FORMAL CASE REVIEW

Chemeketa Community CollegeParamedic Class Fall 06

Irina Bubnova & Jeff Johnson

West Valley Fire District

• Population 2,500• HWY 18 & 22• Spirit Mountain

Casino

Metrowest Ambulance

• Headquarters in Hillsboro

• Serving all of Washington county

• System status ALS division

• Wheelchair division

PRECEPTORS

• Irina• Kim Torris• Senior Paramedic• Medic 56• 1845-0600 2/2/3

• Jen Stanislaw• Lieutenant for West

Valley Fire• Medic 8• A Shift (24 hours)

Holding Lt. Stanislaw’s son

PRECEPTORS

• Jeff• Travis Schlegal• Medic 74• Oliver Mellor- EMT-P

• Tammy Schurter • Medic 62• Maria Roeder- EMT-P• 1045-2300 2/2/3

THANK YOU ALL!!!!!!• Family• Friends• Dr. Kirkpatrick• Rhonda Woods, RN, BSN• Justin Hardwick, NREMT-P• Peggy Andrews, NREMT-P• Gregg Landers, NREMT-P• Erin Wheeler, NREMT-P• Johnny Mack, Associate Dean for EMS

The Call…………• Dispatch:• “Difficulty Breathing”• Code 3 at 1242

• Responding Units:• TVFR ENG 67• MWA 62

• Arrive on Scene:• 1248• TVFR Paramedics

have PIC

History• 50 y/o Male patient complaining of shortness of breath since 0730 this AM• Pt is also complaining of leg/arm numbness, back pain, and bright red blood in his urine!• Initial Vitals: • Pulse 130• RR 32• BP not obtained due to inability to auscultate or palpate radial pulse• CAO-PPTE• SaO2- 100% on 15LPM NRB

History Continued

• PMHx (past medical history) HTN, Anxiety, Depression, FVL (Factor Five Leiden)

• Pt on Warfarin for FVL but stopped taking it one month prior due to financial/social reasons

• All extremities are blue/cold to touch (acrocynosis) cap refill delay of 10 seconds!!!!

TEACHING TOPICFactor V Leiden

FACTOR V LEIDEN

• Factor V is a natural and normal component of the blood clotting cascade• Helps to clot blood and works as an

anticoagulant to prevent clots

• Factor V Leiden was discovered as a gene mutation in Leiden, Netherlands in 1994

Mutation!!!• Not a disease• Most common hereditary

coagulation disorder• 5% of Caucasians• 1.2% African-American• Almost zero in

indigenous people of America, Asia, Australia

• Less then .5% of Hispanics

Field Concerns

• Those people who have this disorder have a much higher risk of blood clots (3-8 greater with one gene mutation and 30-140 times greater with two)

• Most people will not have any clotting issues

• Those at a high risk will be on anticoagulants like Warfarin

Now Where Did I Place That Clot?!?

• Lungs – Pulmonary Embolus• Heart – Myocardial Infarct• Brain – Stroke/Sinus Vein Thrombosis• Intestinal – Mesenteric Vein Thrombosis• Liver – Budd-Chiari Syndrome• Legs – Deep Vein Thrombosis

EMS

• Where there is one there may be many!• Pt that has Factor V Leiden disorder may have

more then one clot and will not always present with symptoms of each………

• Back to the Patient………

Interventions• TVFR established an IV (20G right AC)• Three attempts

• Pt placed on monitor – NSR• Lung sounds – clear and equal• Patient packaged up and transported

code 3 to St Vincent Hospital • Seems cut and dry…PE, right? Why are

his arms and legs blue though???????

More?

• Easy answer… one blood clot to the lungs and one to the femoral/radial arteries….• Chest Pn? Nope• Jaw Pn? Nope• H/A? Nope• Back Pn? Yep, also hematuria…..

ST Elevation!?!?!

• Lead II is showing slight elevation• (noticed by Tammy Schurter)

• 12 Lead EKG time…..• ST elevation noted in Lead II and precordial

Leads II, III, V, VI• Another clot…this one in the heart (AMI)

12 Lead Strip

Treatment Again….

• Aspirin (ASA) – Contraindicated by disorder• Nitro – He doesn’t have chest pain…….• Thrombolytic checklist• Treat with a little more diesel!!!!!!

TEACHING TOPICThrombolytics

What Is It?• Clot-busting drug• “Thrombo” –

Thrombosis• “lytic” – Destroy

What’s Going on Inside

How Does it Work?• Converts plasminogen into the active

enzyme plasmin• The plasmin acts on the fibrin to dissolve it• This restores the blood flow in the

occluded blood vessels• Must be done within a few hours because

the clot undergoes a hardening process, which makes it resistant to breakdown by plasmin

Illustration

Indications• Myocardial Infarction• Ischemic Strokes• Deep Vein

Thrombosis• Pulmonary Embolism• Clear Blocked

Catheters

Contraindications

• Hemorrhagic strokes• Active internal bleeding• CNS procedure or CVA within 2 months• Uncontrolled hypertension• MI due to aortic dissection• Aneurysm

Commonly Used Thrombolytics

• Streptokinase• Alteplase• Reteplase• Tenecteplase• Anistreplase

Streptokinase• Inexpensive

• First thrombolytic available

• Converts plasminogen into plasmin throughout the circulation

• Causes some type of allergic reactions in 5% of patients

Alteplase (tPA)• Expensive• Binds to fibrin at the site of the thrombus• Rate of re-occlusion is greatly decreased

when tPA is used with heparin• Mortality was better for tPA in the US while

no differences were found between streptokinase and tPA in other countries

Drug Administration

• Intravenous• Within the first ninety minutes, up to six

hours after the start of symptoms• Usually given in combination with an

anticoagulant (usually heparin)• Usually administered for 24-48 hours.

Thrombolytics At Work

• 75% of patients will attain reperfusion• Rate of re-occlusion is about 20%• 5% of patients will have some problem with

bleeding• 1% of these patients will have a serious

episode of bleeding• 0.5-1% will have an intracranial hemorrhage

Which to Use?• Hotly debated topic• Allergies• Cost• Drug availability• Convenience in

dosing

Why Thrombolytics Are Important

• Must be administered as soon as possible• Potential 48% reduction in mortality if

treatment is received within an hour of onset of symptoms

• Within the next five years may become a common prehospital drug

Prehospital Thrombolitics

• Used as a prehospital drug in many European countries• France, Netherlands, Belgium, UK

• There are currently studies in the US with participating ambulance services who are giving thrombolytics in the field• Miami, Florida• Atlanta, Georgia

Prehospital Thrombolytics in the US

• More difficulty in establishing, possibly due to liability issues

• Pooled data from 8,318 US patients in published series showed that prehospital thrombolysis was associated with a 17% relative reduction in mortality, compared with standard in-hospital thrombolysis

Sample Case

• Typical chest pain• Over 15 minutes• Less than 6 hours• Not responsive to NTG

• Typical ECG changes• ST segment elevation in two or more

continuous leads of over 1mm leads or 2 mm in chest leads

Sample Case Continued

• Absence of major contraindications

• Expected benefit greater than risk if “relative” contraindication are present

• Candidate for Thrombolytics

Monitoring the Patient• 80% of patients have chest pain resolution• 75% of patients have resolution of ST

segment elevation• Arrhythmias (PVCs or brief V-tach) often

occurs as blood reaches ischemic myocardium

• In patients with no signs of reperfusion nearly 50% will have cleared the thrombus

Results• 18% reduction in

death when thrombolytics are used after a heart attack

Call Continued……..

St Vincent ER!!!!• Assessment for PE• ECG repeated• Lab workup (Troponin level 8.2)• Chest x-ray• Medications given: Ativan, Metoprolol, ASA, Heparin Bolus• Echocardiogram/Cath Lab

ER Impressions…• Acute Coronary

Syndrome• Possible embolic

shower or apical thrombus

• Pt sent to cath lab then to Cardiac Care Unit……

Follow Up

• Cath lab – • Occlusion of proximal left anterior descending

artery• Mild proximal right coronary artery disease• Pt not considered a candidate for

Thrombolytics therapy!!!!!!!

Discharge summary

• Left Ventricular Thrombus

• Embolic Phenomenon to spinal cord

• Acute renal failure• Possible Bipolar

disorder• Pt goes home with no

neurological or sensory function deficits after 5 days in hospital

Questions?

Sources:• www-admin.med.uiuc.edu/hematology • www.factorfiveleidensupport.org/ • www.fvleiden.org/• http://en.wikipedia.org/wiki/Thrombolysis• www.rcr.ac.uk/index.asp?PageID=521• www.strokecenter.org/pat/thrombolytics.html• www.bchealthguide.org/kbase/topic/detail/

drug/hw100796/detail.htm