Clinical Cases in Paramedicine. Группа авторов
href="#ulink_9b7efcf3-89d5-55a5-a869-f643c63a961d">Table 2.3.
Table 2.3 History‐taking questions
| Signs and symptoms: Rapid pulse, pale, clammy, increased work of breathing, complains of mild nausea, palpitations (fluttering feeling in chest) Allergies: NSAIDs Medications: Nil reported Previous medical history: Nil reported Last meal: Breakfast at 07:00 – oats Events leading up to today: Witnessed collapse while running, normal water intake |
| Additional questioning Does the patient remember falling? If so, what caused the fall? Can the patient retain new information? Is there retrograde amnesia? Does the patient have a cardiac history (Hx)? What is your full name and DOB? Is there any family or emergency contact you’d like us to call? |
Case Progression
Despite two attempts at a modified Valsalva, the patient is now feeling short of breath, dizzy, nauseated, has chest pains and palpitations, and states he feels like he is going to pass out. You are unable to palpate a radial pulse and blood pressure is unrecordable.
1 What are your treatment priorities now and what interventions may be required to prevent further deterioration and cardiovascular collapse?In‐hospital treatments may include antiarrhythmic drugs such as betablockers or adenosine, which are often used to try to slow AVN conduction and induction of an intermittent AV block. Adenosine also has a short half‐life and works within 6–10 seconds, so its effects are short term. However, in this case the patient has no other treatments available pre‐hospital, so DC cardioversion should be initiated.
LEVEL 3 CASE STUDY
S‐T segment elevation myocardial infarction (STEMI)
| Information type | Data |
| Time of origin | 12:30 |
| Time of dispatch | 12:32 |
| On‐scene time | 12:40 |
| Weather | 24 °C, blue skies |
| Nearest hospital | 15 minutes (no cath lab) |
| Nearest backup | CCP, 10 minutes |
| Patient details | Name: Robert Henson DOB: 12/02/1950 |
CASE
You have been dispatched code 1 to a GP clinic to attend a 70‐year‐old male who has presented with chest pain.
Pre‐arrival information
The male is not a patient of the GP clinic, he is travelling through town and developed chest pain this morning and presented to the clinic. The clinic called 000 straight away as the patient does not look well.
Windscreen report
You know the GP clinic, it is well respected in your area.
Entering the location
You are greeted by the practice nurse, who states the male is not a patient of the practice, they do not have any records as he is from interstate. He walked into the practice holding his chest and looked very pale, so they called immediately. She has put him on their bed, she attempted to gain a history but he is in a lot of pain. The doctor has come in but is in the middle of an important patient procedure so has been unable to assess the patient. They attempted a 12 lead ECG but he won’t sit still.
On arrival with the patient
The patient is lying on a bed in some distress, his friend is next to him looking concerned.
Patient assessment triangle
General appearance
The patient is very pale in colour, diaphoretic, alert to you walking in the room, able to speak in sentences, holding his chest, unable to sit still.
Circulation to the skin
Very pale, almost ashen in colour.
Work of breathing
Slightly increased with the patient ‘puffing’ in pain every third breath.
SYSTEMATIC APPROACH
Danger
Nil.
Response
Alert and orientated.
Airway
Clear.
Breathing
Increased rate and effort, no accessory muscle use.
Circulation
Slow strong radial pulse palpable, regular, capillary refill time <2 seconds.
Vital Signs
RR: 24 bpm
BP: 135/75 mmHg
SpO2: 93%
Blood glucose: 5.1 mmol/L
GCS: 15/15
Pupils equal and reactive to light (PEARL)
Colour/appearance: Pale, diaphoretic, almost grey/ashen in colour
Respiratory effort/rhythm: Increased effort, regular
Auscultate: Clear air entry both sides
Pulses: Strong radial pulses both sides
4 lead ECG: Sinus bradycardia at a rate of 40 (undiagnostic ST changes)
Exposure
Head‐to‐toe survey reveals no obvious injuries/deformities, no loss of sensation, poor skin turgor, dry mucosa, nil medical alerts.
TASK
Look through the information provided in this case study and highlight all of the information that might concern you as a paramedic.
1 Given the patient’s presentation and initial observation, what is a critical vital sign that assists in the diagnosis of the condition and needs to be acquired as soon as possible?A 12 lead ECG.
2 The patient is rolling in pain and unable to respond to the nurse’s questions. What strategies could you incorporate in your practice to ensure you gather all relevant information?Reassurance, the importance of which is often underestimated. This patient appears to be very unwell and it is vital that he is assessed thoroughly. This requires good communication and plenty of reassurance,