r-sided involvement? 

In the not so distant future, we will be doing a blog detailing how and when to do a 15-lead on your cardiac patients, so keep your eyes peeled.

The patient continues to state that his pain is getting worse despite nitroglycerin infusion; drip titrated from 5mcg/min to 10mcg/min. Patient’s blood pressure is sustaining in the 130/90 range with no gross changes in HR, RR, or SpO2. Patient reports that the pain no longer feels like a “pressure”, but states that it is starting to feel like a “crushing” pain.

  • Nitroglycerin titrated to 15mcg/min; BP maintains with no improvement in pain noted
  • 2mg IV morphine with no change in pain noted
  • 8mg of IV ondansetron with mild relief from nausea and vomiting

REPEAT 12-LEAD

EKG Case Study #7 2nd 12-Lead 001

What type of involvement do you see? 

  • Patient given 2mg of IV morphine with no change in pain or vital signs.

On arrival to the PCI center, patient was transported directly to the cath lab with nitroglycerin and 0.09% NS infusion still running; total of 1.88ml of nitroglycerin infused as well as 700ml 0.09% NS.

DISCUSSION

  • Would your treatment modalities changed if you were in an urban setting vs. a rural setting? 
  • Would you have done anything different? Why? 
  • What is the benefit of performing a 15-lead? What did it show here? 

EKG CASE STUDY #6: 82YOF feeling dizzy and “hot”

This case study was brought to us by a friend and huge supporter of the show that works in an urban EMS service here in Indiana. 

You and your partner are called to a grocery store in the middle of the afternoon on a well-being check for a patron of the store. As you approach the customer service desk, you see the patient reclining on a bench and appearing obviously restless and anxious. The patient, an 82yof, states that she has been walking around the store for approximately 30 minutes, and became acutely dizzy and feels “overheated”. After some general questioning, you find that the patient denies any recent illness, and states that she has been eating and drinking normally for herself. This patient has no substantial medical history, and beyond taking a daily vitamin, does not take any home medications. You and your partner remove the patient from a public setting for her privacy before doing a more thorough assessment.

INITIAL VITAL SIGNS AND DIAGNOSTICS

  • B/P: 92/56
  • HR: 160/Regular
  • SpO2: 98% on R/A
  • RR: 24/non-labored and shallow
  • Blood glucose: 74
  • Temperature: 98.2º F
  • Skin is pale, warm, and dry

As you are setting up your EKG monitor, your partner initiates IV access, starts a 250ml 0.09% NS bolus and places the patient on a NC @4lpm. This is what you see when your 12-lead spits out.

85yof dizzy EKG 2 001

You deduce that this is a pretty straightforward case of SVT, and proceed to your narrow complex tachycardia protocols, administering 6mg of Adenosine followed with a rapid 20ml NS flush. Your partner had the foresight of hitting “print” on the monitor during the exchange.

85yof dizzy EKG 1 001

After short-lived anxiety from your patient, she begins to feel a significant amount of relief from her symptoms.

POST INTERVENTION FINDINGS

  • B/P: 116/72
  • SpO2: 99% on 4lpm via NC
  • HR: 96
  • RR: 18/non-labored and normal depth

EKG 3 85 yof 001

Patient transported to local PCI facility without any further incidents of recurring SVT or changes in V/S or mentation.

DISCUSSION

What do you do to prepare your patients for Adenosine administration? Synchronized cardioversion? 

If vital signs and protocols allow, what is your sedation agent of choice for procedures like this? Do you consider sedation and/or analgesia? 

What are some clinical markers that help you determine if a rapid rhythm is AFib with RVR, SVT, or VT? 

What is the importance of doing a 12-lead prior to giving adenosine? 

For more on rapid rhythm diagnosis and treatment, listen to our interview with Eric Allmon.

 

 

EKG CASE STUDY #5: 75YO Cancer Patient Witnessed Cardiac Arrest

SCENARIO

You and your partner are working in an urban ALS service. At 0430, you are dispatched to an unresponsive party at a private residence, and are told en route by dispatch that the patient is possibly in cardiac arrest. An engine is dispatched for manpower, and arrives to the residence at the same time as your commission. Family members lead your crew through a crowded house upstairs to find your patient, a 75YOM, in full cardiac arrest. The patient’s wife states that the only know medical history that the patient has is prostate cancer and HTN; wife goes on to state that the patient was speaking to her around 0425, and appeared restless; mid-sentence the patient collapsed to the floor. Per family on scene, the patient is a full code.

MEDICATIONS

  • Flomax
  • Opana
  • Lisinopril

ALLERGIES

  • NKDA

INITIAL INTERVENTION

  • Chest compressions initiated
  • OPA/NRB @15lpm placed per local protocol
  • No secretions or obstructions noted in airway

INITIAL RHYTHM

75YOM Initial Rhythm

75YOM Defib #1.jpg

  • Patient presents in VF; 1st defibrillation @360J
  • Compressions resumed
  • Tibial IO established; 1.omg of 1:10,000 Epi
  • 2mg IO Naloxone administered due to Opana usage
  • Blood glucose assessed: 114mg/dl

FIRST PULSE CHECK

75YOM Defib #2

  • Patients persists in VF; 2nd defibrillation @360j
  • Compressions resumed
  • 300mg IO push Amiodarone
  • 250ml NS bolus

SECOND PULSE CHECK

75YOM Defib #3

  • Patient persists in VF; 3rd defibrillation @360J
  • Chest compressions continued
  • Second 250ml NS bolus initiated
  • 1.0mg 1: 10,000 Epi push
  • King LT placement
  • Capnography placed with initial reading of 39

THIRD PULSE CHECK

75YOM Defib #4

  • Patient presents in VF; 4th defibrillation @360J
  • Chest compressions continued
  • 150mg IO Amiodarone push
  • Third 250ml NS push
  • Halfway through CPR cycle, EtCO2 spikes to 72
  • Patient begins to exhibit purposeful movement of the upper extremities

ROSC 12-LEAD

75YOM EKG #1

POST ARREST V/S

  • BP: 94/72
  • HR: 80/irregular; 12-lead reveals A-Fib
  • Patient is currently being ventilated via BVM @10bpm
  • SpO2: 98%
  • Temp: 98.4° F

TRANSPORT

  • Patient transported emergently to closest PCI facility, approximately 10 minutes away
  • En route, patient begins to blink, gag on King airway, and flail arms around
  • After recycle v/s, no gross changes in HR, SpO2, or temp; BP: 104/52
  • 5mg IO Versed push for airway maintenance
  • 16g AC line established
  • Patient sustains ROSC throughout transfer to ED
  • Patient packed with cold pack for therapeutic hypothermia

With no obvious complaints of respiratory distress or cardiac symptoms prior to arrest, what are your thoughts on arrest etiology? 

What would you have done differently? 

Would your treatment modality have changed in a rural setting versus an urban setting?