EMT Drugs Case 3

Patient & Chief Complaint

• You’re buying lunch at Mumtaz when the cook, 46 year old
male, tells you he’s experiencing sudden onset of central
crushing chest pain, which radiates to his shoulder blades and
he’s also feeling nauseated
• You assist him to sit down on a chair and ask your partner to
empty the unit and bring all the gear to you ASAP
 Appearance & Initial Clinical Findings
• He looks pale, sweaty, anxious
• Airway – clear
• Breathing – regular, fast, shallow, audible wheeze,
dyspnoea,
• Circulation – Pulse present, regular but weak and
thready skin cold, diaphoretic (perspiring) colour
flushed, cap refill abnormal (>2 sec)
• Disability – alert, coherent and orientated / pain score
9/10
• Exposure – temperature 36
 Appearance & Initial Clinical Findings
• He looks pale, sweaty, anxious
• Airway – clear
• Breathing – regular, fast, shallow, audible wheeze,
dyspnoea,
• Circulation – Pulse present, regular but weak and
thready skin cold, diaphoretic (perspiring) colour
flushed, cap refill abnormal (>2 sec)
• Disability – alert, coherent and orientated / pain score
9/10
• Exposure – temperature 36
 Observations

• Pulse rate - 102bpm / Pulse rhythm Regular

• Resp rate 27 per minute, shallow, audible stridor and wheeze
• On auscultation - Resp quality bibasilar crackles
• SpO2 - 93%
• Cap Refill >2secs
• BP 90/55
• GCS (E4, V5, M6).
• BM 11.6mmol/l
• Temp – 35.7
• Pupils PEARRL, size 3
 History AMPLE
A Allergies
M Medications
P Previous medical/surgical history
L Last meal (Time)
E Events

• A - NKDA
• M -Not currently taking medication / non-smoker and non-drinker
• P - No medical history of significance
• L - large breakfast, finishing at 0600 – Ramadam
• E – had been feeling normal until sudden onset of pain and nausea
What’s your working diagnosis?
 What’s your working diagnosis?
Myocardial infarction – Heart attack

MI, occurs when a coronary artery is partially blocked leading to

a portion of the heart muscle (myocardium) being deprived from
oxygen and leading to ischemia, necrosis.

Ischemia refers to reduction in blood supply to an organ (heart).

if reversed rapidly there is no permanent damage to the heart
Prolonged ischemia can lead to tissue necrosis an infarct.
What’s your Plan?
 What’s your Plan?
• Call Paramedic (12 lead ECG, Morphine, fluids?)
approach – MONA
 What’s your Plan?
• Call Paramedic (12 lead ECG, Morphine, fluids?)
 What’s your Plan?
• Call Paramedic (12 lead ECG, Morphine, fluids?)
• Entonox / Oxygen? (nasal cannula)?
 What’s your Plan?
• Call Paramedic (12 lead ECG, Morphine, fluids?)
• Entonox / Oxygen? (nasal cannula)?
• Aspirin
 What’s your Plan?
• Call Paramedic (12 lead ECG, Morphine, fluids?)
• Entonox / Oxygen? (nasal cannula)?
• Aspirin – soluble 300mg
 What’s your Plan?
• Call Paramedic (12 lead ECG, Morphine, fluids?)
• Entonox / Oxygen? (nasal cannula)?
• Aspirin
• GTN?
 What’s your Plan?
• Call Paramedic (12 lead ECG, Morphine, fluids?)
• Entonox / Oxygen? (nasal cannula)?
• Aspirin
• GTN? Withhold if Low blood pressure ~90mmHg - if it’s new or been
without use for long time discard first spray to the air
 What’s your Plan?
• Call Paramedic (12 lead ECG, Morphine, fluids?) approach –
MONA, ENA
• Entonox / Oxygen? (nasal cannula)?
• Aspirin
• GTN?
• Inside unit may sit patient in semi-recumbent position?
 What’s your Plan?
• Call Paramedic (12 lead ECG, Morphine, fluids?)
approach – MONA, ENA
• Entonox / Oxygen? (nasal cannula)?
• Aspirin
• GTN?
• Inside unit may sit patient in semi-recumbent position?
It may be worth considering since allows for relaxation of abdominal muscles, and
assists use of intercostals muscles of the back to aid breathing
 What’s your Plan?
• Call Paramedic (12 lead ECG, Morphine, fluids?) approach –
MONA, ENA
• Entonox / Oxygen? (nasal cannula)?
• Aspirin
• GTN?
• Inside unit may sit patient in semi-recumbent position?
• ATMIST
What’s your Plan?
 Interventions and Rationale
Entonox – to relieve pain due to cardiac ischemia, reduce
anxiety and treat hypoxia
Aspirin – to decrease the risk of further clots developing and
causing further myocardial damage anticoagulant /
GTN – coronary artery dilation – systemic effect
reduces preload and in turn reduces myocardial oxygen demand.
 ECG Trace

ECG rhythm Sinus Tachycardia with ST elevation in antero-septal leads (V1-V4)