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CASE OF THE MONTH - FEBRUARY 2019
 

Case Presentation

A 68 year-old male calls 911 after experiencing shortness of breath upon waking.  He tells paramedics that he woke from sleep and “didn’t feel right” and that it felt hard to breathe.    Paramedics find an elderly man in mild distress.  When prompted, the patient denies chest pain, nausea or vomiting but states that he has felt tired during his daily walks for the last week, which he attributed to a recent cold.  His past medical history includes hypertension, hyperlipidemia, coronary artery disease (2 prior stents), and gallstones.  On examination, he is alert and oriented, tachycardic, with normal skin color without diaphoresis.  His lung sounds are clear.  His vital signs are HR 185, BP 142/98, RR 24, oxygen saturation 96% on RA.

1.

What are the next steps in the management of this patient?

The differential diagnosis in this patient remains broad.  A complaint of “shortness of breath” may be associated with a pulmonary process, cardiac ischemia/infarction, or a systemic process like sepsis.  Notable abnormal vital signs are his tachycardia and tachypnea.  This patient has known coronary artery disease and is at risk for myocardial infarction, but the patient’s tachycardia could represent a systemic infection (for example pneumonia, or cholecystitis with history of gallstones) causing a sinus tachycardia, or could be a new dysrhythmia.  One should also consider other pulmonary processes such as pulmonary embolism.  Further prehospital evaluation is needed to determine the most appropriate provider impression.

It is reasonable to begin with a provider impression of ‘respiratory distress, other’ and use TP-1237 to begin treatment for this patient’s undifferentiated shortness of breath.  This patient’s primary presenting complaint is shortness of breath, and he has no abnormal lung findings to suggest pulmonary edema or bronchospasm.  A Cardiac etiology should still be considered in the possible provider impressions for this patient. 

2.

Case Update

The patient is rapidly placed on the cardiac monitor.  The rhythm below is displayed:

Case study

A 12 lead ECG demonstrates:

Case study

3.

What are the next steps in the management of this patient?

This patient has a tachycardic cardiac dysrhythmia, the primary provider impression should be updated to Cardiac Dysrhythmia, and the dysrhythmia should be managed by TP-1213.  A wide-complex, regular monomorphic tachycardia is demonstrated on the cardiac monitor and ECG.  Paramedics should assess the patients perfusion status as per MCG 1355.  The patient has normal mentation, blood pressure, and normal skin findings suggesting normal perfusion.  Therefore, the patient should be treated with adenosine 6mg rapid IV push.  If the wide-complex tachycardia persists, a second dose of adenosine 12mg rapid IV push can be administered.    Cardiac pads should be placed initially, so that synchronized cardioversion can be rapidly performed if the patient’s clinical condition deteriorates. 

Note that the wide complex tachycardia will respond to adenosine if it is a supraventricular tachycardia with aberrancy.  For this reason, stable patients with regular, monomorphic wide-complex tachycardia are treated initially with adenosine.  However, ventricular tachycardia is unlikely to respond to adenosine.  This rhythm is likely ventricular in origin given the patient’s history.  During transport, a change in perfusion status should be anticipated and one should be ready to cardiovert the patient if indicated. 

4.

Case Update

Paramedics administered 2 doses of adenosine (6mg, then 12mg) with no change in the cardiac dysrhythmia.  Upon arrival to the emergency department, the patient’s heart rate increased to the 200s.  He lost consciousness and became pulseless. He was immediately defibrillated.  After 1 cycle of CPR the patient had return of spontaneous circulation.  The following 12 lead ECG was obtained in the emergency department:

The borderline ST elevations in inferior leads III and aVF with reciprocal depression in the antero-lateral leads (I, avL, V2-V6) were concerning for STEMI.  A STEMI activation was initiated.  The patient was taken emergently to the cardiac catheterization lab for percutaneous coronary intervention (PCI) of a 95% right coronary artery occlusion. 

5.

Learning Points

A chief complaint of shortness of breath has multiple provider impressions associated with it and requires additional clinical information before a paramedic can form a provider impression.  Traditionally, tachycardic cardiac dysrhythmias present with palpitations or chest discomfort, but subjective symptoms vary among patients and feelings of dyspnea or ‘not feeling right’ are common.  A complete clinical picture, including past medical history, is needed to prompt further “as needed” testing in the field.  A wide complex regular, monomorphic tachycardia may be SVT with aberrancy or ventricular tachycardia.  In this case, our patient had ventricular tachycardia and was unresponsive to adenosine.

6.

Case Conclusion

This patient had an underlying myocardial infarction that led to ventricular tachycardia.  He arrested in the emergency department but was successfully resuscitated and taken to the cardiac catheterization lab where a right coronary artery stent was placed.  He was discharged from the hospital 5 days later after placement of an automated internal cardiac defibrillator with outpatient cardiology follow-up for medical management of his underlying cardiac disease.

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