Pre-Hospital
Pre-Hospital
Pharmacology Pitfalls
Andrew O’Connor
AMC EM III
Case I - Chest Pain
55 y/o male
hypertension, high cholesterol, heart attack, recurrent angina, and 40 pack year smoking history
developed epigastric pressure like pain after mowing the lawn 1 hour ago.
Now the pain is substernal, 10/10, with dizziness
Vomited x 1
Case I - Chest Pain
Wife called EMS because he looked pale and he’s out of nitroglycerin which he usually takes when he has chest pain.
Case I - Chest Pain
Patient states “Just give me a damn nitro and I’ll be fine.”
AMPLE
Allergies: None
Medications: Lisinopril, Lipitor, Aspirin, Plavix, Isosorbide mononitrate
Past Medical History: Coronary artery disease, High cholesterol, Hypertension, Heart attack 2 years earlier with angioplasty
Last Meal: Three hours ago
Events: Mowing lawn.
Exam
Vitals: HR 58, BP 108/62, RR 22, O2 96% on room air
HEENT: (+) JVD
General: Anxious, mildly short of breath, diaphoretic
Heart: Bradycardic without murmur
Lungs: Clear
Extremities: Trace pitting edema at ankles.
Intervention
O2 applied by NRB
ASA 324mg given
NTG 0.4mg SL while IV attempted
EKG in progress
EKG
Sinus rhythm
Rate 68
Regular rhythm
What else ?
Reassessment
Patient now reports worsening dizziness, SOB, CP still 10/10
Vitals recheck: HR 52, BP 82/50, RR 22, O2 95% on 15 L
What was damaged ?
What’s happening ?
RCA MI
RCA supplies:
RV
posterior LV and inferior LV a large percentage of time
AV node
Bradycardia
Heart block
Junctional rhythm
Physiology
RV is thin walled and loses tone with initial damage.
RV becomes like a water balloon which accumulated large volume of blood.
Need to maintain delivery of blood to right side of heart so lungs and ultimately LV can be perfused.
Pre-hospital intervention
100% Oxygen, ASA 324mg, IV access
Trendelenberg for cerebral perfusion
Avoidance of all venous dilating agents including NTG and Morphine
250 cc Normal Saline boluses with frequent reassessment of BP and signs of perfusion (capillary refill, mental status)
May need to intubate
Atropine 0.5-1.0mg may be of benefit
Pace if symptomatic bradycardia
Dopamine 2.5-5 mcg/kg/min if SBP < 70 and refractory to fluid resuscitation. Use lowest dose to support pressure.
In-hospital intervention
Dobutamine/Dopamine to support cardiac output
IV Fluids
Intubation with mechanical ventilation
Intra-aortic balloon pump placement
Revascularization
NTG
Limit fall in SBP to 120 or >25% reduction from baseline - (would worsen myocardial ischemia)
Use with extreme caution in patients with RV infarct - (1/3 of inferior wall infarcts will significantly affect RV)
Absolutely avoid in patients on Viagara/Cialis - may cause irreversible hypotension or death
Case 2 - Altered Mental Status
44 y/o male with history of asthma, brother states that patient, just returned from a neighborhood July 4th party and was agitated and acting strangely. Was complaining of chest pain and dropped to the ground about 5 minutes ago.
Patient keeps saying “my chest is killing me man.”
AMPLE
Allergies: None known
Medications: Albuterol PRN
Past medical history: Asthma
Last Meal: Unknown
Events: Patient not offering. States “I need something for this pain !” “I think I’m having a heart attack!”
Exam
Airway - Patent, no stridor
Breathing - Lungs clear, no wheezes appreciated
Circulation - Skin flushed, warm and moist, bounding pulses, < 2 second capillary refill
Disability - Eyes open, keeps mumbling “My chest”, moving all extremities spontaneously. GCS 15.
Exam
Vital signs: HR 128, BP 190/100, RR 18, O2 Sat 99%
General: Poor historian, motor restlessness, diaphoretic, not subjectively SOB, holding left chest
HEENT: (-) JVD, pupils dilated, equal and reactive
Heart: Tachycardic, no murmur
Lungs: Clear bilaterally
Abdomen: Soft
Extremities: No edema, capillary refill < 2 seconds, skin warm and moist.
Intervention
Oxygen by NRB applied
ASA 324mg given x 1
IV established, blood drawn
EKG in progress
NTG 0.4mg SL given x 2 q 5 minutes
EKG
Sinus rhythm
Tachycardic
Re-assessment
Patient still agitated and restless, pain “better”
Vitals: HR 140, BP 192/95, RR 20, O2 98%
Exam: Lungs clear, good capillary refill, skin warm and moist, bloody nose has developed.
What do you want to fix now and how?
Intervention
Continue O2 by NRB
Give NTG # 3 0.4mg SL and apply 1” NTG paste.
Call medical control and request Lopressor 5mg IV x 1 for BP and rate control which is given.
Monitor and begin transport
Reassessment
Chest pain is back up to 10/10 and he has a severe headache.
Vitals recheck: HR 115, BP 230/120, RR22, Oxygen 99%
Repeat EKG
Cocaine
Common presenting symptoms:
Chest pain
Abdominal pain
Headache
SOB
Palpitations
Psychiatric symptoms
Paranoia
Mania
Agitation
Coma
Cocaine
Management:
Quiet environment
Oxygen
Cardiac monitor
Nitroglycerin for BP and pain control
Valium 5mg slow IVP for BP control and management of pain and agitation (may need multiple doses)
Beta-blockers must be avoided (no Lopressor)
Beta-Blockers and Cocaine
Cocaine powerfully constricts arteries by turning on alpha receptors causing increased BP
Beta-blockers allow for unopposed alpha stimulation which can paradoxically worsen cocaine induced HTN and cause cardiac ischemia and stroke.
Beta-Blocker contraindications (Relative)
HR < 60
Moderate CHF
First degree heart block PR > 0.24 sec
Severe COPD
History of asthma
Severe peripheral vascular disease
Beta-Blocker contraindications (Absolute)
HR ................
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