100 Cases in UK Paramedic Practice

Christoph Schroth, Peter Phillips

• Publisher: Routledge
• Year: 2018
• eBook ISBN: 9780429952906
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

Pre-hospital care plays an increasingly important part in contemporary healthcare delivery and the skills of paramedics, emergency medical technicians and emergency care assistants are a vital part of this. This casebook supports readers to develop the necessary assessment and decision-making skills they need in order to effectively manage a variety of cases typically seen in UK paramedic practice.

100 Cases in UK Paramedic Practice allows for learning and revision through 100 scenarios which aim to encompass cases that may be seen in daily practice. The book covers scenarios that can occur at any moment of the day, from an ambulance shift to primary care settings to event standby duties. The bite-size structure of this book allows the reader to focus on body systems or random case scenarios, depending on their preference.

This is an essential, evidence-based guide for students of pre-hospital care and a useful reference for qualified staff as a source of continued professional development or as a revision tool.

PART I

SYSTEM-SPECIFIC CASES

Christoph Schroth

CHAPTER 1

CARDIOVASCULAR SYSTEM

CASE 1: AN ELDERLY FEMALE FEELING UNWELL

It is a Sunday afternoon, 16:07, when you are dispatched to a house on the outskirts of the city to a 68-year-old female who is not feeling well. According to the dispatcher the patient described it as ‘feeling under the weather’ and apologised for ‘bothering the ambulance service’ with such a minor complaint.

History

Allergies: None

Medication: No prescribed medication, but took two paracetamol tablets this morning at around 07:15.

Past medical history:

Cardiac: None

Respiratory: Pneumonia 2 years ago

Endocrine: None

Neurological: None

Surgical: Last doctor’s visit about 2 years ago after a 5-day stay in hospital for pneumonia.

Occupation: Retired

Natal: Not pregnant

Last meal and urinary output: Lunch at about 12:30, split-pea soup and some bread. Urine output was the same as always about an hour ago.

Events leading up to the call: Been feeling unwell since she woke up at about 07:00. Did not feel better after taking some paracetamol and she says that she has no way of getting to the local pharmacy or urgent care centre, because she does not have a car, so she decided to call for an ambulance as she did not know what else to do.

Examination

A on the AVPU (alert, voice, pain, unresponsive) scale

Equal, bilateral and clear air entry on auscultation

Radial pulse present (between 60 and 90 beats/minute, regular)

Skin appears a little pale, but closer examination of the mucous membranes does not support the initial impression.

Vital signs

HR 92 beats/minute and regular

RR 18 breaths/minute

SpO₂ 96% on room air

Blood pressure (BP) 98/60 mmHg

Haemo-gluco-test (HGT) 5.1 mmol/l

12-lead ECG showing ST-elevation in leads II, III and aVF

Temperature (tympanic) 36.5°C

Pupils 5 mm equal, round and reactive to light

Capillary refill time (peripheral) 2 seconds

Questions

ST-elevation in leads II, III and aVF most probably points towards an acute myocardial infarction (AMI) in which area of the heart?

What is the diagnosis?

What treatment does this patient require?

ANSWER & DISCUSSION

Leads II, III and aVF most probably indicate an inferior AMI. One rudimentary way of identifying the location of a myocardial infarction on a 12-lead ECG is by using the SALI mnemonic (leads with ST-elevation alongside the region it applies to):

S (septal) = V1, V2

A (anterior) = V3, V4

L (lateral) = V5, V6, I, aVL

I (inferior) = II, III, aVF

But what is the actual diagnosis—after all she has no chest pain? Silent inferior AMI would be the correct answer here. The exact process is not entirely understood, but it affects only older women and diabetics.

Treatment should follow the current guidelines and include oral acetylsalicylic acid (aspirin), if none of the contraindications are met, intravenous access and transport to the nearest, appropriate cardiac care facility, with a pre-alert en route. Oxygen is not indicated, unless the patient is hypoxaemic. Nor are nitrates or morphine sulphate, because there is currently no chest pain present.

Key points

• No chest pain does not mean that it cannot be an AMI.

• Patients tend to feel generally unwell and do not give the impression of being severely ill. Only careful, thorough examination reveals the need for immediate intervention and transportation to an appropriate facility.

CASE 2: PALPITATIONS

During the early hours of a Saturday morning you are called to a 19-year-old university student with palpitations. A staff member from the halls of residence meets you at the entrance and takes you up to the patient’s room.

Thomas, the patient, is alert and orientated, but clearly feeling distressed, which is apparent from his wide-eyed look and some of his vital signs:

HR 142 beats/minute and regular

RR 26 breaths/minute

SpO₂ of 96% on room air

BP 148/72 mmHg

HGT 7.0 mmol/l

Temperature (tympanic) 37.0°C

When asked about the course of events he explains that he went out with some of his classmates and that they spent the whole evening in a pub, drinking and watching football. Upon his return home he felt like ‘his heart was going crazy’ and it started beating really fast, and when this did not resolve after about 15 minutes he asked the reception staff to call 999.

Further questioning reveals that he has no allergies, takes no medication or has no type of medical history, and he mostly drank vodka, mixed with all sorts of things from the drinks menu.

His 12-lead ECG shows sinus tachycardia at 142 beats/minute and is regular with no other abnormalities. Which features of the ECG are of particular importance when making a management plan for a patient with tachycardia (with a pulse)? Is there an algorithm that can guide your management of this patient? What is the likely cause of the tachycardia?

ANSWER & DISCUSSION

Adult patients suffering from tachycardia (with a pulse) should be managed according to the Adult Tachycardia (with a pulse) Algorithm by the Resuscitation Council (UK). Ensure that the patient is being properly assessed and that there are no reversible causes that need to be corrected, such as hypovolaemia, hypoxia and hyperthermia, before looking for adverse features. Signs of shock, and the presence of syncope, myocardial ischaemia and heart failure are not present, thus classifying this episode of tachycardia as stable. A look at the document will also answer the ECG question from the case description, namely the key feature you need to evaluate next, the width of the QRS complexes. His QRS complexes are <0.12 seconds apart and regular, thus vagal manoeuvres, followed by adenosine administration (if in your scope of practice), are the next two steps. Thomas does, however, not respond to vagal manoeuvres and you are not carrying adenosine, so transportation to the nearest ED is your only choice.

The most probable cause of this episode of tachycardia is likely to be linked to the various drinks he mixed with the vodka he drank tonight. Energy drinks mixed with vodka have become a fashionable combination, which may lead to cardiovascular consequences when the maximum recommended doses are exceeded. Asking Thomas about it confirms your suspicions. After a few hours in ED to manage this event he is discharged without further complications of his night out.

Further resources/recommended reading

Resuscitation Council UK (2016) Adult Tachycardia (with a pulse) Algorithm, London: Resuscitation Council UK.

CASE 3: SHORTNESS OF BREATH

You are dispatched to a 64-year-old female with shortness of breath while working a shift on a rapid response vehicle (RRV). Following a short response time you are presented with Susan, your patient, sitting in her living room. While assessing her, your auscultation attempts are interrupted multiple times, because she has a significant cough that turns out to be haemoptysis. Susan explains to you that she developed sudden-onset shortness of breath while watching television.

Her vital signs are as follows:

HR 110 beats/minute and regular

RR 22 breaths/minute

SpO₂ of 94% on room air

BP 100/60 mmHg

12-lead ECG showing a sinus tachycardia with T-wave inversion in leads V1, V2 and V3

Temperature (tympanic) 36.5°C

Her medical history reveals no significant information whatsoever.

You attended a CPD session relating to DVT and PE recently which made reference to something called the Wells’ score. Could this be useful here or is it unrelated to this scenario? What is Susan probably suffering from?

ANSWER & DISCUSSION

The Wells’ score is used to determine the probability of DVT and PE, and is definitely useful here, because Susan meets some of the criteria that make a PE likely.

Before calculating a Wells’ score, red flags that would have classified Susan as severely ill and requiring immediate admission would have been (NICE, 2015):

Before

• Altered mental status;

• Hypotension (<90 mmHg systolic);

• HR >130 beats/minute;

• RR >25 breaths/minute;

• SpO₂ <91%;

• Pregnancy or giving birth within the last 6 weeks.

She is not meeting these criteria, but does still score points on the Wells’ score for estimating the clinical probability of PE.

HR >100 beats/minute = 1.5 points

Haemoptysis = 1 point

Other diagnoses less likely than PE = 3 points

Total = 5.5 points

Patients with a score of <4 points need to be taken to ED for D-dimer testing and further treatment if the test is positive. Susan, however, scored >4 points; hence she requires transportation to ED for an immediate computed tomography pulmonary angiogram (CTPA) or low-molecular-weight heparin, if CTPA is not immediately available.

Further resources/recommended reading

National Institute for Health and Care Excellence (2015) Pulmonary Embolism, London: NICE.

CHAPTER 2

RESPIRATORY SYSTEM

CASE 4: SHORTNESS OF BREATH

You respond to a 28-year-old female with reported shortness of breath in a private residence. On arrival you see her sitting on the edge of the sofa in the tripod position, with wheezing loud enough to hear without a stethoscope. According to her husband, she started getting short of breath and used her inhaler, but it brought no relief after about 10 minutes, so he called 999. After a brief primary survey you nebulise the patient with salbutamol and obtain some vital signs and a medical history.

Part of the decision-making in patients suffering from an acute bronchospasm is based on the severity of the distress: mild, moderate, severe or life threatening.

What are the options to determine severity? Which factors should be considered?

ANSWER & DISCUSSION

Multiple factors need to be considered when making this decision. It can be argued that patients, who look unwell, probably are, but this is not all the information required her...

Table of contents

• Cover Page
• Half Title
• 100 Cases in Healthcare
• Title
• Copyright
• Contents
• Acknowledgements
• Preface
• The Assessment and History-Taking Structure of This Book
• List of Abbreviations
• Part I: System-Specific Cases
• Part II: Mixed Cases for Self-Assessment
• Index