46 Year Old Female: Injuries From a Fall

Here's a great case submitted by "Phil"… As usual, some details have been changed to preserve patient confidentiality.

It's 9 am, and you and your partner are called to an apartment complex for a 46 year old female, injuries from a fall which occurred the previous night.  You arrive to find the woman seated in a chair, in some obvious distress.  She appears pale and diaphoretic.  You ask about the incident, and she tells you that at 11pm last night, she lost her footing on the stairs and fell, bruising her arms and shoulders.  She denies hitting her head or any LOC, but is unsure how many stairs she fell down.  She considered her injuries "minor".

You ask why she called this morning, and she tells you that her arms and shoulders are still sore, and she awoke at 8am feeling "very weak and sick", with nausea and one episode of vomiting. Your physical exam reveals only minor bruising, although her pulse feels a bit slow.  She denies any chest pain or shortness of breath.

Her history is significant for Asthma and Type 1 Diabetes.

Her vitals are as follows:

  • HR:   60, weak
  • BP:   96/P
  • RR:  22, just a bit of increased effort
  • skin:  cool and diaphoretic
  • SpO2:  98% RA, 100% on supplemental O2
  • BGL:  423 mg/dl

Meds:  Albuterol, Insulin

You put her on the monitor, and acquire a 12 lead:

The patient vomits again, as you begin transport… Enroute, you capture another 12 lead:

***UPDATE***

12 Lead with V4R has been added:

 

What do you think is going on with this patient?

How would you treat her?

 

 

33 Comments

  • J says:

    V7-9 available?

  • Jeff says:

    Treat the Hyperglycemia. May be a potassium shift.

  • Erik says:

    Her 12 lead is suspicious for inferior infarct. And as both a female and type 1 diabetic she is likely to have atypical symptoms for acute MI. Weakness, nausea, vomiting, and fatigue are all common MI symptoms among this patient demographic. While she says she lost her footing, could it be possible a brief episode of syncope d/t MI caused the events of the prior evening? Pale, cool, diaphoretic + hypotension + borderline bradycardia all lead to the suspicion of a cardiac event. And although she is hyperglycemic, she has no symptoms of such nor DKA. ASA, IV fluids, serial 12 Leads and transport to facility with Cath lab capability, in my opinion.

  • Texas Rabbi Medic says:

    Due to this Pt being a female who is also diabetic, (both at risk for atypical presentations) and given the obvious STEMI, I'd manage her as an ACS Pt. (I'd leave off the ASA due to her asthma, unless she can assure me that ASA does not agrevate her asthma). The presence or an inferior wall STEMI, combined with a marginal heart rate and SR 1st degree HB, make me very suspicious of a Rt. wall MI. I'd obtain a Rt. side EKG of course. Given the marginal B/P and the potential for Rt. wall MI, I'd withhold NTG. The glucose may be a reflection of sympathetic stimulus from the ACS, or it may truly be elevated from DM management issues. A fluid bolus would help the B/P, as well as begin some level of offsetting any loss due to hyperglycemia. I'd be sure and transport her to a 24/7 interventional cath lab facility, and I'd alert the ER for STEMI protocol. Until more specific labs are available, treat for the worst case, which is STEMI at this point.

  • Lumberjack says:

    Since my rig is BLS, I would call for ALS intercept  🙂

  • Capeless Medic says:

    Hmmmm…..So the first rhythm strip almost looks like a 1:1 flutter but is it too slow for that?  The 12 lead shows a sinus rhythm with 1AVB and ST elevation in the inferior leads with reciprocal changes in the high lateral leads.  Cardiac alert, ASA, fluid & NTG.  Opiate of choice if needed and if pressure allows after NTG.  Are we concerened about right sided involvement and the use of NTG and opiates?  Maybe.  I am not seeing any reciprocal changes in the pre cordial leads suggesting posterior involvement or involvement of the right side.  Still something to be cautious of though.  Are we going to bottom out her pressure with the use of NTG if there is right sided involvement….I've never seen it happen but it doesn't mean it can't.  
    Jeff, how are you going to treat the hyperglycemia other than fluid and albuterol in the pre hospital setting?  Is the hyperglycemia causing the ECG changes in your opinion?  Just trying to elicit conversation about the Pt, not being critical of your Rx plan.

  • Char says:

    Inferior STEMI…V4R??? Texas Rabbi is right on for treatment… I’m not going to retype a perfect answer.

  • Laura Richard says:

    The use of NTG needs to be done with caution, due to low BP and possible right sided involvment.  I have seen the BP bottom out because of that.  Yes, to me because I didn't consider that possiblity….I do now.

  • BigWoodsMedic says:

    Erik and Texas Rabbi have said it all for me. I'd be doing posterior and R 12-leads for sure and sending the EKGs ahead to the ER. I doubt I'd give nitro for pain with a pressure that low, so fluid bolus before I would even consider it should she develop some.

  • Troy says:

    Acute IWMI. STE III>II along with isolated STE in V1 gives me a high suspicion of RVI. Fluid Fluid Fluid and NO nitro. Fentanyl for pain control and 4mg zofran for nausea. Transmit and activate

  • DHarrill says:

    Playing devil's advocate here and entertaining a whole other set of "what ifs":  we can't immediately label this on this as a 100%-with-out-a-doubt STEMI.  Remember that increasing intracranial pressure 2/2 head trauma can also cause ST elevation in some patients.
     
    So, on one hand, we have a patient who has an earlier MOI capable of creating an ICH , but on the other we have a diabetic, female patient and have to keep in mind that they may not even complain of "chest pain"  or other typical symptoms.  Being that "sick/weak" is one of the most common symptoms for women presenting with CAD we also can't afford to NOT highly consider this as ACS.   

    In treating this patient, aside from getting O2 and an IV established, bgl checked, etc, I dont know that I would come right out of the gates firing off ASA (anti-platelet aggregator), fluid boluses (increase ICP/bleeding), and then NTG (vasodialator) *prior* to having contacted medical control and really detailed how this patient presented (in addition to other PE findings that weren't mentioned eg pupils, motor, etc).   Think of how detrimental these treatments could be to a patient with ST elevation 2/2 a head injury.   However, would you be wrong in activating the cath-lab? Doubtful. After all, there is undeniable ST elevation. Would you be wrong in moving expeditiously to the ER regardless? Certainly not. I would just want to make sure she had resources available upon arrival to the ED were this to be ST elevation as a result of something else.

  • ToddB says:

    Agree with IWMI, r/o RVI, and treat accordingly per ACS guidelines (all well stated in previous posts). I would find out a bit more about the traumatic event and assess accordingly. Would also d/c the O2. She is at 98% on RA and does not appear to be SOB. No reason to worsen her MI with hyperoxia. Early notification to inverventional facility and transport.

  • WRSmith says:

    I am suspecting AMI, as the 12 lead indicated ST Elev in II, III and avf approx. 1 mm in elevation from the J point, suggestive of inferior MI. I would estab. .9NS of at least a 20 ga or greater and follow this up with a simple R sided 12 Lead by moving V4 to V4R and confirm the ST elev. MONA protocols are warranted in the situation but be VERY aware of the fact that this Pt is most likely having a R sided MI and thus preloaded dependant. Be ready for a sig. drop in BP with NTG and Morphine admin. Be ready to bolus this Pt should this happen. I would not concern myself with the borderline Brady rate at this time but, would also be ready to correct it should she become symptomatic. Just my 2 cents.

  • Felipe Cardenas says:

    This patient is showing some signs and symptoms of an AMI, but is denying CP or SOB, may be typical with diabetic patients.  I would further ask the patient about any family related medical history such as immediate relative of any heart conditions! as far as my plan of action, I would most definately transport this patient to the nearest hospital with cath lab capabilites.   And treatment goes, i would administer ASA if not already contraindicated, performed a right sided EKG, High flow oxygen NRB, Administer fluid bolous while assess lung sounds, definately withold the NTG (low BP, Right sided STEMI) monitored every 5 minutes.  Of course and I.V. administerd zofran 4 mg IVP or SL for nausea

  • Ben says:

    In addition to the comments above, check out the axis and the limb leads.  Borderline RAD, combined with a large S-wave in I and a small Q wave in III; if that axis shifts to the right a bit we have a left posterior hemiblock, which combined with the 1st degree AV block is a bifascicular block with all the fun hemodynamics that goes along with that.

  • Troy says:

    Nitroglycerin administration in the setting of RVI is a class III treatment. If you don’t know what that is……that’s a lawsuit waiting to happen when you toilet their BP. Just give fluid, ASA, and fentanyl or MS with diphen (to counter the histamine). It’ll be better for everyone 🙂

  • saraswathi thangavel says:

    could be blunt cardiac injury with cardiogenic shock.. ECG  shown 1. CHB. 2,3  first degree a.v block….as her paleness we need to rule out any internal bleeding.. get an urgent echo to r/o injury and rwma pericardial effusion.. give fluids.. start an inotropes.. .. shift to higher centre.. 

  • AW says:

    Really need to examine this patient hands on, but from the reading I want to consider the trauma.  I would divert to a center that can handle both trauma and cardiac if that is possible, do a really good physical exam and call ahead to discuss the case with the receiving as well as transmit the 12 leads if they accept.  I'd be transporting in a hard collar and on a clamshell depending on how she presents and unless she is intolorant of that position.  With the given BP I think she might feel better supine.
    I agree that right sided changes need to be looked for and no way this patient is getting nitro from me.  Her fall down the stairs could have been cardiac true, but we still need to consider the damage she could have done on the landing.  If these changes are strictly a result of trauma I'll be really interested to hear the explainations.  I can accept the brady as being a reaction to pain but the elevations that have reciprocal changes point me to an MI.
    For us here she is not a candidate to go direct to the cath lab in areas that do divert.  Trauma involvment excludes her.  Even those that take their hands off the stearing wheel to clutch their chest, if they so much as park it in a soft shoulder have to pass through an ER before the cath lab.

  • Terry says:

    Inferior Lateral wall MI treat as such. Look at the classic symptoms. Bradycardia, skin cool and diaphoretic, n/v. She denies c/p but she is a diabetic. The fall is important and should be kept in the back of your mind but that is not the issue here. It's just a red herring. Her BGL is high but she probably did not take her insulin.  As for the 1st strip that was not in diagnostic mode. You will get all kinds of wierd st stuff until the machine is in diagnostic mode. Treatment would be IV O2 tirated to 95% or above studies now show too much O2 is a bad thing, NTG– no way, fentanyl— she is in no pain so no, ASA– sure, Zofran, Cath Lab– absolutely and serial ECGs.  

  • 12leadekg says:

    Inferior STEMI with RVI
     

  • Mel Parker says:

    Inferior.  IV, O2, Monitor, Zofran for Nausea.  Avoid NTG, Avoid MS, Give ASA.  Fentanyl for pain.  Continous 12 lead post tx's.  Maintain bp with low volume NS admin, I would not be dumping in large amounts of fluids, maintaining the bp in its current state would not be detramental.  Call medical control for any further guidance.  The pt had a fall, is displaying classic symptoms of AMI, especially since she is a known diabetic.  What does her sugar usually run?  Is this exceptionally high for her, or does she usually run closer to the mid 200's?  Careful monitoring of fluid admin could possibly bring that fsbs down.  O2 by nasal at 2lpm, I wouldnt worry about over oxygenation there… Again, transmit ecg, ask med control for futher assistance.  Transport immediatly, activate cath lab.

  • MEDIC 1 says:

    So yes this pts. 12 lead is showing evidence of a Inferior MI, along with elevation in V4R suggesting right side involvement.  But not at one point in the above scenario is the pt. complaining of chest pains, however only complaining of general weakenss/N/V.  Yes being an elderly female with a HX of diabetes it is a good posibilty of a "silent MI'.   I agree the NTG and the morphine could be beneficial for the vasodilation properties.   But why is everyone wanting to treat the monitor, even though she is not having chest pains! Why not cal and run it by medical control before treating the CP , even though im sure you will get the orders anyway.  Im just not big on treating the monitor.  Thats just my thoughts, plus im a new medic.  Any feedback is greatly appriciated, I love contructive critiscism. 

  • Christopher says:

    For those considering Traumatic vs Cardiac cause of the ST-elevation and reciprocal changes, I would offer that the ED has no means to rule in traumatic causes without ruling out an MI first! How does an ED rule out an MI with ST-E and reciprocal changes? A cardiac cath.

  • flashy says:

    Side question –
     
    Why does lead II on the 4 lead look WAY different than lead II on the 12 lead. Specifically the area around the T wave? I wish I could describe it but just compare the 2 and you'll see. Is it just a physio-control thing?

  • Christopher says:

    Flashy,

    On the 3-Lead, if you look at the frequency filters applied, you'll notice the high-pass is set to 1 Hz and the low-pass is set to 30 Hz.

    Whereas on the 12-Lead, the high-pass is 0.05 Hz and the low-pass is 40 Hz.

    In effect, the 3-lead has filtering applied to minimize interference from baseline wander, muscle artifact, and EMI. All of these combine to distort the ECG signal, most notably the ST-segment and T-wave.

    The 12-lead has "less" filtering applied in order to give a truer, more diagnostic, view of the ECG signal, especially the ST-segment and T-wave.

    The default filters on the LP12 grossly distort ST-T changes in monitor mode as you astutely picked up on. Great catch!

  • David Baumrind says:

    Flashy,

    i can't really add anything to what Christopher said, other than to stress that while the 3 lead is very useful for rhythm interpretation, it really has little value when it comes to diagnosing a STEMI. Good observation though!

  • AW says:

    Christopher I'm not suggesting that this patient is not in need of a cath at all.  For sure she needs one, I just think traumatic injuries could be there and also in need of care.  Generally those with Truama will get at least a chest x-ray before going to the cath lab, without they may go direct right off our stretcher.  I don't know how it works for other larger areas with many hospitals.

  • marionurse44 says:

    1st degree blk. Inf MI poor  R  wave progression R chest leads, R ax devation. Tx like MI

  • medicritter372 says:

    @DHarrill
    "Playing devil's advocate here and entertaining a whole other set of "what ifs":  we can't immediately label this on this as a 100%-with-out-a-doubt STEMI.  Remember that increasing intracranial pressure 2/2 head trauma can also cause ST elevation in some patients."
     

    Your speaking of contractile (or z-band) necrosis 2/2 a sub-arachnoid bleed. Its very atypical to see this in the inferior leads. 90 percent of the time you would see the elevations your speaking of in anterior leads. Not that I'm ruling this out, not many people know about this so I'm very impressed. I know you are playing devils advocate. But she is also showing no vital sign changes of increased ICP. However, I know protocols vary so if I violate other county protocols please forgive, but in my protocols you only give NTG if the patient is complaining of active chest pain. This patient is not. Even with an IV in place I would withold NTG due to her blood pressure, and the fact that shes not having active chest pain. I would give oxygen, ASA, w/h NTG, fluid boluses to increase BP, and rapid txp repeating 12-Leads to look for changes and of course monitering my patient.  

  • Mike G. says:

    Ben wrote:
    “In addition to the comments above, check out the axis and the limb leads.  Borderline RAD, combined with a large S-wave in I and a small Q wave in III; if that axis shifts to the right a bit we have a left posterior hemiblock, which combined with the 1st degree AV block is a bifascicular block with all the fun hemodynamics that goes along with that.”

    This is something that I also noticed. Anytime you imply BLOCK two or more times in your interpretation, it will be a bifasicular block. Reduced CO is a definate concern with this Pt and another reason to consider withholding NTG and MS. As far as trauma vs. cardiac, it is also completely possible that the two could be completely unrelated too. This could be a new onset of possible AMI that she woke up with, unrelated to the fall. OR she could have had a near syncopal episode secondary to poor CO that caused the fall the day before. What came first, the chicken or the egg? Then the possible DKA? I’d just treat the what presents to me appropriately and let the MD figure out what came first. After r/o that she’d be a trauma alert the most severe presentation is the cardiac issue, which is were I’d start. I’d of course keep an eye on the other fun stuff too, but for now tx like a STEMI.

  • Billy Bob says:

    Good call, id agree with most that said inferior with RVI based on the STE greater in 3 than 2 and the elevation in V1 but isn't that the point of the V4R (if i remember right its 90 something percent specific for RVI); to the few who said careful with the nitrates yee ha! yes ive seen it happen a few times and yes it will happen. BOLUS BOLUS BOLUS before inbetween and after the nitrates good for RVI and the hyperglycemia :). Medic 1 you dont have to "treat the monitor" because this pt is symptomatic (hypotension, diaphoresis, pale, "feels weak and sick" N/V) and on top of all that your monitor is trying to tell you why. So, treatment… a few asked about posterior leads. Why not just assume and adjust accordingly, or if theres time then do it, if not then just think there is until proven otherwise (the 3 V leads looked ok). O2 via NC, 2 large IV's, monitor, ASA, and CAREFUL with the narcs and nitrates, and off you go to the PCI 😀

  • chase says:

    Alert the PCI your enroute to their location with a STEMI.

    Treatment:
    -IV- 2 1000 ml NS bolus with a potassium drip (due to hyperglicemia)

    -Place dfib pads on pt. chest

    -Give 325mg. Asprin sl and use NTG with caution (suspect ACS)

    -Give 2mg MS iv for relief of pain

    – 2L O2, via NC

  • Mel says:

    Capeless Medic –

    Ive seen Flutter in patients with a heart rate of 40… 6:1.  Flutter can happen at any rate in all actuality…

    Im going to say R side Inferior MI.  Hold Nitro.  Give ASA, 100 mics of Fentanyl for pain.  O2.  Def the right side V4 to confirm.  Maintain BP.  If it drops and cannot maintain with fluid bolus, give a pressor.  Dopamine at 3 mics to maintain SBP.  Activate Cath Lab, Code STEMI.  II, III, and AVF with R side 12 lead.

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