How Fast A Patient's Condition Can Change

[ohiovolffemtp]

I'd like to share a patient I had this morning with all future PA's as an example of how fast a patient's condition can change and how rapidly your approach can need to change.

A 49 year old man came into my ED (rural critical access hospital) brought in by his wife with complaints of severe substernal chest pain that radiated to his neck and his left arm.  He says it feels like the MI he had at age 31.  He says he had no stents, CABG, or other sequelae.  He's pink, but diaphoretic.  Vitals: P: 97, BP: 178/103, R: 12, O2 sat: 99% on room air.  He does have LLS (Looks Like S....).

Initial EKG:

So, standard chest pain workup was started.  IV, ASA, labs, CXR, SL nitro - pt received 1.  Patient complained of rapidly worsening pain.  Repeat 12 lead:

Notice the difference in time stamp: only 12 minutes.  Call to nearest hospital with cath lab - interventionalist accepts , clopidogrel, heparin bolus and drip, out the door.

Teaching points:

• Just because your 1st results aren't scary, the patient can still be going downhill - keep watching.  Add "about to be sick" to your "sick vs not-sick" thinking.
• Diesel is a very important medication: be VERY willing to transfer a patient (from any setting) quickly once they're beyond what you can take care of where you are.  Do it quickly.

Afterwards:

Cath lab reported a total RCA occlusion that was successfully stented. Patient's initial troponin (which resulted after he left) was undetectable.

Edited October 22, 2020 by ohiovolffemtp

[TheFatMan]

Thanks for sharing. I wonder if anyone could do a study about the sensitivity and specificity of a positive "LLS" sign.

[LT_Oneal_PAC]

Take everyone who is sweating seriously. I’m not sure I’ve ever had a diaphoretic patient not be in some serious shit.

[ohiovolffemtp]

My experience is that LLS is VERY sensitive for badness, not particularly specific for what mechanism is causing it, e.g. cardiac vs trauma....

[EMEDPA]

WIDELY RECOGNIZED IN CRITICAL CARE CIRCLES : https://emcrit.org/emcrit/lls-score/

[bike mike]

May seem like a random question....but did they report any nausea? 

[Apollo1]

19 hours ago, bike mike said:

May seem like a random question....but did they report any nausea? 

In the hypothetical, what if OP said no? Does it change the initial DDx or the subsequent management?

[LT_Oneal_PAC]

On 10/22/2020 at 3:43 AM, ohiovolffemtp said:

I'd like to share a patient I had this morning with all future PA's as an example of how fast a patient's condition can change and how rapidly your approach can need to change.

A 49 year old man came into my ED (rural critical access hospital) brought in by his wife with complaints of severe substernal chest pain that radiated to his neck and his left arm.  He says it feels like the MI he had at age 31.  He says he had no stents, CABG, or other sequelae.  He's pink, but diaphoretic.  Vitals: P: 97, BP: 178/103, R: 12, O2 sat: 99% on room air.  He does have LLS (Looks Like S....).

Initial EKG:

So, standard chest pain workup was started.  IV, ASA, labs, CXR, SL nitro - pt received 1.  Patient complained of rapidly worsening pain.  Repeat 12 lead:

Notice the difference in time stamp: only 12 minutes.  Call to nearest hospital with cath lab - interventionalist accepts , clopidogrel, heparin bolus and drip, out the door.

Teaching points:

• Just because your 1st results aren't scary, the patient can still be going downhill - keep watching.  Add "about to be sick" to your "sick vs not-sick" thinking.
• Diesel is a very important medication: be VERY willing to transfer a patient (from any setting) quickly once they're beyond what you can take care of where you are.  Do it quickly.

Afterwards:

Cath lab reported a total RCA occlusion that was successfully stented. Patient's initial troponin (which resulted after he left) was undetectable.

Im curious about 2 things since the troponin was undetectable:

what type of troponin is your lab using?

how long had the chest pain been going on?

not that a negative troponin would change anything I would do for this guy, just intellectual curiosity

[bike mike]

2 hours ago, Apollo1 said:

In the hypothetical, what if OP said no? Does it change the initial DDx or the subsequent management?

No, of course not. I was just curious. I've seen so many inferior STEMI patients that come in with nausea/vomiting. 

[ohiovolffemtp]

We are using the regular sensitivity troponin, considered undetectable <0.02, 0.02-0.04 is detectable, > 0.04 is considered positive.

Patient said he 1st noticed the pain ~ 03:00, worsened ~ 06:00, arrived at my ED (by spouse, not EMS) ~ 07:05

I mentioned the negative troponin as a teaching point that cardiac badness can happen well before a troponin elevates, ie STEMI on EKG >> NSTEMI on serial trops.

[LT_Oneal_PAC]

2 hours ago, ohiovolffemtp said:

We are using the regular sensitivity troponin, considered undetectable <0.02, 0.02-0.04 is detectable, > 0.04 is considered positive.

Patient said he 1st noticed the pain ~ 03:00, worsened ~ 06:00, arrived at my ED (by spouse, not EMS) ~ 07:05

I mentioned the negative troponin as a teaching point that cardiac badness can happen well before a troponin elevates, ie STEMI on EKG >> NSTEMI on serial trops.

Oh I totally agree badness can happen before troponin elevation. 

 We had troponin T in residency and troponin I at my CAH. Our’s is undetectable is <0.012, positive at 0.04, and “AMI cut off” at 0.120, meaning for some damn reason lab will only call me if it’s greater than 0.12, which always irks me.