Thursday, 20 August 2009

It's all in the history

999 call chest pain, young guy, mid thirties. Unless the patient is a cocaine user or has some congenital heart defect then usually these calls tend to be nothing too serious. But you can't be complacent in this job and have to keep an open mind. Too dismiss such a call prior to arrival on scene is a dangerous thing.

On arrival the patient was providing the dying swan act but was in obvious discomfort. A history of a cough with mild left sided chest pain which started the previous evening. It had now become more severe. I could see my crew mate raise his eyebrow with some disbelief that this was nothing too urgent. Admittedly I was probably thinking along the same lines. He was showing signs of primary hypervetilation with pins and needles in his hands and mouth, cramping of the fingers and a rapid respiratory rate. His pulse was over 100. I took his temperature which was normal. BUT until we have examined the chap and carried out some other observations, including a 12 lead ECG, we needed to keep an open mind. Taking a deep breath aggravated the pain even more and he was wriggling around on the bed.

Whist taking his BP and acquiring the 12 lead ECG it transpired that he had a previous infection....................................around his heart and and some form of heart scan. I took this to be an echocardiogram. When I asked earlier about any previous medical history this had obviously slipped his mind. This is so often the case when in hospital a patient will admit to having a whole array of ailments that they failed to disclose whilst in our care. Can make us look daft at times.

A quick listen to the chest revealed clear & equal air entry and o2 saturations were in the high 90's. Leaning forward eased the chest pain but when asked to take a deep breath or lay back caused the pain to get worse. Now for the 12 lead. Abnormal to say the least. There was ST elevation (sign of a heart attack) and alot of it. But there were clues that lead me to believe that this was not a heart attack. The type of pain was wrong for a start. The ST elevation was wide spread (showing in leads II, II, AVF, v2,v3,v4,v5,v6) and saddle backed. There was also very slight reciprocal changes in I & AVL. My provisional working diagnosis was Pericarditis (an inflammation of the sac surrounding the heart). There are many causes but is usually caused by some form of infection. I popped in a line and took some bloods. Why? Well for one the hospital gets busy and it's one less thing for them to do. They don't have to recannulate, they use our lines and it lets them get on with other things. Also because I like to be prepared for the worst. There is a rare complication of Pericaditis which is caused by blood/fluid filling up the pericardial sac. It's called cardiac tamponade which is life threatening and is usually only seen in severe chest trauma and only a small amount of blood is needed to impede cardiac function. Like I said I like to be prepared.

I also gave some o2 and bags of reassurance. He soon settled and we chatted on the way to hospital. I let the hospital know we were coming in and had an uneventful journey to A/E.

We were met by one of the staff grade DRs and a CCU nurse and made our way into resus. They did do a double take when looking at our ECG and quickly wanted to rule out a heart attack but after I handed over and gave them the history they were thinking the same as me. But they still wanted to check their own ECG. It was agreed that it was pericarditis.

He was discharged some hours later with anti inflammatory drugs and some strong oral analgesia.

I read recently in a DRs blog about how Paramedics can't take a history and are not diagnosticians and how we are all bound by protocols. All I can say to that is that agreed I am not a DR and would never compare myself to one. But as a Paramedic I can obtain important information, examine the patient (obviously not as thoroughly as a DR, we don't have the time or facilities to allow for this) and carry out certain observations which can point towards what the problem may be. Sometimes we may not have a clue. But in this case it was the history and ECG that provided me with a pretty clear cut answer.

As for protocols, yes it was cardiac chest pain but not typical to a heart attack. Yes I know all too well that a lot of heart attacks present with atypical (different to the norm such as no pain, abdominal pain etc) signs & symptoms but this all pointed to Pericarditis. And yes I know that Pericarditis can mimic an MI and that there have been occasions where a patient has received unnecessary thrombolysis (mainly in hospital and occasionally out of hospital. Did I give aspirin or GTN? No. I didn't give morphine and pre hospital thrombolysis certainly wasn't indicated. I could have given Ibuprofen but in the short time he was our care it probably wouldn't have provided any benefit. We work from guidelines now and I try and provide the most appropriate level of care to each of my patients. I don't believe in filling people up with drugs when there is no indication for it.

The ECG is one I found on google and NOT the patients.


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ViatorT said...

Its very good to have you back street medic!
You;ve explained this very well, Im hoping to be a qualified paramedic in the next 3 years (optimistic I know).
I do have a question thats is related to MI,
Im a voluntary first Aider and Community first responder (in the training) and were often given the symptoms, numbness etc, but it dosent really give us a timeline for where these symptoms appear I can imagine theres some variation in type of heart problem and person, but any ideas?

aashvi said...

There can be several kinds of chest pen but when it is related to heart disease, it becomes dangerous. It’s very important that we should keep this in mind. Dilse India provides information about chest pain. The information can be helpful for those who have chest pain and there is danger of heart disease.
Website : Risk of chest pain

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