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By Stewart A. Stancil, NREMT-P Questioning the need for medical interventions is key to patient care The 9-1-1 dispatcher reports a call from a female who says her 66-year-old mother “may be having a heart attack, but is responsive.” On arrival, the crew ﬁnds the older female can answer questions, but responds in a fashion the daughter says is abnormally slow and Photo by Eddie Sperling confused. The patient, Mrs. Jones, says she had a heart attack four months ago and is now taking medication for heart failure. She has felt progressively tired over the past two weeks, and feels dizzy when standing. Today, her chest started “feeling funny” about an hour ago, with some pain at about 2 on a 10 scale. She has a history of hypertension. She is not reporting shortness of breath, sweating or nausea. www.emsresponder.com EMS JUNE 2010 47 case review: atropine Initial physical exam reveals an elderly mental status. She shows evidence of capability. With regard to patient care en female with pale skin in no respiratory poor perfusion and is still confused. Her route, the physician frames the decision distress. Her vitals are: BP 90/55, pulse daughter can’t provide any history of the into three groups: (1) supportive care 48 and irregular, RR 24 with slight bilat- patient’s usual blood pressure, but in a only, (2) give medication, (3) use elec- eral lower lobe crackles, pulse oximetry patient with a history of hypertension, a trical intervention. 92%. Her pupils are equal, round and blood pressure of 90/55 is almost certainly Supportive care is appropriate if the reactive; blood glucose is 90; there is 1+ too low. Her heart rate is low, and she is patient has been deteriorating and ankle edema, and the jugular veins are not conducting the electrical impulses transport has been directed to the nearby distended. effectively and regularly. The patient community hospital. In this case, the “With regard to Oxygen is given by NRB at15 LPM; IV access and the initial lead II strip are obtained. Every third P-wave lacks a shows signs that her vascular volume is not compromised, with jugular venous distention, lung crackles and leg edema. biggest assist to patient care would be maintaining the airway and oxygenation, as well as expediting the patient’s hospital subsequent QRS complex. All P-R inter- To increase perfusion, the patient needs a care by obtaining serial vital signs and patient vals are 0.16 seconds and regular. The heart rate higher than 48 beats a minute. ECG printouts. With this short transport, care en QRS complexes are 0.18 seconds wide Questions the EMS crew will need to the critical decisions involving invasive and upright in lead II. A 12-lead EKG is consider are: How should the bradycardia procedures are better made in the more route, the obtained showing a left axis. The rhythm be treated in light of a suspected left- controlled environment of the emergency physician disturbance noted in the 3-lead rhythm sided bundle branch block and possible department. The other case in which strip is conﬁrmed. Lead V1 shows deep MI? If this patient deteriorates, should supportive care would be warranted is frames QS waves and ST segment elevation she be given atropine or have transcuta- when the patient is maintaining perfu- (see Figure 1). These ECG ﬁndings point neous pacemaking performed? In view of sion. If bradycardia is present but the the to the possibility of left bundle branch these questions and how they will impact patient has normal mental orientation decision block. There are Q-waves in leads II and the transport decision, medical control is and function, then no invasive interven- III, which raises concerns for inferior or contacted. tion in the ambulance would be indicated. into three right-sided infarction. The second decision group involves the BRADYCARDIA groups.” CRITICAL DECISIONS TREATMENT OPTIONS use of medication. Atropine is commonly used for patients with symptomatic brady- The nearest hospital with invasive
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