T (time): Patient reports sudden sharp pain developed 2 weeks ago, but he didn’t think it was enough to seek medical attention. Approximately 4 hours ago pain suddenly increased to severe.
Vital signs
RR: 26 bpm
HR: 120 bpm
BP: 126/78 mmHg
SpO2: 98%
Blood glucose: 6.2 mmol/L
Temperature: 38.4 °C (tympanic thermometer) – warm to touch
12‐lead ECG: Sinus tachycardia at a rate of 120 with global ST elevation. QRS width = 0.12 seconds, no further abnormalities detected
Allergies: Benzylpenicillin
TASK
Look through the information provided in this case study and highlight all of the information that might concern you as a paramedic.
1 What is your initial diagnosis for this patient?The clinical presentation is suggestive of pericarditis. The patient has ECG changes indicative of pericarditis. Patient is febrile with recent viral illness. The 12 LEAD ECG = global or widespread ST elevation and PR depression throughout most of the limb leads (1, 2, 3 and aVL) and reciprocal ST depression and PR elevation in lead aVR.
2 What are some differential diagnoses that you may be considering?Differential diagnoses: myocarditis, benign early repolarisation, STEMI (occlusive myocardial infarction, OMI), pleurisy, chest infection, pleural effusion, pericardial tamponade, pneumothorax (spontaneous/tension), gastric reflux, recent chest trauma, pulmonary embolus (PE), muscle strain, abdominal aortic aneurysm.
3 Identify several causes of pericarditis. (Look up and list as many as you can.)Infections (mainly viral).Immunological – SLE, rheumatic fever.Uraemia.Dressler’s syndrome.Trauma.Following cardiac surgery.Drug induced.Illicit drug use.Post‐radiotherapy.
4 From the following, which best identifies pericarditis?Retrosternal chest pain (generally sharp/burning and often exacerbated by lying supine).Signs of infection (fever, rigors, rash, diarrhoea, vomiting, malaise).Shortness of breathing (particularly when lying flat).ECG changes (specifically PR depression, Spodick’s sign, global ST elevation).All of the above.e. All of the above (these signs can be found in isolation or can all be present during assessment).
5 Which of the following is your treatment goal for this patient?Reassurance, keep the patient in a position of comfort. Adequate analgesia, using paracetamol and opioids if required. Keep patient monitored. AJPIR (assessment, judgement, planning, implementation, reassessment).Non‐steroidal anti‐inflammatory drugs (NSAIDs) – aspirin, ibuprofen etc.Rapid removal to hospital.IV access, 12 lead ECG, oxygen and elevate legs.a. Reassurance, keep the patient in a position of comfort. Adequate analgesia, using paracetamol and opioids if required. Keep patient monitored. AJPIR (assessment, judgement, planning, implementation, reassessment).
Case Progression
Your patient states he is now feeling tired and is finding it hard to breathe. He feels dizzy and nauseated. You notice that he wants to lie down and appears pale. He is now cool to touch and clammy.
Patient assessment triangle
General appearance
The patient is alert but confused, he looks anxious and wants to lay supine. He is pale and clammy, but is able to speak in full sentences.
Circulation to the skin
Slightly pale and clammy. Cool to touch. Weak radial pulses palpated.
Work of breathing
Increased work of breathing. Air entry = L/R clear, nil adventitious sounds. Respiratory rate is now 30.
SYSTEMATIC APPROACH
Danger
The scene is still safe.
Response
Patients is alert but is now confused.
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, some DIB observed, respiratory rate increased to 30 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).
Vital signs
RR: 30 bpm
HR: 150 bpm
BP: 90/62 mmHg
SpO2: 88% on room air
Temperature: warm to touch
12 lead ECG = Sinus tachycardia at a rate of 150 with S‐T segment elevation in all leads. QRS width = 0.12 seconds, QRS appears to be half the amplitude of the original ECG.
1 It is apparent that the patient is deteriorating. What type of shock is the patient in?Distributive.Hypovolemic.Cardiogenic.Obstructive.d. Obstructive. Pericardial tamponade causes an obstructive shock, as the myocardium can no longer adequately pump blood due to being restricted by an excessive build‐up of fluid in the pericardial sac surrounding the heart.
LEVEL 2 CASE STUDY
Narrow complex tachycardia
| Information type | Data |
| Time of origin | 16:55 |
| Time of dispatch | 17:00 |
| On‐scene time | 17:08 |
| Day of the week | Friday |
| Nearest hospital | 20 minutes |
| Nearest backup | CCP, 15 minutes |
| Patient details | Name: Steve Whitefield DOB: 05/09/1982 |
CASE
You have been called to a public address for a 38‐year‐old male who was witnessed to be running along a footpath when he suddenly collapsed.
Pre‐arrival information
The patient is now conscious and breathing, complaining of palpitations and shortness of breath (SOB).
Windscreen