This is the second installment in a multi-part case study; you may want to review the initial description of the patient’s presentation in Part 1. We’re going to save dissection of the ECGs for the next post and continue with his case…
Here’s the patient’s initial ECG again:
You start by administering 324mg of aspirin PO, chewed well. Recognizing that the patient is in rapid atrial fibrillation at about 125 bpm and that his fast heart-rate could be contributing to his symptoms, you start to draw up a loading dose of diltiazem. However, before you can administer the medication, you notice a change on the monitor and shoot a 12-lead.
You shoot a posterior ECG with posterior leads V7-V9 for good measure.
Aside from an obvious decrease in the patient’s heart rate, his vitals are unchanged. You question him closely about his symptoms and they are still exactly the same. He still feels a “burning” in his chest that he rates as a 6 out of 10, but it’s no different from when he first presented.
You start to think that maybe it wasn’t the rapid a-fib causing his chest pain…
You administer 0.4 mg of nitro SL, reassess his pain as being mildly reduced to a 5/10, and run another 12-lead.
You administer a second dose of 0.4 mg nitro SL, his pain drops to 3/10, and you run fifth 12-lead.
You administer a third dose of 0.4 mg nitro SL and the patient tells you that his pain is nearly gone. “Nearly? Not entirely?” you ask. He admits that there is still a little discomfort. “It’s a 1/10.” You print yet another 12-lead.
The patient seems to be responding well to nitro but at this point you’ve reached your ceiling—not due to some arbitrary number of doses but because of the patient’s BP. You would like to keep going but his pressure is now 94/52 mmHg and it’s not within your training, protocols, or comfort level to take him any lower.
His skin is still warm, pink and dry, his radial pulse is strong, and he looks great. In-fact, he feels much better. He’s even questioning why he called the ambulance in the first place and looks forward to getting home to catch a football game later that evening.
What are your next considerations in the care of this patient?
Is this patient a candidate for immediate cardiac catheterization or thrombolysis?
For the conclusion of this case, check out Part 3 (coming soon!).
created 2013.12.31 last modified 2017.08.25