What could be the cause?

[CCEMTP2DOC]

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Ok,

I had a weird call last night and would like your thoughts. I work as critical care paramedic and was called to transfer a post arrest patient to a facility for more definitive care. (catherization etc.). Pt was a 40 yo male who presented to the ER with sub sternal chest pain with burning into in throat and pain down both arms. Pt was being worked up by ER staff and went into v-fib. Pt was shocked twice and converted to NSR. The following meds were hung; Amiodarone, Nitro, Heparin, and mag. Only pt history is that of recently diagnosed,within 3-6 months, of HTN. No meds or allergies.12
leas was pretty much normal, there was some slight elevation in v-1, v-2, and I do mean slight. All labs, CPK, CPK-MB, TROPONIN, CARDIAC INDEX, were normal. The 12 lead didn't show any kind of infarct, it showed some possible axis deviation, but stated otherwise normal ekg. Pt was pretty much pain free enroute. BP held up nice. NSR all the way enroute, no ectopic beats. So what do you think?

Rob


P.S. Also, no significant family history.

P.S.S. I did another 12 lead enroute and it showed no elevation as the irst hospital did. The receiving hospital also showed nothing on their 12 lead.

 

[Dr Alo]

He could be having a silent heart attack. In general, about 25% of heart ischemic and infarction are ekg silent. Troponin takes about 3-6 hours to elevate, that's why they like to draw one immediately, and one in 6-9 hours later. CK, CKMB, and Trop take a while. CK usually rises in 4-6 hours. CK falls faster than Trop (declines in about 4 days), trop can stay elevated for as much as two weeks. If the guy had just had his heart attack, the only enzyme that would be elevated is myoglobin, that rises immediately, but ER docs don't usually order this test, because it is not specific for MI. Also, patients can have enzyme silent heart attacks as well.

For the EKG to show no significant changes, this is also possible. About two thirds of MI that present to the ER eventually evolve into non Q-wave MIs. Meaning, you never see the q-waves afterwards or during. NSTEMI (non-ST elevation MI) is also another possibility, he could be having an MI without ekg changes.

Also, if the pt is having a posterior MI, its hard to pick it up on EKG, and you may need to add leads on the back, leads V7-V9. (yes, its rare, but you can do this) Also if you see a very tall R in V1.... think posterior MI.

If the pt previously had a left bundle branch block, EKG interpretation for MI is impossible.

They probably think he had an MI of some sort, or severe acid reflux. The enzymes did not show anything, neither did the ekg, so they want to do an angiogram in teh cath lab to see if he has blocked vessels. If he does, they'll throw some stents in his vessels. How many sets of enzymes did they draw on this guy? Was the guy severely obese? So much so that it would be difficult to get an ekg on him? or you'd get a low voltage, poor ekg?

The fact that he is 40 indicates he may have severe disease. Especially, if he has had heart disease all his life and HTN.... bad combination.

 

[CCEMTP2DOC]

He could be having a silent heart attack. In general, about 25% of heart ischemic and infarction are ekg silent. Troponin takes about 3-6 hours to elevate, that's why they like to draw one immediately, and one in 6-9 hours later. CK, CKMB, and Trop take a while. CK usually rises in 4-6 hours. CK falls faster than Trop (declines in about 4 days), trop can stay elevated for as much as two weeks. If the guy had just had his heart attack, the only enzyme that would be elevated is myoglobin, that rises immediately, but ER docs don't usually order this test, because it is not specific for MI. Also, patients can have enzyme silent heart attacks as well.

For the EKG to show no significant changes, this is also possible. About two thirds of MI that present to the ER eventually evolve into non Q-wave MIs. Meaning, you never see the q-waves afterwards or during. NSTEMI (non-ST elevation MI) is also another possibility, he could be having an MI without ekg changes.

Also, if the pt is having a posterior MI, its hard to pick it up on EKG, and you may need to add leads on the back, leads V7-V9. (yes, its rare, but you can do this) Also if you see a very tall R in V1.... think posterior MI.

If the pt previously had a left bundle branch block, EKG interpretation for MI is impossible.

They probably think he had an MI of some sort, or severe acid reflux. The enzymes did not show anything, neither did the ekg, so they want to do an angiogram in teh cath lab to see if he has blocked vessels. If he does, they'll throw some stents in his vessels. How many sets of enzymes did they draw on this guy? Was the guy severely obese? So much so that it would be difficult to get an ekg on him? or you'd get a low voltage, poor ekg?

The fact that he is 40 indicates he may have severe disease. Especially, if he has had heart disease all his life and HTN.... bad combination.

Just one set of enzymes. Patient was not obese, 170 lbs. So, you think right sided MI?

 

[Dr Alo]

One set of enzymes is not enough. You have to draw a second set in 6 hours. Even if you do and they are still negative, this makes MI highly unlikely, but because they have to rule it out, the may end up doing an angiogram. Bt even with a second set of negative enzyems, it could still be an MI. Thats why medcine is an art not a science. Without seeing the patient and hearing his story... its hard to tell if he sounded like an MI. I'm sure you know lots of things can cause retrosternal chest pain, acid reflux, anxiety attacks, and a number of other things.

Another thing they can do is send him for a stress test with myoview (nuclear scan). This basically stresses his heart on a treadmill, and sees if his heart muscle is taking up oxygen when resting and when stressed. They inject material your blood that looks like oxygen to your cells and can be seen by the scanner.

They have to continue working this guy up, because the number of lawsuits filed and won against ER docs is usually from Right ventricular infarcts. In fact, more malpractice awards are for this reason than for any other diagnosis. Because missing the diagnosis in a timely fashion is deadly. Reversibility and survival is highly correlated with early diagnosis.

Is it possibly a right sided or posterior MI? Could be, the posterior descending branch of the right coronry artery usually supplies the inferior and posterior walls of the right ventrcle.

As always, it could also be just nothing.

 

[CCEMTP2DOC]

One set of enzymes is not enough. You have to draw a second set in 6 hours. Even if you do and they are still negative, this makes MI highly unlikely, but because they have to rule it out, the may end up doing an angiogram. Bt even with a second set of negative enzyems, it could still be an MI. Thats why medcine is an art not a science. Without seeing the patient and hearing his story... its hard to tell if he sounded like an MI. I'm sure you know lots of things can cause retrosternal chest pain, acid reflux, anxiety attacks, and a number of other things.

Another thing they can do is send him for a stress test with myoview (nuclear scan). This basically stresses his heart on a treadmill, and sees if his heart muscle is taking up oxygen when resting and when stressed. They inject material your blood that looks like oxygen to your cells and can be seen by the scanner.

They have to continue working this guy up, because the number of lawsuits filed and won against ER docs is usually from Right ventricular infarcts. In fact, more malpractice awards are for this reason than for any other diagnosis. Because missing the diagnosis in a timely fashion is deadly. Reversibility and survival is highly correlated with early diagnosis.

Is it possibly a right sided or posterior MI? Could be, the posterior descending branch of the right coronry artery usually supplies the inferior and posterior walls of the right ventrcle.

As always, it could also be just nothing.

I would agree with it could be alot of things to cause the chest pain. But I have one agonizing question? What caused the v-fib? I have been doing this along time and usually am pretty astute in these things; the guy looked ok, but that pesky v-fib thing keeps bothering me.

 

[Dr Alo]

I would agree with it could be alot of things to cause the chest pain. But I have one agonizing question? What caused the v-fib? I have been doing this along time and usually am pretty astute in these things; the guy looked ok, but that pesky v-fib thing keeps bothering me.

Usually if someone had a heart attack and part of the ventricles lost blood or oxygen supply, that can cause them to go into v-fib. There are a lot of things that cause v-fib too, but that is the most common reason.

 

[oldManDO2009]

well it could be genetic - long QT syndrome but denies history
he was not obese so ischemic heart disease may not be an issue
was there an cxr done and did it show an enlarged heart?
many flavors of cardiomyopathy - secondary to drug abuse, infection, etc
Was there any valve defects asculatated?
hx of depression - some antidepressants/antibiotics can cause acquired long QT syndrome

well my 2 cents....

 

[Vince]

Could have been a small MI that caused the arrhythmia and wasn't noticeable on the EKG. 10% of MI's will have stone cold normal EKGs....not EKGs with NSSTT changes, but I mean NORMAL.

As far as Right Ventricular MI, if you don't see anything in the inferior leads, then I usually don't go searching for RV involvement. I had two patients with poss RV involvement a couple nights ago, and both had hypotension, and episodes of bradycardia, both requiring 0.5mg atropine. So, low BP and bradycardia, and AV block are more common with RV/Inf. Wall MI's b/c of RCA circulation. Also, both of these patients had normal Cardiac Enzymes on ER arrival and it was the 2nd set (8hrs later) that were abnormal.

Other important questions are from the history, when did the pain start, how long did it last, etc....but he definitely needs to go for angio. If angio doesn't show something, could he have had an episode of Prinzmetal's Angina(vasospasm)((RARE)), that caused brief ischemia/arrhythmia??? Who knows.

The amiodarone, nitro, and heparin would probably help keep the EKG normal from there on...and its important to note that EKGs are most helpful DURING pain...so always write on the top of the EKG if the patient was in pain or not....classic error that occurs pre-hospital and in-hospital.

If angio normal, and patient goes for stress test, the patient has to have significant stenosis to result in a positive test, so even a negative stress doesn't necessarily mean everything's okay. Stress tests are mostly good for patients that have poss. angina and you are trying to work them up further, and there are many types, treadmill EKG/Echo, and pharmacologic EKG/Echo, and nuclear studies.

Behold the mystery of medicine...lol

Vince, DO (& CCEMT-P too)

 

[Dr Alo]

The art of medicine............