Im an EMT, i had this call the other day, wanted to get your guys' input

[medic25]

Some large hospitals have an EMS coordinator who can get you full access to discharge summaries, progress notes, and the like. If this person doesn't exist or isn't helpful, try tracking down the doc you transfered care to (best option) or the nurse manager of the ED. Don't let them pull any HIPPA BS and go thorugh your agency training coordinator if needed.

 

As the hospital EMS coordinator, providing follow-up to field providers is a big part of my job description. I spent a good part of the day today sending cath lab reports and images back to medics who brought in field cath lab activations (including a 9 minute D2B!). Feedback to our crews is an essential part of the EMS system; I would check with your medical director about how best to get this kind of info.

[Just Steve]

I read through the responses on the EMT forum, there seems to be some head scratching surrounding the cyanosis from the clavicles up. I am going to take a stab in the dark and say that as the AAA dissected down to it's root (DeBakey type 1), it occluded the left subclavian, left common carotid, and brachiocephalic trunk and led to an acute, visible cyanosis of the region of perfusion. Mechanically, not unlike being strangled by a thin wire, cutting off all blood supply to your melon.

 

The intermittent, spotty, non congruent progression of the patient could be attributed to the physiologic reaction of the active shearing during the dissection. The "classic" presentation is that sharp stabbing pain between the shoulder blades but as we all have heard...patients never read the book to learn how to present in the "classic" form.

 

On the upside, if it makes you feel any better, that patient probably would have died regardless of any field intervention you could have done. Heck, if my theory of that dissection holds true, I doubt they would have survived most ORs.

[Just Steve]

I read through the responses on the EMT forum, there seems to be some head scratching surrounding the cyanosis from the clavicles up. I am going to take a stab in the dark and say that as the AAA dissected down to it's root (DeBakey type 1), it occluded the left subclavian, left common carotid, and brachiocephalic trunk and led to an acute, visible cyanosis of the region of perfusion. Mechanically, not unlike being strangled by a thin wire, cutting off all blood supply to your melon.

 

The intermittent, spotty, non congruent progression of the patient could be attributed to the physiologic reaction of the active shearing during the dissection. The "classic" presentation is that sharp stabbing pain between the shoulder blades but as we all have heard...patients never read the book to learn how to present in the "classic" form.

 

On the upside, if it makes you feel any better, that patient probably would have died regardless of any field intervention you could have done. Heck, if my theory of that dissection holds true, I doubt they would have survived most ORs.

[Acebecker]

The other thing from the H&P provided is the inability to get a BP at all - classic for a TAA is to have inconsistent BPs from side-to-side; >10-15 mmHg difference is consistent with some sort of vascular problem, aneurym being the most likely. Having a monitor fail to get a BP is not odd, but being unable to get an audible BP or BP by palp is not normal unless the Pt is already dead, so should always make us think of serious etiologies any time it happens. Did you get bilateral arm BPs? Nasty case - as Steve said, probably a goner before he even called 911, let alone prior to your interventions. Don't beat yourself up too bad, but it's a great case to learn from and catch the next one early.

 

Andrew

[Acebecker]

The other thing from the H&P provided is the inability to get a BP at all - classic for a TAA is to have inconsistent BPs from side-to-side; >10-15 mmHg difference is consistent with some sort of vascular problem, aneurym being the most likely. Having a monitor fail to get a BP is not odd, but being unable to get an audible BP or BP by palp is not normal unless the Pt is already dead, so should always make us think of serious etiologies any time it happens. Did you get bilateral arm BPs? Nasty case - as Steve said, probably a goner before he even called 911, let alone prior to your interventions. Don't beat yourself up too bad, but it's a great case to learn from and catch the next one early.

 

Andrew

[True Anomaly]

The answers on the EMT boards... Yikes.

 

Interesting, yes, but remember that old adage- "You don't know what you don't know". EMS folks are extremely well-meaning professionals who do what they are trained to do well, but that does limit the expanse of medical teaching down to essentials for field medicine. Most of them want to improve upon what they already know and are just as fascinated by cases that may stump them just as we are as PA's, which is why ranchoEMT put the case up here for us to look at. It honestly sounded very much like a straightforward ruptured dissection or AAA to me when reading, but may not be to medics and EMT's. This is my own personal bias, but during my EMT class there wasn't mentioned made of an entity of "aortic dissection"...which purely could've been my own lack of education at that institution and not reading more during my own EMT career.

[True Anomaly]

The answers on the EMT boards... Yikes.

 

Interesting, yes, but remember that old adage- "You don't know what you don't know". EMS folks are extremely well-meaning professionals who do what they are trained to do well, but that does limit the expanse of medical teaching down to essentials for field medicine. Most of them want to improve upon what they already know and are just as fascinated by cases that may stump them just as we are as PA's, which is why ranchoEMT put the case up here for us to look at. It honestly sounded very much like a straightforward ruptured dissection or AAA to me when reading, but may not be to medics and EMT's. This is my own personal bias, but during my EMT class there wasn't mentioned made of an entity of "aortic dissection"...which purely could've been my own lack of education at that institution and not reading more during my own EMT career.

[kargiver]

I've seen many of these arrests in both the field and the ER setting. The overwhelming majority of the time these were massive PEs. Some (a handful) have been dissections but based on presentation, this seems (to me anyway) more likely a PE.

 

G

[kargiver]

I've seen many of these arrests in both the field and the ER setting. The overwhelming majority of the time these were massive PEs. Some (a handful) have been dissections but based on presentation, this seems (to me anyway) more likely a PE.

 

G

[Davo]

Ive had the same call, the pt was in denial and refused transport to a trauma center, instead wanting to go to a further hospital without surgical capabilities. Luckily I was able to document that via radio, as he coded during transport. We ended up diverting to the trauma center. I intubated the guy (WITH ETCO2) and CPR/ACLS was started, I had started one fattie IV before he coded with blood tubing so I was able to run that wide open. After arrival at the ED, the pt had a notable "bulge" on his right abdomen. This was not gastric insufflation, and the MD commented that this appeared to be a AAA. I followed up later and he told me it was indeed a AAA.

 

Just curious what was his ETCO2? That may be low in a massive PE.

[sammedic]

Interesting, yes, but remember that old adage- "You don't know what you don't know". EMS folks are extremely well-meaning professionals who do what they are trained to do well, but that does limit the expanse of medical teaching down to essentials for field medicine. Most of them want to improve upon what they already know and are just as fascinated by cases that may stump them just as we are as PA's, which is why ranchoEMT put the case up here for us to look at. It honestly sounded very much like a straightforward ruptured dissection or AAA to me when reading, but may not be to medics and EMT's. This is my own personal bias, but during my EMT class there wasn't mentioned made of an entity of "aortic dissection"...which purely could've been my own lack of education at that institution and not reading more during my own EMT career.

 

I agree, as a paramedic (headed to PA school in August) I have done much of my education on my own. I think that many pre-hospital providers are taught the "textbook" presentation as the only presentation. I have had many paramedics that I have trained look at me like I have three heads when I question why no 12 lead on the old lady who is weak (inexcusable in the services that I work in). The only upside to any of that is that it has driven me even harder to get into a PA program and "make it out" of the "street".

[ohiovolffemtp]

This ground has pretty much been covered, but tension pneumo is unlikely. You intubated the patient, so whomever was bagging would have noticed resistance, leading to a needle decompression.

 

Did the guy have a history of HTN?

[ohiovolffemtp]

This ground has pretty much been covered, but tension pneumo is unlikely. You intubated the patient, so whomever was bagging would have noticed resistance, leading to a needle decompression.

 

Did the guy have a history of HTN?

[RRivas2004]

ZEBRA ALERT - Right Atrial Myxoma causing massive right atrial embolus and SVC syndrome.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1396755/pdf/annsurg00355-0124.pdf

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC287799/pdf/cardiodis00011-0064.pdf

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC481532/pdf/brheartj00124-0102.pdf

 

The cyanosis above the clavicles could of been blood being trapped above the level of the SVC bifurcation - possible superior vena cava syndrome due to massive clot in the Right Atrium/ SVC, possible causes include atrial myxoma check out this case study. Atrial myxomas are mostly left sided, but can present in the right atrium and can cause significant obstruction to blood flow, and most definitely can cause some A-fib if they irritate the conduction system. They usually go undiagnosed as they are commonly asymptomatic and tend to be benign. AAA can also cause SVC syndrome.

 

Vital signs would definitely yield tachycardia, and tachypnea, as well as profound hypotension as this would cause a "volume" problem. Blood would not be able to adequately enter the RA and thus the RV, and so on so on. A sudden "plug" in the system could cause a sudden decrease in systolic bp causing syncope. As the embolus grew and total obstruction occured the patient would expire.

Treatment would be aggressive volume replacement therapy, heparin therapy, and emergent thrombolectomy, and most likely removal of the myxoma.

He was done for either way..

 

***Disclaimer*** These are just my thoughts on what a zebra dx would be for this gentleman. The PE and ruptured AAA have been covered extensively and are very likely to be the cause of death. However I like Zebra's as much as I like horses :)

[RRivas2004]

ZEBRA ALERT - Right Atrial Myxoma causing massive right atrial embolus and SVC syndrome.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1396755/pdf/annsurg00355-0124.pdf

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC287799/pdf/cardiodis00011-0064.pdf

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC481532/pdf/brheartj00124-0102.pdf

 

The cyanosis above the clavicles could of been blood being trapped above the level of the SVC bifurcation - possible superior vena cava syndrome due to massive clot in the Right Atrium/ SVC, possible causes include atrial myxoma check out this case study. Atrial myxomas are mostly left sided, but can present in the right atrium and can cause significant obstruction to blood flow, and most definitely can cause some A-fib if they irritate the conduction system. They usually go undiagnosed as they are commonly asymptomatic and tend to be benign. AAA can also cause SVC syndrome.

 

Vital signs would definitely yield tachycardia, and tachypnea, as well as profound hypotension as this would cause a "volume" problem. Blood would not be able to adequately enter the RA and thus the RV, and so on so on. A sudden "plug" in the system could cause a sudden decrease in systolic bp causing syncope. As the embolus grew and total obstruction occured the patient would expire.

Treatment would be aggressive volume replacement therapy, heparin therapy, and emergent thrombolectomy, and most likely removal of the myxoma.

He was done for either way..

 

***Disclaimer*** These are just my thoughts on what a zebra dx would be for this gentleman. The PE and ruptured AAA have been covered extensively and are very likely to be the cause of death. However I like Zebra's as much as I like horses :)