Case summary:

An ALS crew responded to a 30s man who had been complaining of chest pain and then fell and was unresponsive.  Crew arrived on seen to find the patient lying on the ground, minimally responsive and breathing shallow.  A bystander reported this patient had a history of congestive heart failure and struck his head when he fell.  The crew placed the patient in a cervical collar, started to bag the patient and obtained vitals:

Vitals: BP 101/54,  HR 74,  RR 2,  Sat 97%,  glucose 90, GCS 6

The crew started extricating the patient and he became more responsive during this time to the point where he no longer needed to be bagged.  Once in the ambulance, the crew obtained a 12-lead EKG that showed some ST elevations in II, III, and aVF with reciprocal T wave inversion in aVL.  This was concerned the crew for a right coronary artery occlusion causing a ST elevation myocardial infarction (STEMI).  This might have caused the patients chest pain and could have been the reason he fell.  They were also concerned about a significant head injury given the patient was still with a very abnormal GCS and could have intercranial bleeding.  The decided to transport to the nearest center that was both a STEMI center and a trauma center and made the patient both a STEMI alert and a trauma alert.  The patient remained stable in route to the hospital with no significant changes in vitals or mental status. 

Highlights of the case:

How to handle patients who meet criteria for multiple alerts.

We have alerts for specific disease processes that require time sensitive treatments to give patients their best chance at a good health outcome.  The most common examples of these alerts are STEMI, stroke and trauma alerts.  Sometimes we will respond to a patient that meets criteria for multiple hospital alerts at the same time.  This is most commonly an overlap between trauma and the other two.  For example, a patient might have a stroke while behind the wheel causing a crash with rollover or causing the patient to fall down the stairs.  In the case mentioned above, the patient was having a STEMI that likely caused a transient arrythmia that caused the patient to collapse and strike his head.  If the closest receiving hospital can handle all the alerts, then great!  However, sometimes hospitals are only certified to handle one of the time sensitive issues that a patient has and we will need to know which alert takes priority.  In general, trauma care is the priority.  This is because the treatments for both stroke and STEMI involve giving blood thinners.  If a patient his undiagnosed internal bleeding and we give blood thinners due to a STEMI or stroke, the patient will likely exsanguinate.  For this reason, we need to rule out trauma BEFORE the patient can get stroke or STEMI care even if this delays the treatments for stroke and STEMI.  This means that if you have a trauma patient that has a STEMI and your options are a STEMI center that can’t do trauma or a trauma center that can’t do STEMI care, you should transport to the trauma center.  The trauma center can then work the patient up for trauma and once that is done, the patient can be transferred to the STEMI center after.  In the case mentioned above, the crew was able to go to a hospital that does both trauma and STEMI so the patient was able to have all their care in one place.  Trauma still needed to be ruled out before the patient could get treated for a STEMI.  The crew in this case handled everything very well!