Danger
The scene is still safe.
Response
Patient is alert and orientated.
Airway
The airway is clear. The patient is able to speak in full sentences. Nil blood or secretions coming from airway.
Breathing
There is breathing with spontaneous effort, equal rise and fall of chest, nil DIB, respiratory rate 28 respirations per minute – adequate ventilation.
Circulation
The circulation is weak with regular palpable radial pulses, nil obvious signs of haemorrhage.
Exposure
Increased respiratory effort, but talking in full sentences – mild shortness of breath (dyspnoea).
1 What is your treatment goal for this patient now? What hospital would you ideally like to transport the patient to?To successfully revert patient into normal sinus rhythm, improving cardiac output and subsequent perfusion. This can be achieved by attempting vagal manoeuvres. Should this fail, transport to hospital for further medical care is required. It would be expected that the patient be transported to a hospital with a cardiac unit/cardiology capabilities.
2 What types of questions would you ask this patient as part of your history‐taking process?See Table 2.3.
Table 2.3 History‐taking questions
| Signs and symptoms: Rapid pulse, pale, clammy, increased work of breathing, complains of mild nausea, palpitations (fluttering feeling in chest) Allergies: NSAIDs Medications: Nil reported Previous medical history: Nil reported Last meal: Breakfast at 07:00 – oats Events leading up to today: Witnessed collapse while running, normal water intake |
| Additional questioning Does the patient remember falling? If so, what caused the fall? Can the patient retain new information? Is there retrograde amnesia? Does the patient have a cardiac history (Hx)? What is your full name and DOB? Is there any family or emergency contact you’d like us to call? |
Case Progression
Despite two attempts at a modified Valsalva, the patient is now feeling short of breath, dizzy, nauseated, has chest pains and palpitations, and states he feels like he is going to pass out. You are unable to palpate a radial pulse and blood pressure is unrecordable.
1 What are your treatment priorities now and what interventions may be required to prevent further deterioration and cardiovascular collapse?In‐hospital treatments may include antiarrhythmic drugs such as betablockers or adenosine, which are often used to try to slow AVN conduction and induction of an intermittent AV block. Adenosine also has a short half‐life and works within 6–10 seconds, so its effects are short term. However, in this case the patient has no other treatments available pre‐hospital, so DC cardioversion should be initiated.
LEVEL 3 CASE STUDY
S‐T segment elevation myocardial infarction (STEMI)
| Information type | Data |
| Time of origin | 12:30 |
| Time of dispatch | 12:32 |
| On‐scene time | 12:40 |
| Weather | 24 °C, blue skies |
| Nearest hospital | 15 minutes (no cath lab) |
| Nearest backup | CCP, 10 minutes |
| Patient details | Name: Robert Henson DOB: 12/02/1950 |
CASE
You have been dispatched code 1 to a GP clinic to attend a 70‐year‐old male who has presented with chest pain.
Pre‐arrival information
The male is not a patient of the GP clinic, he is travelling through town and developed chest pain this morning and presented to the clinic. The clinic called 000 straight away as the patient does not look well.
Windscreen report
You know the GP clinic, it is well respected in your area.
Entering the location
You are greeted by the practice nurse, who states the male is not a patient of the practice, they do not have any records as he is from interstate. He walked into the practice holding his chest and looked very pale, so they called immediately. She has put him on their bed, she attempted to gain a history but he is in a lot of pain. The doctor has come in but is in the middle of an important patient procedure so has been unable to assess the patient. They attempted a 12 lead ECG but he won’t sit still.
On arrival with the patient
The patient is lying on a bed in some distress, his friend is next to him looking concerned.
Patient assessment triangle
General appearance
The patient is very pale in colour, diaphoretic, alert to you walking in the room, able to speak in sentences, holding his chest, unable to sit still.
Circulation to the skin
Very pale, almost ashen in colour.
Work of breathing
Slightly increased with the patient ‘puffing’ in pain every third breath.
SYSTEMATIC APPROACH
Danger
Nil.
Response
Alert
