NASCAR Fan Presents with Significant Chest Pain and Numbness

 

 
 
 

John McCarthy, DO, FACEP | Marianne Kostenbader, RN, BSN, CEN, PHRN | Michael Wargo, RN, MBA, BSN, PHRN, CMTE | From the May 2013 Issue | Thursday, May 9, 2013


Of the 36 NASCAR races held each year, two of them take place at the Pocono Raceway located in Long Pond, Pa. During each race in this rural mountainous location within the Poconos, the racetrack becomes the third largest city in the state with 110,000–130,000 fans in attendance.

Lehigh Valley Health Network (LVHN) provides medical services and EMS needs for both fans and the NASCAR drivers. The medical staff includes 68 EMS providers, 32 nurses, six physicians, 16 ambulances, and one air medical helicopter on site with three additional helicopters readily available should back-up be required. Many of the nurses and physicians staffing these events are also EMS providers.

Providers working the track see an average of 370 patients during each of the two, three-day-long NASCAR races held at the raceway. Transport from Pocono Raceway to LVHN, in Allentown, Pa. is 54 miles with a one-hour ground transport time vs. 35 miles and 17 minutes by air medical transport.

The volume of patients treated in the Infield Care Center begins several days before the race, while steadily increasing in the hours prior to the start of the race.

Starting the Race
It’s just another typical race day as the medical staff is getting ready for the increased volume of the day. Suddenly, at 8:30 a.m., a 51-year-old male presents to the Infield Care Center pale and markedly diaphoretic. He has significant chest pain with numbness of the left upper extremity. He has no past medical history but is a smoker. Immediately on arrival, a 12-lead ECG is obtained showing a normal sinus rhythm with significant ST-segment elevation, consistent with an acute anterior wall myocardial infarction (MI). Treatment within the Infield Care Center includes nitroglycerine, aspirin and Plavix. Flight Nurse Judy Gagnon and Flight Paramedic Keith Tokonitz prepare the patient at the Infield Care Center for the flight to the LVHN cardiac catheterization lab.

An LVHN MI alert is activated by direct notification from the Infield Care Center prior to the liftoff of MedEvac 2. The patient is awake and oriented. His chest pain score has slightly improved from a 10/10 to 8/10 after treatment was administered by the Infield Care Center treatment prior to departure.

While en route to LVHN, his pain level improves to a 4/10. Occasional ventricular beats (bigeminy) are noted on the monitor. The patient is alert and discussing the NASCAR race with the flight crew.

Halfway into the flight, Gagnon asks him again to rate his chest pain. Before answering, the patient goes into sudden ventricular fibrillation with profound tonic-clonic seizure activity due to decreased perfusion of the brain. In the limited-space confinement of the aircraft, Tokonitz controls the patient while Gagnon charges the defibrillator. Defibrillation at 120 joules is delivered immediately followed by initiation of CPR. IV administration of 1 mg epinephrine and 300 mg amiodarone is given with continued CPR.

Two further attempts at defibrillation at 200 joules are unsuccessful to convert the ventricular fibrillation. Just prior to intubation and on final approach to the LVHN helipad, the patient suddenly converts to normal sinus rhythm at 83 beats per minute with palpable radial pulses. Additional assistance to off-load from the helicopter is necessary due to the patient’s combativeness and intermittent seizure activity after the return of spontaneous circulation.

Pit Stop
The MI alert team has prepared for the usual MI alert, but this case is different. The patient appears markedly postictal after his seizure. He is awake and agitated, looking around but not interacting with his surroundings. With his agitation, diminished respirations and difficult bag-valve mask assistance, the decision is made for rapid sequence intubation to facilitate endotracheal intubation. The emergency department (ED) staff administers 24 mg etomidate and 120 mg succinylcholine via IV.
In the process of intubation, the patient vomits several times. He proves to be a difficult intubation, requiring four attempts with probable aspiration during the process. The initial ECG in the ED shows sinus tachycardia with a new onset of right bundle branch block in addition to the ST-segment elevation.

After 40 minutes of critical care management in the ED, the patient is rapidly transported directly to the cardiac catheterization lab. Cardiac catheterization reveals a complete occlusion of the left anterior descending coronary artery. A stent is successfully placed within the coronary artery, regaining blood flow to the left ventricle and stopping further myocardial damage.

Teaching Points:

  • ECG changes: During an infarct there is normally ST elevation & T wave inversion. The location of the infarct will be identified by which leads are affected in a 12-lead ECG.
  • Anterior wall: V1–V4.
  • Lateral wall: I, aVL, V5 & V6.
  • Inferior wall: II, III, & aVF.
  • Septum: V2 & V3.

AMIs & STEMIs
Heart disease is the leading cause of death in the U.S. Each year, approximately 650,000 patients have a new acute myocardial infarction (AMI). Approximately 370,000 are ST-segment elevation myocardial infarctions (STEMI). Each year, 450,000 patients have a recurrent AMI. Anterior-wall MIs remain at high risk for recurrent cardiac events, and approximately 10% of these patients die within the first year. Of these deaths, most occur in the first three to four months as a result of advanced atherosclerotic coronary artery disease (CAD).(1) The primary risk factors for atherosclerotic CAD and anterior-wall MI are hyperlipidemia, diabetes, hypertension, cigarette smoking and males. A history of a family member dying from a MI at a young age is always a concerning risk factor.

Early recognition of signs and symptoms, along with prompt treatment, can significantly improve patient outcomes (80% for cardiac ischemia/angina or MI present with chest pain or pressure.) A classic concern for cardiac pain is when the patient presents complaining of chest “pressure” and holds a clenched fist tightly against the chest (Levine’s Sign). In some AMI patients, diaphoresis may be the only presenting symptom.(2) CAD and MI symptoms may not appear like the classic cardiac symptoms, specifically within the female population. The female cardiac presentation may just be shortness of breath, gastrointestinal symptoms and fatigue without any chest pain.

In this case, the patient had an anterior MI which is the most serious and has the worst outcome. A study comparing outcomes from anterior and inferior infarctions (STEMI + NSTEMI) found that on average, patients with anterior MI had higher incidences of in-hospital mortality (11.9% vs. 2.8%), total mortality (27% vs. 11%), heart failure (41% vs. 15%) and significant ventricular ectopic activity (70% vs. 59%) and a lower ejection fraction on admission (38% vs. 55%) compared to patients with inferior MI.(3) The anterior coronary artery supplies larger areas of the heart compared to other coronary arteries. Due to the large area and location supplied by the left anterior descending coronary artery, it predominately affects the left ventricle.  Once the muscle of the left ventricle is affected, it produces wall-motion abnormalities and significantly lower ejection fraction resulting in a drop in the blood pressure.  Irritation of the muscle and affecting the electrical pathways in the left ventricle increases the risk of ventricular tachycardia and ventricular fibrillation.

The current American Heart Association target is less than 90 minutes from door-to-balloon time (from patient presentation to cardiac catheterization). The fastest door-to-balloon times have been achieved by hospitals with paramedics who perform 12-lead ECGs in the field.(4)

Crossing the Finish Line
The STEMI patient is a local resident to the Pocono Raceway. He and his wife have been devoted NASCAR fans and they have attended every race at the Pocono Raceway for many years. He has never missed any of the NASCAR races, including that day. He and his wife watched the race while in the Cardiac intensive care unit after his cardiac catheterization. The most upsetting thing for him that day was that his favorite driver only finished sixth in the race.

References
1. Go AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke statistics—2013 update: A report from the American Heart Association. Circulation. 2013;127(1):e6–e245.
2. Rahm SJ, Pollak AN: Medical case studies for the paramedic. Jones & Bartlett Learning: Sudbury, Mass., 7, 2004.
3. Stone PH, Raabe DS, Jaffe AS, et al. Prognostic significance of location and type of myocardial infarction: Independent adverse outcome associated with anterior location. J Am Coll Cardiol. 1988; 11(3):453–463.
4. Bradley EH, Roumanis SA, Radford MJ, et al. Achieving door-to-balloon times that meet quality guidelines: How do successful hospitals do it? J Am Coll Cardiol. 2005;46(7):1236–1241.

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Related Topics: Case of the Month, Cardiac and Circulation, Patient Management, STEMI, Raceway EMS, NASCAR, medevac, HEMS, EMS case, case, AMI, air medical services, Jems Case of the Month

 

John McCarthy, DO, FACEP

John McCarthy, DO, FACEP, is the chief of the division of EMS at Lehigh Valley Health Network (LVHN) and medical director of LVHN MedEvac in Allentown, Pa. He started his career as a volunteer EMT/firefighter at age 16. He graduated from the Philadelphia College of Osteopathic Medicine, completed the Emergency Medicine Residency as well as the EMS Fellowship at Albert Einstein Medical Center in Philadelphia, Pa.

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Marianne Kostenbader, RN, BSN, CEN, PHRN

Marianne Kostenbader, RN, BSN, CEN, PHRN, is the director of the division of EMS at Lehigh Valley Health Network (LVHN) and a flight nurse at LVHN MedEvac. She has been an EMS provider since age 18.

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Michael Wargo, RN, MBA, BSN, PHRN, CMTE

Michael Wargo, RN, MBA, BSN, PHRN, CMTE, is the administrator of emergency operations and public safety at LVHN in Allentown, Pa, and the executive director of operations at the Pocono Raceway. He has been an EMS provider since age 18 and is also currently a flight nurse at LVHN MedEvac.

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