Clinical Cases in Paramedicine. Группа авторов
with age >60 years of age Previous proven deep vein thrombosis (DVT)/PE Immobility Thrombotic disorder Neurological disease with extremity paresis Thrombophilia Hormone replacement therapy and oral contraception Prolonged bed rest >3 days Other recent trauma
1 What validated assessment tool could assist you with assessing the probability of PE in this patient? See Table 1.3.Table 1.3 Wells’ criteria for PESource: JRCALC (2019), p. 368.CriteriaScoreClinical signs and symptoms of DVT (leg swelling and pain with palpation of the deep veins)3An alternative diagnosis is PE is less likely3Pulse rate >100 bpm1.5Immobilisation or surgery in the previous 4 weeks1.5Previous DVT/PE1.5Haemoptysis1Malignancy (treatment ongoing or within the last 6 months or palliative)1Clinical probabilityHigh>6 pointsModerate2–6 pointsLow<2 pointsNote: When using the Wells’ criteria, a low probability does not rule out PE.
Case Progression
You decide to move your patient to the back of the ambulance to continue the examination in a warm and private environment. On standing, the patient complains of feeling dizzy and faint and is unable to walk even a couple of steps. You instruct your crewmate to fetch the carry chair as you can’t get the stretcher close enough to the patient.
Patient assessment triangle
General appearance
Patient feels better when lying flat.
Circulation to the skin
Normal.
Work of breathing
Increased. Patient complains of not being able to ‘catch her breath’.
SYSTEMATIC APPROACH
Danger
None at this time.
Response
Alert.
Airway
Clear.
Breathing
RR: 30.
Circulation
HR: 128. Weak radial.
Disability
Moving all four limbs.
Exposure
Normal temperature in the ambulance.
Vital signs
RR: 30 bpm
HR: 128 bpm
BP: 88/60 mmHg
SpO2: unable to obtain
Blood glucose: not repeated
Temperature: not repeated
GCS: 15/15
12 lead ECG: sinus tachycardia with right bundle branch block (RBBB)
1 What is the most common ECG finding in PE? What other ECG changes are associated with PE? The most common ECG finding in PE is sinus tachycardia. PE can cause any of the following ECG changes:T‐wave inversion.New‐onset atrial fibrillation.Right bundle branch block.Right axis deviation.S1Q3T3 (this is a specific pattern that is seen rarely in PE):S waves in lead I.Q waves in lead III.T‐wave inversion in lead III.
2 Explain why females taking the oral contraceptive pill are at greater risk of developing a PE. Virchow’s triad explains the three broad categories that play a part in thrombus formation:Hypercoagulability.Hemodynamic changes (stasis, turbulence).Endothelial injury/dysfunction.Taking contraceptive drugs that contain oestrogen can actually change the constitution of the blood, increasing plasma and other clotting factors. This causes the woman to be in a hypercoagulative state, increasing the risk of developing DVT/PE.
LEVEL 2 CASE STUDY
Life‐threatening asthma
| Information type | Data |
| Time of origin | 07:13 |
| Time of dispatch | 07:15 |
| On‐scene time | 07:26 |
| Day of the week | Monday |
| Nearest hospital | 20 minutes |
| Nearest backup | 10 minutes |
| Patient details | Name: Billy Bob DOB: 01/06/1995 |
CASE
You have been called to a residential address for a 25‐year‐old male with difficulty in breathing. Caller states he has been breathless all night and has had a cough recently.
Pre‐arrival information
The patient is conscious and breathing and is located in a third‐floor flat/unit – there is no lift.
Windscreen report
The location appears safe and you are greeted at the communal entrance by the patient’s partner.
Entering the location
The partner appears agitated and hurries you up the stairs, stating that the patient was having his breakfast and his breathlessness got a lot worse.
On arrival with the patient
The patient is sat leaning forward and appears panicked. He does not say hello when you introduce yourself and states repeatedly that he cannot breathe, in short sharp breaths.
Patient assessment triangle
General appearance
Alert, but does not acknowledge your presence. Acutely distressed. Unable to speak in full sentences, leaning forward with clear dyspnoea.
Circulation to the skin
Pale and peripherally cyanosed.
Work of breathing
He has increased breathing effort and only giving 1 word answers.
SYSTEMATIC APPROACH
Danger
None at this time.