Advanced Clinical Insights and Practice: Ischemic Heart Disease

This issue sees the debut of a new series of continuing education articles. The series, Advanced Clinical Insights & Practice, is designed to provide continuing education to an ever-expanding realm of paramedicine that needs more of it: the critical care transport paramedic. Secondly, and equally important, are the benefits that can be reaped by other certification levels reading this feature. For EMT-Basics and Intermediates, it will provide a great enhancement to your core knowledge, although most of the interventions discussed will be beyond your traditional scope. For paramedics, it will augment both your pathophysiological understanding and clinical assessment/management skills of diseases and injuries discussed. Ultimately though, it is hoped that anyone who reads these articles will become a better clinician. The next article will appear in the July issue.

CEU Review Form Advanced Clinical Insights & Practice: Ischemic Heart Disease (PDF)Valid until May 2, 2008

     Ischemic heart disease (IHD) is the leading cause of death in the United States for both men and women. The worst manifestation of IHD is a myocardial event that leads to infarction and death. Up until the last five years or so, it was thought that primarily males suffered from IHD; however, the diagnosis of acute myocardial infarction (AMI) is becoming more common in women, with an incidence approaching that of males. Often, female patients with chest pain were diagnosed with panic attacks, anxiety, hormonal changes and other diagnoses. Today, IHD kills more women than breast cancer, but public outcry and recognition are much larger for the latter.

CASE STUDY
     You are a critical care paramedic working with an EMT-Basic and CCRN nurse as part of a critical care transport team. Your team is activated as the station's alert tones go off. Data provided on your pager indicates a woman is experiencing an MI in a nearby urgent care center and is to be transported immediately to the sponsoring medical center's cardiac catheterization laboratory, where an interventional cardiac catheterization team and cardiologist will be awaiting your arrival. Within 15 minutes of your alert, you pull the mobile MICU unit up to the doors of the referring facility and walk into the emergency department. Your first impression of the patient reveals a diaphoretic, 145 kg woman in her mid 40's, who looks very anxious and uncomfortable. She is moving around in the bed, complaining of "stomach gas" that she can't pass. You glance at the bedside monitoring equipment, which shows a heart rate of 112 bpm, blood pressure of 128/86, MAP of 100 mmHg, SpO₂ of 92% on 4 lpm. The bedside 3-lead ECG shows a sinus tachycardia without ectopy in Lead II. After speaking to the patient to ensure the adequacy of the airway, breathing and circulatory components, your CCRN partner begins to switch over monitors and you go to find the referring physician.

     You learn that the patient has smoked two packs of cigarettes a day for the past 20 years, and suffers from HTN and COPD. She is not allergic to anything, and you only get a partial list of her medications. You review the 12-lead ECG and note ST elevation in V2, V3 and V4, with reciprocal changes in the inferior leads. The nursing staff has inserted two intravenous catheters, with one capped and the other infusing normal saline. A urinary catheter is also already in place. Finally, you learn that her cardiac enzymes, blood work and chest x-ray results will be sent electronically to the medical center and arrive much sooner than you will.

     You and your partner quickly apply the pacing/defib pads, along with a portable 12-lead ECG, NIBP, SpO₂ monitor and EtCO₂ monitor, and hang a bag of normal saline to the capped IV site. You increase the oxygen to 15 lpm via mask, and secure the patient and equipment to your cot. After the family says their good-byes to the patient, you're out the door and on the way to the receiving hospital.