Posted by: medicblog999 | August 3, 2009

Jumping to Conclusions – Post 1

Before I get started, I would like to say a hello, to the not insignificant amount of new visitors I have had since Trauma Queens edition of ‘The Handover’

I hope you like what you have seen so far, and if so, I would like to think you may pop back and read some more. The more the merrier!

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250px-Gray513So, where were we……..

Last week, in my post ‘Sometimes’, I mentioned a couple of jobs which served the very important purpose of a swift reminder of not becoming complacent and tarring everyone with the same brush. Here’s the first one:

I was working on the RR car and was sent to a male with chest pain. No other details yet, but off I went ‘blues and twos’ to go and save another life!!

As I was weaving through the standstill traffic that is the signature of ‘rush hour’ where I work, I receive an update informing me that the patient is a 20yr old male.

Now, excuse me for being skeptical, but I would place money on virtually every paramedic reader of this blog, when receiving this update to think the same thing……..Yeah right!….another panic attack.

As I drive along, my mind set changes from swift action and transferral to a PPCI unit, to still a swift assessment, but more than likely a nice chat and a referral to their own GP the next day (If they settle well)

I arrive on scene and am met by a young lady standing at the door. I say a quick hello and tell her I will be “2 seconds!!” whilst I get my bags out of the back of the car.

I struggle to load up with my large first response bag, my oxygen bag, my patient report form holder, the lifepack 12 monitor/defibrillator whilst locking the car and heading towards the gate of the property, which remains closed!!

I gently knock into it and pray to the saint of over burdened rapid response paramedics, to give members of the public the common sense to think about opening a gate for a paramedic who has no spare hands to do it himself!!

Anyway….

I walk up the stairs and find our patient, Mark.

Mark looks well, he is a good colour, seems happy, alert and orientated. No signs of hyperventilation (actually hypoventilation, but that’s another story) or dyspnoea. All seems rosy!

M999: “Hi there, what can I do for you today?”

Mark: “Ive had this pain in my chest for the last hour, and my heart has been beating really fast”

M999: “Okay, have you been feeling short of breath at all, or breathing quickly?”

Mark: “Yeah, I used to get panic attacks, and this seems a bit like that, but my chest really hurts today”

BINGO!!!

As is the case whenever I get any patient, during the first couple of questions, I will ask for their hand, check their radial pulse, and feel the heat and moisture of the skin of their arm. It all helps with a rapid initial assessment.

I reach out for his hand and place my index and middle finger over his radial pulse………………….

Eh??…..Right, wasn’t expecting that!!…….Time to change gear!

As I feel for his radial pulse, I can barely feel the usual pounding of the artery against my finger tips. Its more like a rapid, week fluttering under his skin. I take a second to check that it isn’t some sort of muscular twitching over his artery, but instead trust my initial instincts. Its going so fast that I cant get a rate, but in all honesty I tend to go with a scale of 5 rates anyway:

  • REALLY slow
  • Slow
  • Normal
  • Fast
  • REALLY fast

Why make things more complicated than they need to be? Marks pulse definitely fell into the really fast band!

I take another look at him whilst calmly asking him if he has ever had a problem with his heart rate before? I cant help but wonder how he is tolerating it so well. His colour remains good, he show no signs or symptoms of being poorly perfused, the only symptom is this chest pain, which I can pretty much diagnose without the aid of an ECG. Its bound to be rate related ischaemia.

He tells me that he has had a number of episodes since he was 15 when he felt his heart was racing, but he had learned to stop it by putting his head between his legs and holding his breath (I guess he was doing his own valsalva manoeuvre) He had been to the doctors a number of times but he said they didn’t really believe him as it never happened when they were there.

I turn on the lifepack and start of by placing the limb leads which gives me:

SVT 236

This shows a fine example of an SVT (supra ventricular tachycardia) of 236 beats per minute, along with probable rate related ST depression which is the likely cause for his pain.

It was at this point that my back up crew arrived with the same presumptions that I had 10 minutes before hand. A quick look at the monitor, made them suddenly turn around and dash back to the ambulance to bring the carry chair.

On with the O2. In with the cannula (after telling him I was great at cannulas and it will only hurt for a second, as he has VERY reluctant to ‘have a needle’). Thank the lord I got it in straight away and swiftly!!

I got him to try the valsalva manoeuvre with no effect, then moved on to some carotid sinus massage prior to him getting packaged and onto the vehicle. Neither worked, and he stayed pounding along between the 230 and 250 mark throughout my time with him.

The crew left scene whilst I radioed ahead to pre-alert the hospital.

Once he had left and his friends had gone back into the house, I sat in the front seat of the car to complete my patient report form. Half way through I stopped for a second and said out loud to myself..

“Well, that will teach you!!”

Soon afterwards, I took another patient upto the hospital and called in to resus to check on him.

He looked fine (as before), but this time when I look at the monitor, his heart is going at a steady rate of 84 beats per minute.

I asked the doctor what happened with him, and she told me that he had required some Adenosine to slow his heart rate down, but it worked on the first dose. Aross the table in front of the doctor was a long rhythm strip which showed his SVT, then a mark when the Adenosine was given shortly followed by some PVCs (premature ventricular contractions), a run of VF (!!!!! for about 2 seconds), a couple more PVCs, then into sinus rhythm.

I look at the doctor and point at the VF section

M999: ” I bet that made you twitch a bit!”

Doc: “Your not wrong mate, not at all!!”

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Responses

  1. Made me laugh a little bit about the VF as my wife who is a nurse gave Adenosine to one of her patients one time and she went into a brief period of asystole for about 2-3 seconds. Just long enough to get the pucker factor going. Great post.

  2. Yea, we give adenosine every so often here. The HR’s always gone on ticking for me after the initial asystolic period.

    Mark, don’t you give that in the field over there? It’s common over here. Cardiazem (diltiazem) is less common, but is carried on some trucks.

    Lotsa pucker factor when I give it though.

  3. Indeed Mark, of all the meds you discuss, no Adenosine? I give it once a month, easy. And like CK says, It is always hard to explain to the patient, “I’ll be putting you into a chemical cardiac arrest…but for only a second or two!” Push, flush, squeeze “Whoah…That was odd.” They say.

    Indeed we need to make sure we don’t get tricked by our pre-conceptions.

  4. We’ve had Adenosine for SVT in Tassie for a few years now, and if the Adenosine doesn’t work and the patients perfusion is deteriorating we Sync Cardiovert.

    Or if their perfusion is bad and their conscious level is dropping, then when can bypass Adenosine and go straight to Sync Cardioversion with sedation (Midazolam) if time / patient condition permits.

    That’s pretty rare though, I haven’t done it or seen it done pre-hospital but I can do it now. I have seen two done in the ER.

    We do try a valsalva first but carotid sinus massage is a no no.

  5. We’ve had Adenosine for SVT in Tassie for a few years now, and if the Adenosine doesn’t work and the patients perfusion is deteriorating we Sync Cardiovert.

    Or if their perfusion is bad and their conscious level is dropping, then when can bypass Adenosine and go straight to Sync Cardioversion with sedation (Midazolam) if time / patient condition permits.

    That’s pretty rare though, I haven’t done it or seen it done pre-hospital but I can do it now. I have seen two Sync Cardios done in the ER.

    We do try a valsalva first but carotid sinus massage is a no no.

    I have also seen Adenosine not work a couple of times. Also the P waves with no ventricular response for several to many seconds on the monitor is pretty freaky.

    Please delete the first post, I left a few things out of that one.

  6. Adenosine?
    anti-arrhtyhmic drugs?
    Like yourself, medic999, we have amiodarone but thats you’re lot! Even carotid sinus masage is off limits in scotland.

  7. Which blogger was it that recently did a post on antiarrythmics (or, actually antidysrhythmics since the only true arrythmia is asystole) and called them “Selective cardiotoxins”? He expounded upon the virtues of juicing the patient with synchronized cardioversion early.

    I’m surprised that you don’t give adenosine in the field. Tachydysrhythmias are somewhat common emergencies that can be quickly and safely managed in the field. The consequences for not managing them efficiently can be pretty bad for the patient if the heart beats that fast for too long.

    Something the US has that the UK doesn’t??? REALLY?! Wow! Usually you guys beat us in, well, most things.

  8. CK, I believe it was Rogue Medic who commented on the cardio toxins, but can’t find the link, so maybe not.
    Mark, Now I’m DYING to get over there and see first hand what is different.

  9. Really? Wow. I didn’t know that.

    We have CPAP, which is an absolute godsend for CHF patients. I mean, the days of pushing a load of lasix, popping as many nitros as the patient can stand, and driving really fast to the hospital so you didn’t have to tube them ended just like that once we got CPAP. Now it’s a 2minute fix and the patient is just fine.

    IO? Well, we haven’t quite had the adult IO drills for a year yet… but I really like them. I’m a little leery on the way that medication makes it into central circulation, but the literature says that it’s just the same. For cardiac arrests (codes) I attempt one IV (or have an EMT-IVT or EMT-Intermediate do it) and then go right to the IO. If the IV looks hard, right to the IO I go. It takes 15 seconds and there’s almost no chance of missing it.

    Syncronized cardioversion and pacing? Wow. I don’t have the chance to use it all that much… but every time I need it, it is life saving. I’ve had a patient go into V-tach in mid-sentence and start to seize right in front of me. I zapped him with 100 syncronized joules quick enough that he just picked right back without breaking the conversation. Then he asked me why he pissed himself and why he was smelling burnt chest hair

    I should remember to use gel on the paddles.

    We should each do a post on our formularies and techniques. I’ve got an idea for here in the US that’ll come out on the blog.

  10. […] had just cleared from lesson number one, when I was assigned to a further […]


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