Case of the Month
October 2005

57-year-old male - sudden collapse

Dispatch
"Engine 72, Medic 2; 57-year-old male, sudden collapse"

En route your crew discusses the following considerations:

• Possibility of CPR
• Request additional resources - MSO or Battalion Chief
• Need for extra equipment - extra oxygen, suction unit

Just prior to your arrival dispatch reports the patient is now conscious and complaining of chest pain.

Scene Survey
You arrive at a residence and the wife of the patient meets you in the front yard, she is very concerned. She takes you to the patient who is in the living room, lying on the floor.

Initial Assessment
The patient holds a fist to his chest and is in obvious distress. His skin appears to be pale and moist. He moans occasionally. A quick interview ascertains that he has a "sharp, knife-like" pain in his chest. It does not radiate. He has some shortness of breath and nausea. Your partner completes an initial assessment:

CC/MOI	—	Sharp chest pain, non-radiating. Shortness of breath and nausea
RR	—	26/min
Pulse	—	Radial at 130, irregular
Mental Status	—	Alert: knows person, place, time, and events
Skin	—	Pale, with cool moist skin
Body Position	—	Lying on his left side on the floor

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 this patient is SICK based on his chest pain and skin signs. You quickly advise the medic unit that you have "a SICK patient, who is patient, complaining of sharp chest pain". You begin administering oxygen at a flow rate to meet the patient's needs using a non-rebreathing mask and you continue your interview.

Physical Exam
Your partner gives you the following information:

HEENT	—	Skin is pale, cool, and moist. Pupils are equal and react to light.
Chest	—	Bilateral breath sounds, equal. Patient's pain does not change with palpation of the chest.
Abdomen	—	Soft in all four quadrants and without pain. Femoral pulses are moderate and equal.
Extremities	—	Unremarkable
Neuro	—	Alert, knows person, place, time, and events

SAMPLE

S	What are the signs and symptoms?	Sharp pain in chest, 9 out of 10 but not radiating. Nausea and shortness of breath.
A	Are you allergic to any medication?	None
M	Are you currently taking any medication?	Cholesterol med, unknown name, Lotensin for high blood pressure, Amioderone for cardiac arrhythmias
P	Any medical history I should know about?	HTN, occasional episodes of ventricular tachycardia, high cholesterol
L	When was the last time you ate or drank anything? What was it?	Lunch at 11:30 AM, a ham sandwich and an apple
E	How did this happen?	Patient was helping his wife move some furniture in the family room and suddenly had an onset of chest pain and then pasted out. He was only unconscious for a few moments once he hit the ground. The pain continues, unchanged.

Second Set of Vital Signs

Respirations	—	24 and non-labored
Pulse	—	Radial at 140-weak and irregular
BP	—	86/40
Breath Sounds	—	Equal with good tidal volume
Pulse Oximetry	—	98% on NRM

The focused history reveals that the patient's pain is very similar to his previous episodes of ventricular tachycardia. This is quickly discovered by asking the question "Have you ever had this before and what was it then?" The EMTs keep the patient in a supine position, well oxygenated, and prepare to deploy the AED if necessary. As part of their exam for chest pain, they obtain blood pressure readings on both arms and find them equal. The crew gives the incoming medic unit a second update, mentioning the similarity of this presentation to past episodes of ventricular tachycardia. The patient is reassured and informed as to what is happening.

The medics arrive and place the patient on a heart monitor. The monitor indicates ventricular tachycardia. His true heart rate is 184 and regular. An IV is started and pads are placed on his chest so that a shock can be delivered. Prior to shocking, the crew prepares for the possibility of CPR. The medics give the patient a medication for relaxation. A single shock is delivered and the rhythm is converted into a normal sinus rhythm. The patient states the chest pain is now mostly gone and his shortness of breath and nausea have ceased. He is transported without incident to the local emergency department.

Ventricular Tachycardia
Ventricular tachycardia (VT) is a dangerous heart dysrhythmia that can cause unconsciousness and quickly degrade into ventricular fibrillation. AEDs are set up to shock rapid VT if detected. When VT occurs it is because a portion of the lower heart becomes irritable and begins to take over the electrical system of the bottom of the heart, almost always at rate of 150 to 180 beats per minute.

Since the upper part of the heart is not impacted by this arrhythmia, it continues at it's own pace. This results in the lower portion of the heart not getting primed properly prior to each contraction so the pulse we feel is often rapid, weak, and irregular because we do not feel every contraction. This is a true, life threatening, emergency. If VT is suspected place the patient on high flow oxygen, confirm that a medic unit is responding, and prepare in case of a shockable rhythm develops and/or deterioration into pulmonary arrest.

The lesson learned from this case:
One of the fastest most effective questions an EMT can ask a patient is "Have you ever had this before, and what was it then?" Although this "self-diagnosing" question will not always give you the true answer to what is happening today, it will often guide the rest of your interview down the correct path.

Not-so-trivia question: What is one of the most effective anti-arrhythmia (heart-calming) medications carried on a medic unit?

OXYGEN! It's cheap, it's easy to use and BLS units carry it too! Don't hesitate to use it!