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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