and orientated.
Airway
Clear.
Breathing
Increased rate and effort, no accessory muscle use.
Circulation
Slow strong radial pulse palpable, regular, capillary refill time <2 seconds.
Vital Signs
RR: 24 bpm
BP: 135/75 mmHg
SpO2: 93%
Blood glucose: 5.1 mmol/L
GCS: 15/15
Pupils equal and reactive to light (PEARL)
Colour/appearance: Pale, diaphoretic, almost grey/ashen in colour
Respiratory effort/rhythm: Increased effort, regular
Auscultate: Clear air entry both sides
Pulses: Strong radial pulses both sides
4 lead ECG: Sinus bradycardia at a rate of 40 (undiagnostic ST changes)
Exposure
Head‐to‐toe survey reveals no obvious injuries/deformities, no loss of sensation, poor skin turgor, dry mucosa, nil medical alerts.
TASK
Look through the information provided in this case study and highlight all of the information that might concern you as a paramedic.
1 Given the patient’s presentation and initial observation, what is a critical vital sign that assists in the diagnosis of the condition and needs to be acquired as soon as possible?A 12 lead ECG.
2 The patient is rolling in pain and unable to respond to the nurse’s questions. What strategies could you incorporate in your practice to ensure you gather all relevant information?Reassurance, the importance of which is often underestimated. This patient appears to be very unwell and it is vital that he is assessed thoroughly. This requires good communication and plenty of reassurance, while at the same time treating the underlying problem. Remember the patient is scared, he has never had chest pain before and is frightened of what might happen.
3 What history would you like from the patient?The patient appears to be having chest pain, so it is important to ascertain what type of chest pain this is. Cardiac chest pain can be fatal and needs to be treated and assessed appropriately. In this case we need to find out when the pain began, does anything make it better or worse, what it feels like, does it radiate anywhere, what is the quality of the pain, has he ever experienced this pain before and if so does he know what it was. Use the OPQRST mnemonic:Onset: What were you doing when the pain came on?Provocation: Does anything make the pain better or worse?Quality: How do you describe the pain?Radiation: Does the pain move anywhere?Severity: On a scale of 1–10, what number would you give the pain?Timing: How long have you had it?
4 What are some of the differential diagnoses for this patient?Trauma to the area – broken ribs, pneumothorax (tension).Pulmonary embolus.Muscle strain.Pericarditis.Myocarditis.Abdominal aortic aneurysm (AAA).Aortic dissection.
5 How would you treat this patient? (Use a bulleted list.)Pharmacology:Aspirin.GTN.Oxygen (to treat hypoxia).Antiemetic (anti‐sickness).Pain relief.Make the patient as comfortable as possible.Rapid removal to a cardiac cath lab.Lots of reassurance.Close monitoring for deterioration.Prepare for cardiac arrest.Thorough history taking.
LEVEL 3 CASE STUDY
Hyperkalemia
| Information type | Data |
| Time of origin | 14:30 |
| Time of dispatch | 14:31 |
| On‐scene time | 14:39 |
| Weather | 34 °C, very humid |
| Nearest hospital | 15 minutes |
| Nearest backup | CCP, 15 minutes |
| Patient details | Name: Steve Roberto DOB: 09/09/1965 |
CASE
You have been dispatched code 1 to the residence of a 55‐year‐old male who has been unwell for several days. He has collapsed and is not breathing.
Pre‐arrival information
The male is unconscious and his breathing is absent. CPR instructions are currently being provided over the phone.
Windscreen report
The house is a located in a low socioeconomic neighbourhood that is well known by your ambulance service for many different calls, including a fatal stabbing on your last run of shifts. There are several people gathering outside the house due to the commotion occurring inside. You are advised that the police have also been dispatched due to the location.
Entering the location
The residence appears safe, with no pets in the yard and a large driveway to the side of the house. You are met at the door by a very distressed female. She states that the patient is in the bedroom and their 18‐year‐old son is performing CPR. She is extremely anxious and yelling at you to ‘hurry up and do something’. She states that the patient has been very unwell for 5 days and has missed his appointments at the renal centre. You walk through a well‐kept house into the bedroom.
On arrival with the patient
The male patient has been moved to the floor, where the son is performing good‐quality CPR. You note the patient has significant swollen lower peripheries and scratch marks on his lower limbs.
Patient assessment triangle
General appearance
The patient is unresponsive, lying on the floor.
Circulation to the skin
Pale in colour, cool to touch.
Work of breathing
