What do you suspect?

[Guest feraldan]

Scenario:

Female in her late 30's states that she was awoken in the early morning hours by a sharp 6/10 chest pain located just below her breast. Pain has been ongoing for roughly 2 or 3 hours since she woke up. It does not radiate however patient complains of difficulty breathing and left side weakness. No slurring of words and patient is able to walk easily.

Having the patient squeeze your hands confirms weakness in the left side. Patient's skin is warm but dry and pale. Blood pressure is 150/110. Pulse is regular and strong but rapid at 98. Respirations/lung sounds are unremarkable at 16 and clear. Patient has type 1 diabetes and no other medical history. No known allergies. Taking unknown prescribed medication for high cholesterol. Last meal was at 7PM the night before. Vitals stay as listed throughout transport.

Questions:

If you're ALS, what would you do? Would you immediately turn it over to BLS without further assessment or would you get a strip or run any other tests?

If you're ALS or BLS, what would you suspect given the above? How would you treat the patient?

Ask any other questions you need info for. I'll provide it if I can.

Edited February 25, 2008 by feraldan

[Oswegowind 17]

2 things off the top...Pulmonary embolism, do not delay transport, we can't do anything in the field. Other may be AAA (abdominal aortic anyeurism), and again EMS can do nothing for this in the field...get going, not worth waiting to find out. Both can be deadly and need specific tests that printing a strip in the field will not assist in. However, as common practice, if ALS is on the field, it is their job and they should at least get bloods and a valid line going. If BLS is on the field, no stay and play, get up and go to the closest receiving center. 3 hours in already!

Now, I read this same scenario to my wife (ER nurse, St. John's Riverside Hospital):

She says rule out PE, AAA, and MI due to the fact that diabetics tend to have atypical type symptoms during an MI. She says she hopes that someone put the patient on a monitor and started a line. Bloods they can do themselves, but obviously this patient needed ALS care, not BLS, however no one should wait on scene for ALS to arrive!

Edited February 25, 2008 by Oswegowind

[Guest X963toOEM9]

If you're ALS, what would you do? Would you immediately turn it over to BLS without further assessment or would you get a strip or run any other tests?

I would Absolutely NOT turn it over to BLS... 12 lead EKG/FS/IV/O2 at the minimum

If you're ALS or BLS, what would you suspect given the above? How would you treat the patient?

I would want more information before making a Dx... race, obesity, diet, family hx, recent activities (poss head inj.), recent hx of headache, blurred vision, pupil response, naseau, vomitting?

I would be leaning more towards a neurological etiology then cardiac, but the DM does make it difficult to gauge her pain.

[20y2 43]

Are pedal pulses equal?

[JJB531 652]

Are pedal pulses equal?

I was gonna ask the same thing.... blood pressure comparison between right and left arms?

[FFD941 20]

Does the chest pain increase on inhaltion/exhalation or on palpation?

Has she taken all of her prescribed medication as required?

Has ALS checked blood sugar?

Edited February 25, 2008 by FFD941

[FFD941 20]

Hey who's a CIC.... I want CME Credit!!!!

[bil14ga 1]

Hey who's a CIC.... I want CME Credit!!!!

Justin,

NO CME FOR YOU!!! Tradition hater!!!!!

As far as the case goes... ALS work up for R/O MI. Females with MI can present atypically. With a Hx of DM and hyperlipidemia it is a good idea to look at this first. This is not to say to not look at other possible causes. Work up should include blood sugar, full round of tubes (bloods), and a 12 lead.

Regarding the ALS crew, paramedics are obligated to complete a full history and physical whenever they arrive at the scene. If there are strong BLS providers on the scene that assessed the patient, the paramedic may take that providers assessment and turf the patient BLS if it is clinically indicated. Putting the patient on a monitor in my mind is working a patient up and once that happens the patient should not be turned over BLS.

Unfortunately, I see alot (not all) paramedics take the easy way out and tend to turf patient that need to be worked up. When I was working full time as a paramedic, ALS patients always got my full undivided attention. A complete history and physical was completed. I always erred on the side of working up patients as opposed to sending BLS. This was not because I did not trust the BLS crews, but instead it was my a$$ on the line if something went bad. Patients who were truely BLS were sent with the BLS crew.

[Guest feraldan]

race, obesity, diet, family hx, recent activities (poss head inj.), recent hx of headache, blurred vision, pupil response, naseau, vomitting

Hispanic female

Athletic build

Had Chinese takeout the night prior, no other diet info available.

Family hx of diabetes

No exceptional recent activities

No headaches, blurred vision or nausea, no vomitting

Pupils were sluggish but eventually reactive

Does the chest pain increase on inhaltion/exhalation or on palpation?

Negative.

Are pedal pulses equal?

PMSx4, no differences in strength of pulse. Despite the inability to firmly squeeze with the left hand there were no differences.

Has she taken all of her prescribed medication as required?

Has ALS checked blood sugar?

No blood sugar check done, PT reports taking meds.

Edited February 25, 2008 by feraldan

[helicopper 1,050]

Hispanic female

Athletic build

Had Chinese takeout the night prior, no other diet info available.

Family hx of diabetes

No exceptional recent activities

No headaches, blurred vision or nausea, no vomitting

Pupils were sluggish but eventually reactive

Negative.

PMSx4, no differences in strength of pulse. Despite the inability to firmly squeeze with the left hand there were no differences.

No blood sugar check done, PT reports taking meds.

Chinese food, huh? MSG toxicity!!!

[Remember585 815]

As a BLS provider I would treat it for the worst-case scenarios (cardiac emergency, PE, etc.). and transport without delay. If ALS is there I would assume they would ride it in.

From what I am reading and from seeing it both with a patient and with myself, I wouldn't be surprised if it's just acid reflux or even severe indigestion. It's amazing how differently the body responds to things from one person to the next.

Good post!

[ny10570 745]

Anything in the 12 lead? SpO2? Pulsatile mass? If all are unremarkable she gets nitro, ASA, morphine, at least a 16g IV and a nice relaxed trip to the ER.

[FFD941 20]

If all are unremarkable she gets nitro...

But does she have a cardiac history?? If not what does Med Control say?

[ny10570 745]

No apparent cardiac hx, but she's a diabetic with high cholesterol. The chat with telemetry is going to be very one sided and short because I'm asking for morphine for a hemodynamicaly stable adult with chest pain.

[FFD941 20]

No apparent cardiac hx, but she's a diabetic with high cholesterol. The chat with telemetry is going to be very one sided and short because I'm asking for morphine for a hemodynamicaly stable adult with chest pain.

Agreed, I was just wondering about the nitro since she has no cardiac hx

What is our outcome...You can't leave us hangin!!

Edited February 26, 2008 by FFD941

[Guest feraldan]

What happened: (for the sake of anonymity, no names or locations here)

BLS crew arrives to find ALS already on scene. ALS walks the patient out to the ambulance as BLS crew walks up to the residence. Paramedic reports abdominal pain with no vomiting or nausea and then promptly cancels him/herself.

BLS crew brings patient on board. The EMT asks the patient where her pain is, she points to the left side of her chest, just beneath the breast. Pain as described above. EMT takes vitals and finds them elevated. EMT gets concerned and tells the driver to start rolling. Local hospital on full diversion so the crew had to go further away but still within 5 or 6 minutes. EMT applies high concentration of O2 prior to start of transport and continues to monitor vitals/gather information. Patient reports some relief of pain with O2.

Rather uneventful, but its concerning that ALS apparently didn't even perform a BLS level assessment.

I wanted to see what other people had to say about it.

Edited February 26, 2008 by feraldan

[ny10570 745]

FFD, just about any possibly cardiac chest pain get nitro.

feraldan, how did the pt do on the look test? One of the most reliable tests I've seen, especially in the absence of any significant clinical findings is "How does the patient look?" Did she look ok or did she leave that impression that something wasn't right. This is an excellent case to follow up on, because if the medic did miss something they need to be held appropriately accountable.

[Guest paramedico987]

Sooooooo...

what was the diagnosis?

Feraldan, you can't leave us all hangin' on this one. You simply must go find out what the deal was.

I find the concomitant unilateral weakness in the presence of chest pain very strange, to the point that I wonder if the patient is making some or all of this up.

I can come up with a few very unlikely circumstances, but nothing that doesn't require a stretch of imagination.

I don't think PE with a pulse of only 98 unless she's on beta-blockers, and based on that BP I doubt it...

Dissecting aorta perhaps, but where's that unilateral weakness coming from? It'd be nice to know bilateral BP's.

And then, what I think is most likely, anxiety!

My synical attitude toward sick people aside, I'd likely work her up for the blood pressure ALONE. The last AHA guideline for hypertensive crisis lists a diastolic of 110 as the criteria.

I don't think I'd be treating her for AMI, since the risk of that weakness being a bleed is too high for me to be giving ASA OR NTG.

With those vitals and PE described, she doesn't meet Westchester's Criteria for HTN crisis either.

I WOULD, however, take her to the hospital where people with more impressive letters after their names and far superior diagnostic tools can take a crack at it.

[Guest alsfirefighter]

Could she be on the pill and not forthcoming as well?

Besides keeping the other conditions mentioned in the back of my head I'm also going to try to rule out anxiety. Given the patient's particulars and with the BP its possible it could be a case of status hispanicus or PRH as well. A good assessment in a professional caring tone will help weave through the BS and find out if there is something going on outside of the big picture.

I'd palpate the abdomen well to see if there are any palpations or masses. If not...and with that BP I'm going with AMI work up...ASA, NTG. I'm not particularly worried about the grip being weak on one side...could just be a function of the pain, and yes that could also means its muscular, but without further indicitive reasoning as to why it could be muscular I'm not going to take that chance. If her speech is normal, grimace is normal and she has no sway then I'm ok with giving NTG. If all else fails..you call medical control and let them make the decision. I'm not exactly sure why everyone keeps asking about the blood sugar, nice ot know info but if they are CAOx3, alert and interacting normally, then it shouldn't be an issue and none of the other S/S point to a problem in that manner.

The elevated BP could be HTN, that the patient isn't being forthcoming about or has developed with the other PMH stated. Or as Chris pointed out with the consumption of chinese food, the sodium and MSG could also cause a spike..that high probably not in a normal person, but this patient does have a PMH that usually doesn't happen at the ages stated here.

[NWFDMedic 58]

Obviously everyone agrees that this patient at least required an ALS assessment. The possibilities with this patient go from AMI to psychiatric, but there's no reason the patient shouldn't get O2, EKG, IV, and a blood sugar. Pain in the chest and/or abdominal cavity is often non-descript and not well located because of the way the brain receives and processes the information. A couple of things that I haven't seen mentioned are cholecystitis (which of course usually has some other s/sx and RUQ pn.), hepatitis or pancreatitis. As far as history is concerned, we'd also want to find out if she is or was a smoker and birth control has been previously mentioned.

You aren't going to rule out any of these conditions in the field, but you darn sure should prepare yourself to deal with any of them and give this patient a full assessment and rapid (not balls to the wall) transport. I'm not a big fan of the "diagnostic" NTG since the vasodilation of NTG can cause pain relief of non-cardiac chest pain, not to mention the fact that it may give the patient a distracting secondary condition (the killer headache). If the 12 ld. is clear and other cardiac S/Sx do not exist, I'm not going to give NTG. ASA on the other hand, I might give, because it's really not likely to increase the degree of any bleeding that may be going on.