Case summary:

An ALS crew responded to a 60s woman who was feeling dizzy and sweaty.  She had woken up 20 minutes prior with epigastric pain and was trying to get to the bathroom but became too weak and fell onto the floor.  The crew found her to be very diaphoretic and the immediately obtained the following 12-lead EKG.

The crew correctly diagnosed this patient with am ST elevation myocardial infarction (STEMI).  Due to this patient’s large size and the home being too small to fit the stretcher into, the crew called for an additional unit to help with extrication.  While waiting on the back up, they obtained vitals and placed an IV.  Her vitals were:

Vitals: BP 54/36,  HR 42  RR 22,  Sat 98% on RA

The crew placed pads on the patient and attempted transcutaneous pacing but were unable to consistently maintain mechanical capture.  They quickly extricated once back up arrived and then called in a report to the receiving facility to activate the cath lab.  While in route, the crew gave the patient doses of push dose epi to support the patients blood pressure.

Highlights of the case:

Request additional resources as soon as possible.

This crew realized that this patient was critically ill and needed immediate extrication; however, the initial crew did not have the needed manpower to safely extricate.  They correctly called for backup right away to make sure that they could get the help they needed to safely extricate this patient.  While waiting for the additional help, the crew continued aggressive EMS care.  This was very well handled by this crew!

Unstable patients with tachy or brady arrythmias should be treated with electricity.

If patients are unstable, they need the treatment that is most effective first.  In the case of tachyarrhythmias and bradyarrhythmias, we want to cardiovert or pace respectively.  Both rhythms can cause cardiogenic shock in patients, and electricity works much faster and is often more effective than medications.  This patient was profoundly hypotensive likely both from the heart not squeezing hard due to the myocardial infarction, but also from the bradycardia.  The crew correctly went straight for pacing as well as added in push dose epi to help the failing heart squeeze harder.  These were great decisions by the crew.

Activate the cath lab right away for patients with STEMI.

The ultimate goal of STEMI patient care is to get the patient to the cath lab so that their blocked coronary blood vessel can be opened as soon as possible.  To achieve this, the first thing we should do after making the diagnosis of STEMI is transmit the EKG to the receiving facility and notify them that the cath lab should be activated.  The reasons this is critical is that often the cath lab team must drive in from home and are not in house at the hospital.  The earlier we call, the earlier they can be mobilized.  If we extricate a patient and render care before calling everything in, there is a good chance that the patient will end up sitting at the receiving hospital and waiting for the cath team to arrive while their heart continues to die.  If we had called everything in earlier, the team could have started mobilizing while we were extricating and ideally would be waiting for us ready to go when we arrive at the receiving facility.  While this crew did a ton great things for this patient, this was one area they could have handled better.  They waited until after back up arrived and extrication was complete to transmit the 12-lead.  It would have been better for them to have transmitted the 12-lead while waiting for second crew so that the cath team could have been mobilized sooner.