Case 10: Reperfusion Woes

UPDATED: 12/04/2007 - Patient Follow-Up Posted.  CLICK HERE FOR THE ANSWER

EKG Case Discussion:
EMS professionals continue to encounter challenging patient presentations in the field. We are no longer confined to just practice cookbook medicine and are held to a higher standard of care. Current trends in protocol development give EMS providers the ability to use professional judgment when deciding how to treat a particular patient. As this week’s case will demonstrate, it is important to look at the entire picture when responding to a call and to understand why a specific  treatment — or no treatment at all — may be the best option. Please review the following case and offer your thoughts on potential treatments you would initiate for this patient. DISCUSS this case below.

EKG Case Presentation:
ALS1 is dispatched to a rural medical facility to transport a patient diagnosed with an acute coronary syndrome to the closest cath lab, which is about 55 minutes away. Upon arrival, you are briefed on the current status of your patient: She is a 64-year-old diabetic, hypertensive female, who was brought to the facility an hour ago with evidence of a STEMI. She arrived within 30 minutes of her symptoms' onset and has been treated with Aspirin, heparin and thrombolytics for several minutes now. She reports that she is pain-free and actually feels much better. 

Initial Assessment:
Her current vital signs are 110/80, heart rate 84, respiratory rate 18, and is saturating at 98% on 3 lpm of oxygen. On the hospital's monitor, you see a normal sinus rhythm without PVCs. After completing the appropriate paperwork and information regarding the patient, you and your partner attach the monitor, connect her to your portable oxygen cylinder, load her onto the stretcher, and attach the IV bags into the stretcher IV pole. As your patient continues to calmly talk to you en route, you glance at the rhythm monitor casually and notice a rhythm change.

Initial EKG (click for larger image):

Above is the 12-lead EKG for the patient.

Initial Assessment:
The patient exhibits no change in her current condition. She denies feeling any chest pain, dizziness, dyspnea, palpitations or any other discomfort. She is alert, conscious and oriented to person, place, and time. BP is 105/60. You gather the following information:

Past Medical History:
Diabetes
Hypertension
Denies any prior cardiac history

Allergies:
No known drug allergies (NKDA) 

Meds: (generic names)
Metformin 850mg
Enalapril 20mg

Case 10 Discussion Questions:

• Given the 12-lead EKG and initial assessment, would you divert the patient to a closer facility?
• What interventions, if any, would you carry out?
• What medications may be indicated?

UPDATED: 12/04/2007 - Patient Follow-Up Posted.  CLICK HERE FOR THE ANSWER