Hold That Epi!

      Attack One responds to a call for a woman having an allergic reaction. This has been a frequent call this summer, with the bee population increasing and the hot, dry conditions. The lady's 10-year-old daughter meets the crew at the door and guides them to a woman sitting at the kitchen table. They notice she is in mild distress, with beads of sweat on her forehead. She describes being very light-headed and a little short of breath. They apply some oxygen and prepare a small syringe with some epinephrine.

   The lady is 41, and the paramedic finds her perfusing well, with an elevated blood pressure and normal pulse rate. She is speaking clearly, and says she's having no trouble breathing. She relates developing a sore throat that started about an hour ago while she was outside mowing grass. She was sweaty when she came inside, and her throat hurt, so she took a penicillin pill her husband had been given a couple of months earlier for strep throat. She believed the sweating was due to a fever. Getting worse, she felt she must be having a reaction to the penicillin, although she had taken it many times before without problems. She has no other allergies. When asked, she reports no chest pain, palpitations, loss of consciousness, nausea or vomiting. Her past medical history includes only high blood pressure and a tubal ligation; her last menstrual cycle was three weeks ago and normal.

   The paramedic examines the patient and notes she's now diaphoretic only around her head--she'd said it was over her entire body when she first noticed it. She is breathing normally, with no distended neck veins, clear lungs, a regular heartbeat, no rash or signs of trauma, and no edema in her feet. Her blood pressure is up a little, but other vital signs are normal.

   "Ready for the epi?" the other crew member asks the medic.

   "I don't think she needs it," the medic replies. "She's perfusing well and doesn't give any other indication she's having a major allergic reaction. Vitals are stable, no swelling of the mucous membranes, and clear lungs. I don't think she'll benefit from it."

   Instead, the paramedic is now concerned about why the woman got so sweaty, and why her throat hurts. She denies being diabetic, and her fingerstick blood sugar is 92. Her throat is still painful, she says, but when the medic examines her, there is no redness, enlargement of lymph nodes or difficulty swallowing. When pressed to describe the pain, she says it's like a tightness in her throat. It has not changed since taking the penicillin, nor has the sweating.

   The paramedic recalls that diaphoresis is associated with hypoglycemia and acute myocardial ischemia, and he's already ruled out a blood sugar issue. He tells the patient he's concerned that her symptoms could be from something other than an allergic reaction, which is why he checked her blood sugar and now wants to do an EKG. She says she's never had an EKG done, but knows what it is--many of her family members have heart disease. The female crew member assists in placing the 12 leads, and the paramedic is surprised as the machine prints out an EKG that is interpreted as acute MI.

   He quickly reads the EKG himself, finding a normal sinus rhythm and ST segment elevation in the inferior leads, II, III and aVF. The anterior leads have reciprocal changes. The paramedic then turns to the patient. "I'm concerned the problem you're having isn't related to the medicine, but is from your heart," he starts. "Although you have no chest pain, the heart tracing shows you may be having a problem related to an area of your heart not getting enough blood. You're doing well right now, but we need to take you to a hospital that specializes in heart care, and the doctors will read our EKG again and do some other tests to see if there is, in fact, a heart problem. Your vital signs are stable, we're going to keep you on a heart monitor and some oxygen, and give you an aspirin, because you're not allergic to it and it's helpful to patients having heart problems."

   The patient is surprised by the news but understands the explanation. She volunteers that people in her family have had heart problems, but they all had chest pain. She continues to deny having that.

   As the crew puts her on the monitor and oxygen and she swallows the aspirin, the paramedic calls the ED with a report. They move to the medic for transport to a hospital with a cardiac intervention unit. En route, the patient says her sore throat is gone.

Hospital Management

   The ED is prepared by the time the patient arrives. Her initial EKG is reviewed again by the paramedic and the emergency physician, and another is performed. The EKG done in the ED is completely normal. The physician examines the patient, who again reports no chest discomfort, diaphoresis or shortness of breath. The EMS EKG is shown to the cardiologist, who orders preparations for the patient to go to the cardiac intervention unit for catheterization. Although she is completely symptom-free in the ED, with a normal EKG, her acute symptoms and the abnormal EKG obtained by the paramedic indicate a high-risk patient. The catheterization is performed 30 minutes after arrival, and the patient is found to have two critical coronary artery lesions, one of which had clearly caused her symptoms. Both are opened, and stents placed. The patient is released the next day. She and the cardiologist both send notes of gratitude to the Attack One crew for suspecting something beyond the initial complaint, and identifying an acute coronary syndrome.

Case Discussion

   This incident demonstrates the wide net that is cast in evaluating patients for acute myocardial infarction. Emergency providers, both prehospital and in the emergency department, have noted a changing presentation of acute coronary syndromes (ACS), which include acute MI. The term is now used globally to refer to symptoms beyond just chest pain. The American Heart Association has initiated an educational program that teaches patients about the range of symptoms that may represent a sudden or worsening heart problem. EMS providers should be knowledgeable about the expanded nature of presenting complaints that may indicate cardiac ischemia.

   Acute coronary syndrome is an umbrella term used to describe a group of clinical symptoms compatible with acute myocardial ischemia due to insufficient blood supply to the heart muscle. This usually results from coronary artery disease. Patients who have symptoms of ACS or are suspected of having acute myocardial ischemia should have 12-lead EKGs performed, which may or may not show ST segment elevation. Patients who have discomfort (particularly with exertion) without ST segment elevation may have unstable angina. Thus ACS refers to the spectrum of clinical conditions ranging from unstable angina to acute ST segment-elevation myocardial infarction (STEMI).

   It is likely that most ACS cases now present with symptoms that do not include chest pain. These may include:

• Discomfort in the upper body, from groin to jaw. The patient may describe uncomfortable pressure, squeezing, fullness or pain, and it may be directly related to exertion. The discomfort can occur in either arm, the back, neck, jaw or abdomen;
• Shortness of breath not typical for the patient;
• Diaphoresis;
• Syncope or light-headedness;
• Sudden-onset nausea or vomiting;
• Palpitations.

   Physical evaluation of a potential ACS patient will focus on the cardiovascular system, to include blood pressure, pulse rate and regularity, evidence of respiratory distress, and indicators of overall perfusion. A very important symptom to ask for and physical finding to examine for is diaphoresis. Diaphoresis indicates a sudden release of catecholamines from the adrenal glands, and is a consistent finding in patients having hypoglycemic insulin reactions or acute coronary syndromes. As in this case, it may be the only physical finding that indicates an ACS condition.

   Once a patient has been evaluated--in many systems that includes a 12-lead EKG--medical protocols may call for removal to a hospital capable of providing interventional services to reverse myocardial ischemia and prevent or minimize myocardial infarction. A system that has such a program will preferentially remove suspected ACS patients to that hospital's emergency department, where many forms of testing may be utilized to identify the heart problem. From there, the patient may be transferred up to the hospital's cardiac intervention unit (often called the cath lab) for further evaluation and any necessary treatment.

   Several elements of care combined to save this patient's life. The paramedic recognized that she was sweaty and, after confirming a normal blood sugar and no history of diabetes, considered an acute coronary syndrome. The 12-lead EKG found ST segment elevation in the inferior leads, she was given aspirin and oxygen, and her symptoms resolved completely. Her EKG changes had completely disappeared by the time she arrived in the ED, so if the crew had not performed the electrocardiogram, her disease process would likely not have been found.

   The crew did not give the patient the epinephrine that ordinarily would be administered for an allergic reaction. That would likely have been a disaster in this patient, considering her critical coronary artery disease. The patient's clinical status did not indicate an acute allergic reaction and she was perfusing well, so they deferred the epi, and further diagnostic work led to the real problem. The patient's taking a penicillin dose also could have led the EMS crew astray.

Initial Assessment

A 41-year-old female complaining of light-headedness and sweating, which she believed was an allergic reaction to medication.

Airway: Intact and uncompromised.

Breathing: No distress, but mild dyspnea.

Circulation: Normal capillary refill, pink skin. Slightly diaphoretic. Neck veins not distended.

Disability: No neurologic deficits.

Exposure of Other Major Problems: Patient had taken one of her husband's penicillin pills for her fever and throat pain.

Vital Signs

AMPLE Assessment

Allergies: None prior, but believes her symptoms are related to an allergic reaction to penicillin.

Medications: Vasotec.

Past Medical History: Hypertension. Family history of coronary artery disease, but patient has had no chest pain or prior cardiac workup.

Last Intake: Lunch three hours ago.

Event: Acute ST segment-elevation myocardial infarction (STEMI).

12-lead EKG: Normal sinus rhythm. ST segment elevation in the inferior leads (II, III and aVF).

Customer Service Opportunity

When considering a cardiac etiology for a patient's symptoms, it is critical to communicate to the patient and their family only what you know and why you're making decisions about care and transport. It will be very concerning to those individuals when you tell them you're concerned about a heart problem, possibly including a heart attack, being behind the patient's symptoms. Many won't believe there can be heart problems without chest pain, and will have questions about why treatment is being done when classic symptoms aren't present. When a patient is being removed to a hospital capable of cardiac intervention because of their symptoms and prehospital EKG findings, it is even more important to explain. Fortunately, in some patients, the ED workup for ACS will be negative, and the patient will be able to go home or receive care for another, less frightening medical problem. That patient will want to remember that the EMS crew that helped them had appropriate concern for a cardiac problem, but didn't frighten the patient by telling them, "This is a heart attack!"

Beyond the 'Big One': Signs and Symptoms of Heart Attacks

Not all heart attacks, the American Heart Association warns people, are "movie" heart attacks—the sudden, dramatic, chest-clutching, make-no-mistake kind seen in popular entertainment. Most actually start slowly, with mild pain or discomfort. This often leaves people unsure what's happening and waiting too long to seek help.

Symptoms to look for include:

• Discomfort in the center of the chest that lasts more than a few minutes, or stops and starts. This may feel like pressure, squeezing, fullness or pain.
• Discomfort elsewhere in the upper body, such as arms, back, neck, jaw or stomach.
• Shortness of breath, with or without chest discomfort.
• Other signs may include cold sweat, nausea or light-headedness.

Women are somewhat more likely than men to experience symptoms other than chest pain/discomfort, particularly shortness of breath, nausea/vomiting, and back or jaw pain. For more: www.americanheart.org. --JE

Learning Point

Emergency care providers, both prehospital and in the ED, have noted changing presentations of ACS patients. Evaluate patients in ACS presentations for a wide range of symptoms and treat appropriately, including transport to a hospital that can provide interventions for acute myocardial infarctions.

James J. Augustine, MD, FACEP, is medical advisor for Washington Township Fire Department in the Dayton, OH, area. He is director of clinical operations at EMP Management in Canton, OH, a clinical associate professor in the Department of Emergency Medicine at Wright State University in Dayton, and an editorial advisory board member for EMS World. Contact him at jaugustine@emp.com.