74 year old female CC: Chest pain

Here’s another great case from Michael M.

EMS is called to the residence of a 74 year old female with a chief complaint of chest pain.

On arrival the patient is found lying on her side in bed. She is conscious but lethargic and it’s clear she has vomited.

Skin is cool, pale and diaphoretic. She looks very ill.

The spouse states that he “thinks it’s her heart.”

Past medical history: MI x 3 years ago with stents, HTN, high cholesterol
Meds: ASA, atenolol, simvastatin, spironolactone

Vital signs are assessed.

RR: 24 shallow
Pulse: radial absent, carotid very rapid
NIBP: unable to auscultate
SpO2 does not register

The cardiac monitor is attached.

Is there anything else you’d like to know about this patient?

What is your interpretation of the ECG?

How would you treat her and why?

See also:

74 year old female CC: Chest pain – Conclusion

51 Comments

  • Brian H. says:

    ****zap****

  • chris T says:

    Wide complex tachy
    Sounds too unstable for any pain meds or sedation, id consider fentanyl Intra nasally but id need orders for that so. “Im sorry ma’m this is going to hurt” Sync cardiovert, use increasing jules until acheived. Consider Ami 150mg over 10 min. I would like to see a new rhythm and improved vitals with cardioversion so there are a lot of different directions to go from here.
    Any Hx of rhythm distubances in the past? If so does she know what it was and what they did to treat it the last time?

  • Rick P says:

    HOLD ON MR. TOAD THIS IS GONNA BE A WILD RIDE!!!!

    I agree with Chris T. assessment and treatment. This is obviously a wide complex tachycardia that the patient presents as hemodynamically unstable and is in need of immediate synchronized cardioversion. It would be difficult to judge from reading this just how “lethagic” she is as to wether I would consider sedation first or go straight to cardioversion. I think that is one of those questions that can only be best answered if you are there in front of the patient.

  • Lonnie says:

    Sedate, Cadriovert the rhythm and reassess. I like Chris’ Amiodarone

  • AMRmedic says:

    Unstable wide complex tachycardia equals immediate cardioversion……judging by the looks of the EKG and his history, I’d be willing to bet he had a massive MI. I’d like to see a 12 lead, but its usless if you can’t get him stabilized first

  • Mark L says:

    Ma’am would you hold this lightbulb please? This is something I’ve always wanted to see…

  • chris T says:

    I am glowing right now you have no idea!!! Thanks!

  • chris T says:

    The fentanyl IN was a new thought for me I was curious of opinions. I say fentanyl because it tends not to effect BP much or at all. And I would not delay cardioversion for IV access at this point. IM would be too slow to take effect. What do you guys think? If the patient say had a BP where you would consider pain med with cardioversion what would you do ? Sorry if this isnt the place to ask this stuff but im curious.

  • Royce says:

    It is a great idea idea Chris…and one we have standing orders to do…

  • chris T says:

    Oh cool Royce. Thank you. It will give me some security knowing its practiced and not an idea lol

  • AGW 3483 says:

    In order…

    1. “CLEAR”
    2. ZaP
    3. IV
    4. Versed (For introduction of the 5 min retrograde amnesia effect)
    ……
    5. Paperwork

  • gerard says:

    i would cardio vert and get a bgl then if nec seaate and continue cardio vert

  • Rich L says:

    I agree with everyone. I don’t think you would have time for sedation of any kind. That is straight up V Tach and you have only a few minutes brfore you start pumping on this pt’s chest and possibly losing her for good so, unfotunately she gets to ride the lightning. She will be angry for a minute, but may send out a thank you letter when she walks out of the hospital.

  • Marti says:

    Definately needs cardioverting ASAP as the Pt isvery unstable. I woulds sedate the Pt first – and if IV access is an issue – it only takes a few seconds to do an IO.

  • Nick says:

    Great treatment plan, Chris.

    Personally, I would forget about sedation at this point. Shes already circling the drain, I don’t need to spend that extra time unlocking my narcotics, pulling out a syringe, drawing up the med, and spraying it. The fact is this lady is going to die real soon if you don’t do something. You could loose a pulse before you even get the fentanyl out of the box. I’m sure prolonged CPR hurts more than cardioversion. Blast her with electricity, blast her with amiodorone, and screw to the hospital.

  • Bill says:

    I guess the BP is too low for 5mg of Versed IN.

  • Robert F. (Las Vegas) says:

    Ooooo I feel that hairs on my arm sticking up… Zzzzap!

  • prefer to see 12-lead

  • even though it most likely is WCT.

  • Dauphine says:

    I agree with all that have posted I would like a d-stick and a 12 lead before I would cardiovert with the meds she is on this could be a diabetic or a problem with her meds causing a sodium potassium pump problem once I got a good d-stick and could look at the 12 lead I would then proceed with the cardioversion. both of these test would only take a min or so.

  • G says:

    Cardioversion, no time for sedation. I’d worry about the 12 lead, glucose, etc after she has a BP!

  • Troy says:

    IN fentanyl is the wave of the future. It virtually has no effect on the BP and is enough to take the edge off the zap. We use it as our drug of choice for peds and its my choice for CP now a days

  • chris T says:

    Thanks Troy, I not saying delay for this patient, I was curious of the treatment idea. I work in two different states. One is a mother may I state and I can’t transport without a docs permission it seems. And the other I have a mobile ER of drugs and nothing I NEED to call for. It isnt something considered in my either of my protocols and not mentioned in any ACLS, so I was wondering what peeps thought as it made sence to me. Sounds like it is a decent practice as I didnt know it was used anywhere. Cool.

  • Charles Phillips says:

    Ventricular tachycardia! Defibrillate @ 200 joules immediately. It’s obvious that the patient’s cardiac output is severely decreased since the only palpable pulse is a weak carotid. Immediate agressive intervention is indicated.

  • Troy says:

    Chris T,

    If u look online there’s a study of using .2mg/kg on dogs with no hypotensive effects. IN is studied in the ACLS resource text if I remember right.

  • chris T says:

    thanks Troy appreciate your time.

  • brenden murphy says:

    i had this happen to me i was cardioverted 2 times and defibbed 18 times coded for 45 min now back to work 7 months later.

  • Steve B. says:

    O2 via NC @ 4LPM
    Activated Charcoal per Medical Control
    360 J
    Diesel

    Lather, rinse, repeat.

    pwnd.

  • Steve B. says:

    ^^ Obviously a joke ^^

    You all are nuts for using the Fentnyl.

  • Caleb D. says:

    Yeah, without a doubt would be prepping for immediate synchronized cardioversion. No protocols for IN Fentanyl here, or buccal versed, either of which I would love consideration of, but this lady needs electricity and needs it in a hurry. There’s lots of things I’d like to know on her, but at this point in time, I agree with everyone so far, light her up. 12-lead once she’s stable, and then start looking at possible drug interventions.

  • VinceD says:

    Regular wide complex tachycardia at somewhere around 180 bpm. Also, there is likely 5:1 retrograde V-A conduction evident in lead II, which coupled with her history, makes me about 95% certain this is V-Tach.

    Cardioversion without sedation following my local protocols for energy dosing would be my treatment choice. Personally, I’d prefer to start high on the energy dosing so that repeat shocks are less likely to be required, but protocols are protocols…

    Intranasal fentanyl is a nice thought and a wonderful drug in certain circumstances, but I don’t think it’s ready for prime-time on critical patients like this one just yet; the risk to benefit ratio is just too high in my opinion. True, it’s more hemodynamically stable than morphine, but it’s not inert and I don’t want to play games with this lady’s BP. Plus, it’s not like she’ll coast through the cardioversion comfortably with only some fentanyl on-board; it’ll still suck, maybe just a little less. I’ve never seen a study of analgesia-only for cardioversion (or in person), usually it’s combined with a sedative or dissociative agent, so I really wonder just how much good it would do. It’s a judgement call, and for some folks that bit of analgesia is worth it, but for me it’s not.

    Now ketamine in this situation, that’s something I might consider more strongly if we had it…

  • Matt says:

    Well, I agree with most everyone that synchronized cardioversion is indicated, but I’m somewhat curious about some of the sedation debate. Obviously, we aren’t in front of this patient, but I’d probably be willing to see if I could spend two minutes getting a line and a little versed on board.
    Also, several folks have mentioned wanting a glucose level. What are you hoping this will add to the clinical picture?

  • chris T says:

    I was just asking for opinions, and Its getting them. I love helping to spark controversey. Gets good comments! I would hope that this doesnt make any of us “crazy”. Besides it cant hurt that long 🙂

  • Christopher says:

    1 mg IN Versed or 50 mcg IN Fentanyl from me for this lady. Although if she’s made it this long If she’s mentating well enough I’m going to be starting my line while the machine charges and maybe give 1-2 mg IV Versed. I’d prefer the IN route just due to the fast access to her CNS considering her heart isn’t going to circulate much meds I push via any line. Either way I think she deserves some sedation.

  • Katie says:

    Is she talking to us??? I want more info about what happened prior to the episode, sure she has a cardiac history but what happened today??? Has she vomited prior to this?? Been sick?? Possibly taken something?? How stable is she?? Maybe it’s cuz I’m new at all this but I want WAAAAY more history, VS, info!!!

  • Lance says:

    I’d also like to be employed when I’m done with my paperwork… Pads, charge, shock and drive.

  • Dennis says:

    Does she have a DNR? Seriously!

  • M says:

    A-fib with WPW

  • Troy says:

    I’m with Chris…..both of them.

    If mentating, sedate. If they are with it enough to talk and walk they deserve to be sedated in my mind, if even just mildly. But that’s me

  • Mike says:

    It sounds pretty unanimous for cardioversion as the first intervention. IMHO, the debate to sedate or not sedate is one of those where you just have to be on-scene to see what “lethargic” and “very ill” means.

    One thing I would do while I’m setting up for cardioversion is send someone with the husband to make damn sure that the listed meds are all she’s taking. If we’re dealing with a possible toxic ingestion (e.g. tricyclic OD), I’d like to work on dealing with that before it throws her back into wide-complex tach or worse. Electrolyte levels would be nice; but I haven’t heard of anyone stocking I-STAT handhelds on a bus yet.

  • ARSHAD HASAN says:

    NO ‘T’&NO ‘P’
    ‘QRS’..Wide
    HR–300
    Dx
    VT
    Pt–Unstable
    Cool&Calm periphery with—Abscent Radial pulse

    Rx
    Immidiate Cardioversion

  • TS says:

    Definitely immediate cardioversion, Id deal with the other stuff later (H&Ts), as far as sedation and/or retrograde amnesia, what are the chances of this converting and everything being hunky dory. What Im wondering about is a prior comment about versed immediately after. As a benzo, wouldnt you be worried about what really caused this episode before giving something that can cause hypotension? Just wondering from a student perspective.

  • chris T says:

    TS Versed to my knowledge is NOT recomended after a procedure to help someone forget what just happened. Thats how that post read to me. And versed WILL cause hypotension all by itself

  • TS says:

    Ok, just making sure I had that right thanks.

  • AW says:

    Here by protocol everyone gets sedation prior to syncronized cardioversion. If we are not taking the time to sedate we are not to take the time to make sure the sync is flagged right either so they have to be ‘that’ sick that we are willing to defibrillate. I’d like to have been by pt side on this to know for sure but it sounds unlikely that she was ‘that’ sick by our treatment guidlines given the conscious but lethargic comment. For our service, which works paired ACPs targeted and layered backing up PCP crews, I don’t see the delay in sedation being significant if any. History (and I agree I’d want more than given) and the monitor set up will be longer, and often the IV is already in place PTA. Worst case we have no back up or we are first in, but still I personaly would want sedation for someone that has a pulse and any level of LOC.

  • Swede says:

    AW: What meds do you have in you protocol for sedation in hypotension VT pt ?

    Do anyone have ketamin for this kind of pt ?

    /chris, from sweden.

  • Rose says:

    All the comments are great and the idea of IN Fentenyl is good. I agree that synchronized cardioversion is needed and asap. But if I have time to sedate to help the patient I would.

  • TS says:

    Id would want to ask if anything like this has happened before, whether she’s had a disrythmia in the past, and maybe find out what it was and how they fixed it although that’d be unlikely if there is a hx. As far as after she’s stabilized starting with immediate cardioversion, I’d want to know how long she’s been ill looking for, compliance with meds, etc. From what it looks like that last med is a pretty strong diuretic, id consider hyperkalemia/renal failure. definitely would want to ask some more questions while applying pads. The spouse is there, id use him.

  • Swede,

    If I had a line and ketamine, I would love to give this patient some ketamine. Absolutely appropriate tool in the toolbox for conscious sedation.

  • VinceD says:

    Swede, I agree with Chris that I wish we had ketamine. Maybe someday….
    While I am not very knowledgeable when it comes to EMS outside of my region, most services I know carry some combination of diazepam, midazolam, lorazepam, etomidate, and either morphine or fentanyl on their rigs. Most of my area has diazepam, midazolam, etomidate, and morphine, but only diazepam is actually part of our protocols for synchronized cardioversion (as a med control option). I’ve heard of others also carrying haloperidol, and I’m sure there’s some advanced flight programs that carry goodies like propofol and maybe ketamine.

  • Paul says:

    I’m going to get stoned for this, but with all the debate about giving meds sedation and taking two minutes to try something, I would be inclined to slam 12 of adenosine considering this is a wide complex monomorphic rhythm. I don’t think the argument can be made that it isn’t worth trying, if you can make the argument that there’s time to draw sedative medications or do something else. After all it takes 15 seconds, is in the ACLS protocol, and I have had it work.

1 Trackback

Leave a Reply to Dennis Cancel reply

Your email address will not be published. Required fields are marked *