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Triage and Management of Acute Myocardial Infarction in a Military Support Hospital
TRIAGE DECISIONS
Triage and Management of Acute Myocardial Infarction in a Military Support Hospital Author: CPT John S. Kerns, BSN, Bagdad, Iraq Section Editor: Patricia Kunz Howard, RN, PhD, CEN
John S. Kerns is Captain, U.S. Army Nurse Corp, 10th Combat Support Hospital, Baghdad, Iraq. For correspondence, write: CPT John S. Kerns; E-mail: [email protected]. J Emerg Nurs 2007;33:87-8. Available online 6 December 2006. 0099-1767/$32.00 Copyright n 2007 by the Emergency Nurses Association. doi: 10.1016/j.jen.2006.10.001
A
35-year-old female contractor presented at the entrance of a major military combat support hospital in Iraq. She was found lying in the front seat of a pick-up truck, alert, complaining of nausea, headache, and pain between her shoulder blades. The patient denied any chest pain at the time of presentation but stated that the pain in her back had begun several days before. Medical history was negative except for a 10-pack-per-year smoking history. She had an administrative job, lived an active lifestyle, and was taking no medications at the time of presentation. Initial physical impression revealed an anxious-appearing pale woman who was diaphoretic. The triage decision was to bring the patient into the emergency treatment area for monitoring and further evaluation. Two large-bore intravenous lines were established and blood was drawn for a complete blood cell count, chemistries, coagulation studies, and a cardiac profile. Initial vital signs were as follows: blood pressure, 93/60; pulse, 76; respiratory rate, 28; and oxygen saturation, 100% on nonrebreather mask. An EKG was done, and it revealed ST segment elevation in the inferior leads (Figure 1). The patient was placed into a monitored bed, at which time aspirin by mouth was given. She maintained her airway and remained alert during the evaluation.
Medical history was negative except for a 10-pack-per-year smoking history. Within 30 minutes of transfer to the monitored bed, the patient’s rhythm was witnessed to change to ventricular tachycardia with subsequent cardiac arrest (Figure 2). The patient was immediately defibrillated with 200 joules and converted to sinus tachycardia with multifocal premature
February 2007
33:1
JOURNAL OF EMERGENCY NURSING
87
TRIAGE DECISIONS/Kerns
FIGURE 1
Baseline EKG. FIGURE 2
ventricular ectopy. Following defibrillation, the patient was given 1 g of magnesium sulfate intravenously and 100 mg of lidocaine intravenously, which resolved the premature ventricular beats. A lidocaine drip was initiated at 1 mg per minute with a no further ventricular ectopy noted. Morphine was given for continued pain between her shoulder blades. Weight-based doses of enoxaparin sodium and tenecteplase were administered. The patient was diagnosed with acute inferior myocardial infarction and transferred to the ICU within the hour. She was later f lown to another medical facility in Europe where she underwent cardiac catheterization, which showed blockage in the right coronary artery and the circumflex branch of the left coronary artery. The patient was later discharged after stent placement.
Within 30 minutes of transfer to the monitored bed, the patient’s rhythm was witnessed to change to ventricular tachycardia with subsequent cardiac arrest. This case of atypical cardiac pain in a healthy woman can easily be overlooked by the patient or the emergency nurse at triage resulting in treatment delays. This case underscores the need to be vigilant in assessment of female patients with thorax pain. The clinical presentation for acute coronary syndromes in women often is not consistent with what is considered the ‘‘classic cardiac presentation.’’
88
Second EKG.
Approximately 20% of persons diagnosed with acute myocardial infarction do not have chest pain, and on average, they delay seeking medical attention for 2 hours or more after onset of chest pain.1,2 Through community education and a thorough assessment and patient history at the time of triage, an impending cardiac event can be treated in a timely manner and perhaps prevented.
. . .she underwent cardiac catheterization, which showed blockage in the right coronary artery and the circumflex branch of the left coronary artery. REFERENCES 1. Sheehy’s emergency nursing principles and practice. 5th ed. St. Louis: Mosby; 2003. p. 465. 2. Tintinalli JE, Kelen GD, Stapczynski JS. Emergency medicine: a comprehensive study guide. 6th ed. New York: McGraw-Hill; 2004. p. 350.
Submissions to this column are welcomed and encouraged. Submissions may be sent to: Patricia Kunz Howard, RN, PhD, CEN [email protected]
JOURNAL OF EMERGENCY NURSING
33:1
February 2007
Triage and Management of Acute Myocardial Infarction in a Military Support Hospital Author: CPT John S. Kerns, BSN, Bagdad, Iraq Section Editor: Patricia Kunz Howard, RN, PhD, CEN
John S. Kerns is Captain, U.S. Army Nurse Corp, 10th Combat Support Hospital, Baghdad, Iraq. For correspondence, write: CPT John S. Kerns; E-mail: [email protected]. J Emerg Nurs 2007;33:87-8. Available online 6 December 2006. 0099-1767/$32.00 Copyright n 2007 by the Emergency Nurses Association. doi: 10.1016/j.jen.2006.10.001
A
35-year-old female contractor presented at the entrance of a major military combat support hospital in Iraq. She was found lying in the front seat of a pick-up truck, alert, complaining of nausea, headache, and pain between her shoulder blades. The patient denied any chest pain at the time of presentation but stated that the pain in her back had begun several days before. Medical history was negative except for a 10-pack-per-year smoking history. She had an administrative job, lived an active lifestyle, and was taking no medications at the time of presentation. Initial physical impression revealed an anxious-appearing pale woman who was diaphoretic. The triage decision was to bring the patient into the emergency treatment area for monitoring and further evaluation. Two large-bore intravenous lines were established and blood was drawn for a complete blood cell count, chemistries, coagulation studies, and a cardiac profile. Initial vital signs were as follows: blood pressure, 93/60; pulse, 76; respiratory rate, 28; and oxygen saturation, 100% on nonrebreather mask. An EKG was done, and it revealed ST segment elevation in the inferior leads (Figure 1). The patient was placed into a monitored bed, at which time aspirin by mouth was given. She maintained her airway and remained alert during the evaluation.
Medical history was negative except for a 10-pack-per-year smoking history. Within 30 minutes of transfer to the monitored bed, the patient’s rhythm was witnessed to change to ventricular tachycardia with subsequent cardiac arrest (Figure 2). The patient was immediately defibrillated with 200 joules and converted to sinus tachycardia with multifocal premature
February 2007
33:1
JOURNAL OF EMERGENCY NURSING
87
TRIAGE DECISIONS/Kerns
FIGURE 1
Baseline EKG. FIGURE 2
ventricular ectopy. Following defibrillation, the patient was given 1 g of magnesium sulfate intravenously and 100 mg of lidocaine intravenously, which resolved the premature ventricular beats. A lidocaine drip was initiated at 1 mg per minute with a no further ventricular ectopy noted. Morphine was given for continued pain between her shoulder blades. Weight-based doses of enoxaparin sodium and tenecteplase were administered. The patient was diagnosed with acute inferior myocardial infarction and transferred to the ICU within the hour. She was later f lown to another medical facility in Europe where she underwent cardiac catheterization, which showed blockage in the right coronary artery and the circumflex branch of the left coronary artery. The patient was later discharged after stent placement.
Within 30 minutes of transfer to the monitored bed, the patient’s rhythm was witnessed to change to ventricular tachycardia with subsequent cardiac arrest. This case of atypical cardiac pain in a healthy woman can easily be overlooked by the patient or the emergency nurse at triage resulting in treatment delays. This case underscores the need to be vigilant in assessment of female patients with thorax pain. The clinical presentation for acute coronary syndromes in women often is not consistent with what is considered the ‘‘classic cardiac presentation.’’
88
Second EKG.
Approximately 20% of persons diagnosed with acute myocardial infarction do not have chest pain, and on average, they delay seeking medical attention for 2 hours or more after onset of chest pain.1,2 Through community education and a thorough assessment and patient history at the time of triage, an impending cardiac event can be treated in a timely manner and perhaps prevented.
. . .she underwent cardiac catheterization, which showed blockage in the right coronary artery and the circumflex branch of the left coronary artery. REFERENCES 1. Sheehy’s emergency nursing principles and practice. 5th ed. St. Louis: Mosby; 2003. p. 465. 2. Tintinalli JE, Kelen GD, Stapczynski JS. Emergency medicine: a comprehensive study guide. 6th ed. New York: McGraw-Hill; 2004. p. 350.
Submissions to this column are welcomed and encouraged. Submissions may be sent to: Patricia Kunz Howard, RN, PhD, CEN [email protected]
JOURNAL OF EMERGENCY NURSING
33:1
February 2007