The patient’s condition continues to improve en route to the hospital. With an estimated time of arrival at the ED of 20 minutes, you begin an IV infusion of nitroglycerin at 10 µg/min and perform an ongoing assessment (Table IV). Within 10 minutes, the patient tells you that the pressure in his chest has improved and is now a “3” on a 0–10 scale. Because three doses of nitroglycerin failed to relieve his pain, you administer 2 mg of morphine sulfate via IV push. Reassessment of his blood pressure reveals a reading of 140/88 mmHg. En route to the hospital, you continue oxygen therapy and successfully establish an IV of normal saline with an 18-gauge catheter. You place him on the stretcher and load him into the ambulance. The patient’s chest pressure is unrelieved following two more doses of sublingual nitroglycerin. Last oral intake: “I ate supper last night, but can’t remember the exact time.”Įvents leading to the present illness: “I was asleep when the pressure in my chest woke me up.” How could this patient’s current blood pressure and heart rate affect his condition? He gave me the nitro to take when I have chest pain.” Pertinent past history: “I have high blood pressure and the doctor told me I may have a heart attack if I don’t startĮxercising. Medications: Nitroglycerin (as needed) and Vasotec. Signs and symptoms: Chest pressure, restlessness,Īllergies: None. Respirations: 22 breaths/min and unlabored. Pulse: 112 beats/min, strong and regular. As your partner stands up to retrieve the stretcher from the ambulance, you tell him that it looks as though the patient may be having an anterior wall MI. You attach the patient to a cardiac monitor and interpret his cardiac rhythm as sinus tachycardia at 110 beats per minute.Īfter administering 0.4 mg of nitroglycerin sublingually to the patient, you and your partner attach the remaining ECG leads and obtain a 12-lead tracing of the patient’s cardiac rhythm. The patient remains conscious and alert, but is becoming increasingly restless. Your partner obtains baseline vital signs and a SAMPLE history (Table III). What are the physiologic effects of nitroglycerin?Īfter confirming no history of bleeding disorders or allergies, you administer 324 mg of aspirin to the patient. Interventions prior to EMS arrival: None.Ĭhest exam: No sign of trauma, chest wall is symmetrical and nontender.īreath sounds: Clear and equal bilaterally to auscultation. Time of onset: “This began about an hour ago.” Radiation/Referred: “The pressure stays in my chest. Nothing that I do makes it better or worse.” Provocation/Palliation: “This pressure in my chest isĬonstant. Level of consciousness: Conscious and alert to person, place and time restless and anxious.Ĭhief complaint: “My chest feels tight and I feel really weak.”Īirway and breathing: Airway is patent respirations are slightly increased and unlabored.Ĭirculation: Radial pulse is rapid, strong and regular skin is cool, clammy and pale. The patient tells you that his doctor prescribed nitroglycerin for him however, because he recently moved into the house, he thinks it’s still packed in one of the boxes. Your partner administers 100% oxygen to the patient with a nonrebreathing mask while you perform a focused history and physical examination (Table II). Your partner attaches a pulse oximeter and prepares to administer oxygen to the patient. You sit the patient down and perform an initial assessment (Table I). What is the significance of the patients clenched fist in the center of his chest? You note that he is diaphoretic and anxious, and is clenching his fist against the center of his chest.ġ. A middle-aged male answers the door and identifies himself as the patient. You arrive at the scene, don appropriate BSI precautions and ensure that the area is safe, then knock on the door of the patient’s residence. The closest hospital from the scene is 40 miles away. You and your partner proceed to the scene, with a response time of approximately eight minutes. Use this case study as an educational tool by answering the questions posed by the author, then reviewing the answers further down.Īt 6:45 a.m., your unit is dispatched for a 50-year-old male with chest pain.
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