Case Presentation by Dr. Tim Scott, DO
CHIEF COMPLAINT: “MY chest hurts”
HISTORY OF PRESENT ILLNESS: 62yo white male presents from home with chest pain. He states it is substernal and non-radiating and started 30 mins prior to arrival while he was helping his wife in the garden. He was kneeling down cutting thorns off of a rose bush. It states it felt like indigestion and he tried to burp a couple of times but it did not help. It was 8/10 initially and is now 6/10. He went in the house and sat down and drank a glass of water but this did not help. He takes an aspirin daily and did not try any other medications. He states he feels a little sweaty and light headed but denies any other symptoms. Otherwise usual state of health. States he has hypertension, no previous history of heart attack or coronary artery disease he is aware of.
REVIEW OF SYSTEMS:
Constitutional: Denies weight losst
Cardiovascular: Denies palpitations or syncope
Respiratory: Denies hemoptysis
Gastrointestinal: Denies rectal bleeding
Genitourinary: Denies hematuria
PAST MEDICAL/SURGICAL HISTORY: HTN – only surgery was tonsillectomy many years ago
SOCIAL HISTORY: Pt denies smoking, socially drinks alcohol and denies ever using any illicit drugs
EXAMINATION OF ORGAN SYSTEMS/BODY AREAS:
VITAL SIGNS: Blood pressure 106/54, pulse 92, respirations 20, temperature 36.3, SpO2 95% on RA
GENERAL: Well-developed, well-nourished, alert and oriented x3 and mildly uncomfortable secondary to acute condition.
HEENT: Head is normocephalic and atraumatic with no gross signs of trauma. The pupils are equally round bilaterally with extraoccular movements grossly intact and no conjunctival pallor. Sclera are icteric and non-injected. Mucous membranes of the mouth are moist without erythema.
Neck: No adenopathy. Trachea is midline.
LUNGS: Clear to auscultation bilaterally without wheezes, rales or other adventitious breath sounds. Good airflow, no accessory muscle use.
HEART: Regular rate and rhythm. S1-S2 noted. No clicks rubs or gallups auscultated. No murmurs auscultated.
ABDOMEN: Soft, non-tender, non-distended. No pulsatile masses appreciated.
MSK/EXTREMITIES: Normal strength bilaterally in upper and lower extremities. Peripheral pulses are present and symmetric bilaterally at 2+ in all extremities. Homan sign negative bilaterally. Good pulses at radial and posterior tibial arteries bilaterally
Skin: No edema. Warm and moist. No calf erythema.
NEURO: Patient is awake alert and oriented x3 with normal speech and normal hearing. Patient is responding and cooperating appropriately to exam. Face is symmetrical.
Pt placed on a cardiac monitor and 2L O2 via NC and an IV is established with an accucheck performed before you ever see the patient (yes, you are at an outside institution … a very rural ED to be exact). The nurse grabs you because the monitor looks funny. You agree and order a 12 lead EKG. You are handed the following gem:
Lucky for you, the cardiologist happens to be in the ED seeing another patient. You grab an old EKG which shows an obvious LBBB and you show this new one and the old one to the cardiologist. The cardiologist tells you to go ahead and admit to him for “repeats and serials” …
It is a perfect world. You have mentally ruled out PE and Aortic Dissection and you are right.
1) Your next step is to …
A: Give the patient 325mg ASA PO. Order CXR and labs including CBC, lytes with BUN/Cr, troponin now and 3 hours from now, PT/INR.
B: Give the patient 325mg ASA PO. Order CXR and labs including CBC, lytes with BUN/Cr, troponin now and 3 hours from now, PT/INR. Perform a rectal exam with FOBT and start the patient on Heparin.
C: Give the patient 325mg ASA PO. Order CXR and labs including CBC, lytes with BUN/Cr, troponin now and 3 hours from now, PT/INR. Perform a rectal exam with FOBT and start the patient on tPA via STEMI protocol
D: Give 325mg ASA PO. Repeat an EKG in 15 minutes and evaluate for evolution of suspected acute ischemia.
2) If you agree with the cardiologist, you know you will be monitoring the patient until the first troponin comes back. At that time, if it is elevated you know this cardiologist will want you to transfer the patient to a place that can do an interventional left heart cath and has a CCU. If you didn’t agree with the cardiologist and pushed tPA you know you have to do the same. Either way, you know you have to consider your transfer options. You ask the secretary to find out if flight is available today (yes they do these things) and what your ground crew options are. She tells you that you have BLS and ALS ground, no ICU transfer via ground team. You have fixed-wing and helo both flying and available at both can be to your hospital and ready to ship in equal amounts of time. Should you need to transfer this patient, what will you choose and why?
A: ALS ground because the first troponin came back at 0.125 and you and your cardiology friend decided this was a classic NSTEMI but he is scared to admit so you have to transfer the patient to a tertiary care center
B: ALS ground because you immediately pushed tPA and the crew can be there 30 minutes quicker than the helo team. Time for ground transport is 1hr 45 minutes.
C: Fixed-wing because you immediately pushed tPA and you feel that it is safer than helo (though it may take slightly longer overall).
D: Helo because you immediately pushed tPA and you feel it is the fastest.
3) Which of the following is NOT an indication for Air Medical Transport (AMT)?
A: Use of local ground transport would leave the local area without adequate EMS coverage.
B: Based on information available at the time and your best clinical judgement, you determine need for AMT.
C: The roads are icy and it is late at night. Ambulance driver says “I can do it, but I don’t like it”.
D: The interventional cardiologist at the tertiary care center was screaming in your ear on the phone “YOU HAVE TO SEND THIS PATIENT HERE ASAP in a HELICOPTER!!!!!!”
E: Local ground crew says “sorry doc, we cant go more than 100 miles” (tertiary hospitals is 150 miles away)
4) PCI and thrombolytics are the standard of care for treatment of acute STEMI. One of the known complications of either one of these is a reperfusion injury which is though to be induced by the restoration of blood flow to previously ischemic tissue as the reintroduction of oxygen and energy into a now anaerobic and acidotic environment can lead to further myocyte damage. Which of the following are true regarding coronary reperfusion? (More than one acceptable answer)
A: ST-segment normalization and terminal T-wave inversion in the first hour after thombolysis are poor and clinically insignificant indicators for reperfusion
B: Factors contributing to reperfusion injury include: mitochondrial damage, myocyte hypercontracture, free radical formation, inflammatory mediators, platelet activation and complement activation
C: The arrhythmia that is most commonly associated with reperfusion is atrial fibrillation.
D: Ventricular tachycardia and ventricular fibrillation can also occur after thrombolytic therapy; however, these arrhythmias are more likely to reflect persistent occlusion and infarction than a reperfusion injury … but more importantly, they are the most common cause of spontaneous death in the reperfused patient and sphincter tone should elevate to catastrophic levels when this is encountered.
Answers & Discission:
4) B & D
1. C – This is a STEMI. Clinically and electrographically this is a STEMI. Using Sgarbosa and/or modified Sgarbosa criteria, this is a STEMI. Your sister in third grade thinks this is a STEMI. You are 150 miles from a tertiary care center so you must do something to attempt to treat this STEMI until you can get them to the definitive spot. You should tell your nurses to initiate the in-house STEMI protocol. Give the patient 325mg of ASA. Ask the clerk to get whatever interventional cardiologist on the line that your hospital has a transfer agreement with. Tell them you will be giving ASA and thrombolytics (unless you encounter an absolute contraindication) and transporting the patient to them. Ask them if there is anything else they want. Hang up. Go through the tPA checklist, making sure there are no absolute contraindications. Explain the risks and the benefits to the patient. This can be as easy as saying: “Risks include bleeding in your gut, your chest and your head. You could die or become permanently disabled from this medication. Benefits: Those things I said rarely happen and you have also have a chance (somewhat higher) of dying if you don’t get this medication.” DOCUMENT that you did all this. (At the end of all of this, don’t forget to document your critical care time minus all billable procedures as well… I digress)
2. D – How to transfer a patient can be one of the toughest decisions to even the most seasoned physician. There are multiple modalities, most of which are listed above and pretty self-explanatory. The correct answer here is D. Helo is fast and though it is dangerous, ambulances and airplanes crash too. If the skies are clear and the team is available to fly helo, it is no doubt the fastest form of travel (with rare exception) and in stroke and STEMI which are the most common time sensitive conditions requiring medical transport, time is tissue and it is your job to get them where they need to be. A is wrong because this is NOT an NSTEMI. B is wrong because the helo or fixed-wing transport will still be quicker than ambulance in this scenario despite the initial delay. C is wrong because helo is faster. Fixed-wing is ARGUABLY safer but it is slower and anything can crash. If you still want to argue with me and say “Fixed-wing isn’t that much slower and I think the benefit of less fixed-wing crashes outweighs the risk of the small time delay vs helo” … then I say fine. When you are out there, you can make whatever decision you want but think of this. You have a very important morning meeting today and you woke up late. If you arrive late to this meeting, you might die. You don’t have to get on the national transportation safety website to know that more car crashes and vehicular deaths occur on the expressways than the surface streets every year. You know your risk of crash and death is higher if you take the expressway. Are you really going to take the back roads? …. I have included some more information for your leisurely reading on the types of transport teams.
BLS bus usually staffs EMT-B and refers to the use of emergency care without the use of advanced therapeutic interventions and includes airway management (oral and nasal, BMV), CPR, hemorrhage control, fracture and spine immobilization, and child birth assistance. They often have an AED as well.
ALS bus usually staffs EMT-I, EMT-P or equivalent and offers more comprehensive service such as an advanced airway, IV line placement and medication distribution en route, cardiac monitoring and manual defibrillation and certain invasive procedures.
ICU transport varies considerably but in generally you want this team when the patient is intubated, or you have a high index of suspicion they could need it en route (though if this is the case more often than not you should intubate before you send them out). ICU transport teams can run a vent and manage drips such as pressors, paralytics and sedatives and vasoactive agents. Almost all flight crews are staffed by an ICU team.
3. D is an incorrect answer. A, B, C and E are all true statements. I will refer you to Box 191-3 from Rozen’s
A refers to #8 and is self-explanatory. B refers to #9. Remember you are the one with the training and the knowledge. There might be a million protocols and suggestions out there but it is your job to integrate all things available to you from patient history, presentation and condition to hospital and city policies to what may happen on the way, to where the patient is going. You have the full clinical picture, you make the call. C refers to # 1 and 2. Your ambulance driver knows these roads and he/she has probably made the trip you are sending them on many times. If they are suggesting to you that they don’t think the drive is safe for some reason or another, don’t let them be a hero. Explore your next option. D refers to #9 again and look at my previous explanation. The cardiologist doesn’t make the call, you do.
4. B and D are correct.
There is a very good discussion of reperfusion injury on UpToDate, which is where I pulled this info from. I’m not going to copy and paste it but I highly suggest you read it. I don’t usually like UpToDate and you will rarely hear me say something good about it, but this article is a solid 30 minute read.
A is wrong. ST segment normalization and terminal T-wave inversion within the first hour are good markers for reperfusion. You can argue which is better, but that isn’t the question. Please pay attention to your patient first and foremost, they are a pretty good marker too for what is going on post thrombolytics. If they say “I don’t feel good, something isn’t right”, be scared. Don’t walk away yet. Watch the monitor and watch them and charge some paddles.
B is correct. These are all pathologic causes of reperfusion injury. Cell ischemia gets the ball rolling and nature does the rest.
C is wrong. An accelerated idioventricular rhythm (AIVR) is the most common arrhythmia seen with reperfusion after thrombolytics. AIVR usually pretty easy to distinguish on the monitor but you have to be thinking about it or you will be tricked into thinking it is a standard BBB. Basically an AIVR means a rhythm being paced by the ventricles. Now anytime you have a ventricularly paced rhythm you can count on a wide QRS so you know this will be present. And normally, ventricles would pace at less than 50bpm, so in AIVR you have a rate >50 and a wide QRS with a BBB morphology. More often than not, it is originating from the left ventricle. One more caveat, if the rhythm is driven by the ventricles and the rate goes greater than 120, you are out of the realm of AIVR and you are now talking Vtach (and be ready for Vfib, either way, get ready for some electricity and draw up some amiodarone, you might need both soon).
Recap of this. AIVR is the MC reperfusion arrhythmia and is characterized by a wide QRS and a rate greater than 50 but less than 120.
D is correct. It is pretty clear. Again, check out this article UpToDate