Good morning providers,

Most of you are extremely aggressive at getting 12 leads on anyone that may have any cardiac concern. Occasionally I see departments placing and monitoring limb leads without an official 12 lead. Although that is very acceptable in situations in which you are following a patient’s clinical course during transport, it is usually appropriate to consider a 12 lead with any patient that might have a cardiac origin for their complaint. The protocol lists 12 leads on numerous guidelines. Everyone is getting 12 leads on chest pain, but if you’re asking, “should we do a 12 lead?” the answer is usually YES! The protocol has 12 leads as part of the pre-hospital care path for the following emergencies:

1. Chest pain

2. Shortness of breath

3. Altered mental status

4. Stroke (not on scene)

5. Poisoning/toxic exposures

6. CHF

7. Renal emergencies

8. Shock

9. ACLS emergencies

10. Nausea and vomiting

11. Syncope/near syncope

12. Abdominal pain

13. Seizure (new-onset)

14. Weakness

These are the obvious reasons to get a 12 lead in the field.  

Remember that our basic providers are a valuable tool and can help get the 12 lead and aren’t supposed to just read them per the Ohio scope of practice. The case today is: 

As many of you know, the answer is shortness of breath. Although many diabetics do have chest pain when they are having an MI, more do not. Sadly, the number one complaint of a diabetic having an MI is shortness of breath. Knowing this helps us get the 12 lead done and sent to the ED in under 10 minutes for any diabetic who is short of breath. The question as to why this is a different presentation for this patient population? The answer may be the decreased sensation frequently seen in diabetic neuropathy. Many of you know the patient with diabetic foot ulcers that appear severe and they have no pain. This is due to their diabetic neuropathy. The same parasympathetic pain fibers around the heart may have very similar neuropathy. Sadly, it leads to late-diagnosed MIs because they don’t present until an element of heart failure ensues. Larger MIs may present earlier with a sudden weakness or shortness of breath caused by a suddenly poorly functioning myocardium. When in doubt, grab the 12 lead, and if the story is a good one and the EKG looks good, consider a right-sided EKG by moving V4 to the right same position chest lead.

Providers, thank you as always for being our frontline Heroes. We appreciate all that you do and the many lives you save.

Sincerely,

Don Spaner MD

Sympathomimetics - June  13, 2022

Good morning providers,

I was reviewing charts this morning, and Ashland Fire (shout out for a job well done) picked up a 72-year-old altered mental status patient. He had an ischemic 12-lead and was arousable to noxious stimulation.  Samaritan had a negative head CT but ran a toxicology screen on a 72-year-old. Shout out to Samaritan for a very thorough evaluation.    

Low and behold, our geriatric patient was positive for cocaine and marijuana. This reminded me of a 66-year-old patient having an MI. IN FACT, HE IS SOMEWHAT KNOWN AMONG NURSES AT GENEVA???? The nurses knew him at Geneva and said that he is a bit of a wild man in the area. He told us he uses two teaspoons of methamphetamine in his coffee each morning to start his day off with a jolt! I bring these real events up generically to protect any identities, but the reality is that drug abuse is ubiquitous throughout our society and generations. Stimulants are a major culprit to heart disease and myocardial infarctions in our younger MI patients. Any patient under 30 presenting to the ED with an MI needs a toxicology screen. Specifically, we are looking for cocaine. Consider asking about drug use in all your chest pain patients, but always ask for it in younger chest pain patients.

The case to consider is a 25 year old male who develops severe crushing chest pain after snorting a line of cocaine. He is diaphoretic, nauseous, and appears very uncomfortable clutching his chest. The following is his EKG:

The answer to the question for MIs in this age group is 1) cocaine abuse and 2) congenital anomaly. 

Since this patient has suffered an MI, you would be correct in treating for a STEMI in the field. Defibrillation patches are in place.  Constant monitoring is established. The use of 324mg of aspirin, 180mg of Brilinta, and 4000 Units of Heparin are appropriate as you transport to an interventional facility.

What else needs to be done for this cocaine-induced STEMI?

1. All cocaine-induced chest pain patients deserve and require a Benzodiazepam. Ativan departments should administer 1-2 mg IV. Versed departments need to give 2.5mg IV. Remember the Versed only lasts about 20 minutes and can be redosed for longer transports. The Benzodiazepams will help calm the very high sympathetic tone of cocaine-a strong sympathomimetic agent.

2. We carry both Metoprolol and Labetalol. Remote literature discussed the use of Metoprolol, a pure beta-blocker, that could cause increased blood pressure, by allowing unopposed alpha stimulation in cocaine toxicity. The choice with medical control oversight is Labetalol, which is both an alpha and beta-blocker at a dose of 10-20mg IV per medical control.

Remembering stimulant abuse as part of our review of systems in myocardial infarction can help you provide safe treatment for these patients and sustain a much better outcome. As always, thank you for being our front-line heroes. We appreciate all that you do! Keep fighting the good fight to save lives.

Sincerely,

Don Spaner MD

12 Leads - June 20, 2022

Good morning providers,

Most of you are extremely aggressive at getting 12 leads on anyone that may have any cardiac concern. Occasionally I see departments placing and monitoring limb leads without an official 12 lead. Although that is very acceptable in situations in which you are following a patient’s clinical course during transport, it is usually appropriate to consider a 12 lead with any patient that might have a cardiac origin for their complaint. The protocol lists 12 leads on numerous guidelines. Everyone is getting 12 leads on chest pain, but if you’re asking, “should we do a 12 lead?” the answer is usually YES! The protocol has 12 leads as part of the pre-hospital care path for the following emergencies:

1. Chest pain

2. Shortness of breath

3. Altered mental status

4. Stroke (not on scene)

5. Poisoning/toxic exposures

6. CHF

7. Renal emergencies

8. Shock

9. ACLS emergencies

10. Nausea and vomiting

11. Syncope/near syncope

12. Abdominal pain

13. Seizure (new-onset)

14. Weakness

These are the obvious reasons to get a 12 lead in the field.  

Remember that our basic providers are a valuable tool and can help get the 12 lead and aren’t supposed to just read them per the Ohio scope of practice. The case today is: 

As many of you know, the answer is shortness of breath. Although many diabetics do have chest pain when they are having an MI, more do not. Sadly, the number one complaint of a diabetic having an MI is shortness of breath. Knowing this helps us get the 12 lead done and sent to the ED in under 10 minutes for any diabetic who is short of breath. The question as to why this is a different presentation for this patient population? The answer may be the decreased sensation frequently seen in diabetic neuropathy. Many of you know the patient with diabetic foot ulcers that appear severe and they have no pain. This is due to their diabetic neuropathy. The same parasympathetic pain fibers around the heart may have very similar neuropathy. Sadly, it leads to late-diagnosed MIs because they don’t present until an element of heart failure ensues. Larger MIs may present earlier with a sudden weakness or shortness of breath caused by a suddenly poorly functioning myocardium. When in doubt, grab the 12 lead, and if the story is a good one and the EKG looks good, consider a right-sided EKG by moving V4 to the right same position chest lead.

Providers, thank you as always for being our frontline Heroes. We appreciate all that you do and the many lives you save.

Sincerely,

Don Spaner MD

June 27, 2022

Good morning providers,

We have been evaluating the effects of increased nitroglycerin use with our updated CHF exacerbation protocol.  

The use of nitroglycerin is extremely beneficial. The compromised myocardium gets more oxygenated blood through the vascular dilation of the coronary arteries. This allows the heart to work more efficiently. The reduced systemic vascular tone also decreases the workload of the heart.   Evaluate the patient: who calls ems with shortness of breath. They most likely won’t lay flat (orthopnea), have JVD, edema, and HJR (hepatojugular reflex). You will clinically have rales bilaterally (focal rales only on one side should warrant a review of possible pneumonia). Prior history is also helpful. Once you have narrowed the differential to CHF exacerbation, notice the two treatments that will provide comfort in the field are CPAP and Nitroglycerin.  

CPAP will open up collapsed alveoli and increase the surface of the alveoli to improve oxygen delivery. Nitro will provide the above benefits, but the days of dropping one nitro and hoping for the best have been replaced with nitroglycerin every 5 minutes until the systolic drops below 120. We all know how much CPAP improves heart failure; you should see similar benefits from serial nitroglycerin as you consider the contraindications for nitroglycerin.

Years ago, it was commonplace in the emergency departments to intubate a heart failure patient almost every shift. Nowadays, thanks to CPAP, it is extremely rare. As we become more aggressive with nitroglycerin, we are not only benefitting from our better oxygenated CPAP patient, but we are resting the heart and getting more volume out to the periphery.  So once you enter the emergency department, we successfully diuresis the patient. It is amazing how much more effective Lasix works when the patient is properly prepared with CPAP and nitroglycerin.

Thanks to all of you who are our frontline heroes. Have a wonderful summer, stay safe, and be well.

Sincerely,

Don Spaner MD