Case of the Month
November 2005

62-year-old male – chest pain, shortness of breath

Dispatch

“Truck 16, Medic 42; 62-year-old male, shortness of breath with chest pain”

En route your crew discusses the following considerations:

• Reasons for chest pain
• Pulse oximetry

Dispatch relays that the patient has had shortness of breath and chest pain for the past 30 minutes, 2 nitro without relief.

Scene Size-up
You arrive at a residence and the wife of the patient meets you in the front door, she quickly leads you upstairs to the bedroom where you find the patient sitting on the edge of the bed.

Initial Assessment
The patient is in a tripod position and working hard to breathe. His skin appears to be pale and moist. He tells you in short, five word sentences that his pain came on suddenly and he quickly became short of breath.

Your partner completes an initial assessment:

SICK or NOT SICK?
Based on what you see so far, would you consider this patient SICK or NOT SICK? What steps will you take based on the direction you choose?

• Types of treatment needed for this patient?
• Short report to the medics?

Initial Treatment
You decide that the patient is SICK based on his chest pain, shortness of breath and body position. You quickly advise the medic unit that you have “a SICK patient speaking in five word sentences."  You immediately address the patient's breathing needs using a non-rebreathing mask and continue your interview.

Physical Exam
Your partner gives you the following information:

SAMPLE

Second Set of Vital Signs

The focused history reveals that his chest pain is of the same Severity (6 out of 10) as in the past but with today’s episode the pressure is more intense. In addition, the pain Radiates into his left arm and jaw. Today’s shortness of breath is also much worse than previous episodes and it continues to become more difficult to breathe. 

The above symptoms are accompanied by a mild nausea and vague sense of fatigue. He is very scared. Because you suspect a possible MI and CHF, you examine the ankles and neck.  In the neck you see some distention of the jugular veins and in the ankles pitting edema is found.

Given the difficulty breathing, other members of your team set up the bag-valve mask and begin assisting respirations. At first the patient is very anxious about the mask being put over his face, but with coaching he allows the EMTs to provide positive pressure ventilations.

The medic unit arrives and agrees with your assessment. His BP is confirmed and sublingual nitroglycerine and an IV are administered. The combination of the EMT's positive pressure ventilation and the medic's nitroglycerine begin to turn the patient around. The addition of Lasix by IV further improves breathing. During transport the paramedics perform a 12-lead EKG revealing evidence of a new heart attack (AMI).

The patient is stabilized in the ED and quickly sent to the cath lab where physicians perform angioplasty to open two coronary arteries. The patient had a smooth recovery after the procedure. 

Congestive Heart Failure
Congestive heart failure (CHF) is a condition where damage to the heart impedes it’s ability to keep blood flowing effectively. This results in a back up of blood in the extremities or in the lungs, depending on which side of the heart is affected. When the backup is in the extremities it is most visible in the ankles and in the jugular veins. The ankles can become so swollen that they react like bread dough when pressed. This is called ‘pitting edema’. Likewise the neck veins can become so distended they can look like little sausages under the skin. When the backup is in the lungs the tell tale sign is the presence of crackles, also known as rales, or the complete absence of breath sounds in the areas completely saturated by the building backup of fluid.

When CHF is suspected you must begin immediate treatment. This may include high flow oxygen via a non-rebreathing mask. In more severe cases, consider the use of positive pressure ventilations with a bag-valve mask. To do this, you must first gain the patient’s trust and explain the procedure. Then you must slowly introduce the BVM as the patient will naturally resist anything placed on his or her face in a moment of respiratory distress. Once the mask is on the patient’s face you must time the patient’s respirations with squeezes of the bag. You should reassure the patient and coach breathing. Practice of this skill is essential.

The lesson learned from this case:
Although the patient’s initial complaint was chest pain, his breathing was also an important component in this call. When confronted with chest discomfort, it is easy to sweep other issues aside. However all of the symptoms must be addressed. In this situation both the chest discomfort and the breathing difficulty were life threatening, so they both deserved assessment and treatment.

Not-so-trivia question: When is the only time you should consider forcing secretions back into a patient with a bag-valve mask? In cases of extensive pulmonary edema. Occasionally a patient may present with pulmonary edema that is so severe that the fluids rise into the mouth. This is fairly rare, but it would appear similar to whipped egg whites foaming out. Trying to suction this patient would be futile, the only answer, short of intubation, is aggressive positive pressure ventilation. Since the secretions in CHF are a blood product, forcing them back down does not carry the same danger that any other secretion would.