How would you approach this patient? Case History Paramedics have arrived on the scene. A 46-year-old waitress has developed severe indigestion at work. She has mild chest pain and numbness in her left arm. Vital signs: BP = 110/60 mm Hg, HR = 60 bpm, RR = 22/min Physical exam: pale and diaphoretic, JVD, no crackles in lungs, no heart murmurs or rubs Key Concept: Women with ACS present most often with chest pain and characteristic radiation and associated symptoms. Atypical presentations, however, are more common in women than men. Ask participants if they believe symptoms are ischemic in origin. Is there a differential? How would participants initially proceed? Discussion Points: The patient in Case 1 presented with classic symptoms of ischemic-type chest pain. This patient presents with severe indigestion. As with many patients, this atypical presentation is accompanied by some chest discomfort, which the patient acknowledges during further questioning. The patient’s age, the presence of chest pain, and abnormal vital signs qualify her as having “suspected ischemic-type chest pain.” The chest pain protocol should be initiated. Participants should know that drug therapy (oxygen, aspirin, nitroglycerin, and morphine) is the next step in management of this patient. (These drugs were reviewed in Case 1.) A few participants may advise caution with use of nitroglycerin. In this case note that an IV was started and saline is being infused. Then go to the next slide. How would you approach this patient? 2

How would you assess and Clinical Information Oxygen is administered. Aspirin is given. IV normal saline infusion is started. Nitroglycerin 0.4 mg is given sublingually. Key Concept: Nitroglycerin is administered with caution in patients with SBP 100 mm Hg and is contraindicated in patients with SBP <90 mm Hg. For patients at risk of developing hypotension, it is prudent to start IV NS before administration of vasodilators (eg, nitroglycerin). Now ask if the 5th Quadrad assessment is helpful. Why is JVD present when the lungs are clear? Discussion Points: The patient now becomes hypotensive and symptomatic (altered cerebral perfusion). She has vomited and now has a symptomatic bradycardia. But her BP was 110 mm Hg at presentation in the setting of a probable ACS. Participants should recognize the need for immediate treatment of hypotension and begin assessing the cause of hypotension. In addition to low BP, a symptomatic bradycardia is now also present. The majority of experienced providers will treat symptomatic bradycardia with atropine. If so, discuss indications for atropine in patients with MI. An initial dose of 0.5 mg is prudent. Tell participants that HR increases to 60 bpm with atropine 0.5 mg, but BP is only 80/P. Ask what should be done next and review the significance of clear lungs and the development of hypotension after administration of nitroglycerin. Go to the next slide. The patient’s BP is now 70/P and she is confused. HR is sinus bradycardia 46 bpm. How would you assess and now treat this patient? 3