Another one

[Paseo Del Norte]

I thought I would present an interesting case based on one of my Afghanistan experiences. I'll see what you guys think.

You are pulling clinic duty out in the middle of nowhere when a 36 year old male presents to the clinic with complaints of sudden onset chest pain.

He is alert, awake, and oriented with a patent airway.

Pmhx: appy about 5 years ago
No allergies/intolerances, no meds, smoker about 10 pack years, 2-3 drinks a night, dad has DM
HPI: Sudden onset chest pressure about 10 minutes ago while entering data on his computer, first time he's ever felt this way, no C/O stress or anxiety, "just started all the sudden."
ROS: anxious, complains of chest pressure at about 7/10, otherwise unremarkable
VS: p-94 rrr, 22 non laboured, 160/88, 97% RA,
PE: Fairly unremarkable, lungs clear, S1S2, no JVD or edema, belly soft and non tender, neuro status intact, obese with a BMI ~ 30

It's a small clinic and you have a fully stocked ALS equipped ambulance. You can evac to a military hospital about 30 minutes away depending on Kabul traffic, but risk versus benefit is a big deal due to security concerns. The hospital is reasonably well equipped with labs, xray, ct, and even ICU facilities. Cath lab is a 6 hour flight via King air 200 to Dubai and about 3 hours via a Hawker 950.

Ask, discuss, and I will try to fill in details.

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[pianoman511]

OK - i'll bite. CXR & EKG results ?

 

[Paseo Del Norte]

Not his exact ECG, but exactly what his XII looked like.

No radiology resources at your clinic, but you have those resources at the military hospital.

 

[pianoman511]

Lab facilities available at the clinic ?

 

[Paseo Del Norte]

A local can run labs out for you and you may have results by the late afternoon. You can always risk an ambulance run to the military hospital.

 

[pianoman511]

Hmm.....obviously a LBBB which complicates things a great deal. It's a bit hard to r/o a MI with the LBBB obscuring any overt ST elevations. For a smoker I would always tend to rule in the possibility of a PE but with a good O2 sat and no complaints (per se) of SOB and the addition of a history of regular ETOH, family hx of DM, obesity, and the smoking I would go with a further workup for MI since the LBBB could be secondary to myocardial damage. For the short term, I would definitely say give nitro titrated to pain relief/BP and recheck 12 lead. Bottom line though, if you roll the dice and just go with tx to the military hospital for labs (CKMB, Troponin, etc) and they come back positive you still have the 3-6 hour flight for cath lab.

 

[Paseo Del Norte]

Yeah, new or presumably new onset LBBB with his symptoms and I proceeded to treat as an ACS.

1) gave supplemental oxygen
2) placed an iv
3) ASA 325 mg chewed
4) GTN 400 mcg SL
5) metoprolol 5 mg slow iv

Also did evac him to the military hospital. Pt had complete resolution of his symptoms on the way over. Following arrival; remained symptom free, cardiac workup was negative, chest x-Ray was unremarkable and coags were unremarkable including a D-Dimer.

What do you think?

 

[pianoman511]

Hmm.....did the LBBB persist ?

My initial reaction is take the easy way out and just go with Prinzmetal's angina, but again - that's the easy way out.

 

[Paseo Del Norte]

Repeat XII Lead:

 

[pianoman511]

Any chance that an echo was done as part of the workup ? If not then I am sticking with my guess above (either that or cocaine )

 

[Paseo Del Norte]

No echo at the point of care facility, but a random act of quantum trickery allows you to extract information from the future, and you are assured that the echo would be unremarkable.

 

[malkboy]

Just curious, but do field clinics carry i-STATs or other POC testing equipment.

I also suspect prinzmetal's angina primarily based on 12 lead, (-) cardiac enzymes, suggestive hx, and relief by nitro, etc.

Did they do a stress test?

 

[Paseo Del Norte]

Perhaps some do, BGL was the only POC test we had. Prior to my going home, there was talk about letting us have an I-STAT with our Medevac kit, mainly for patients on ventilators.

You guys nailed the diagnosis. The patient was eventually diagnosed with variant angina out of theatre. I hope you guys enjoyed the case. I was always taught that ST elevation is a typical finding, so it was interesting to see a case where a transient LBBB was noted on the XII lead.