Emergency Medicine · Year 3 · from Emergency Medicine

Case 1: The "Sick" Patient - Rapid Primary Survey Saves a Life

Patient Demographics

  • Age: 58 years
  • Sex: Male
  • Occupation: Truck driver

Chief Complaint

"I don't feel right."

History of Present Illness

EMS brings a 58-year-old male found slumped in his cab at a truck stop. Bystander called 911 after noticing him unresponsive for "a few minutes." On EMS arrival, patient was lethargic with weak pulse. Limited history available - coworker reports patient complained of chest discomfort earlier in the day.

Initial Assessment (Triage and First Impression)

ESI Level: 1 - Immediate life-saving intervention required

First Impression (Across the Room):

  • Appearance: Pale, diaphoretic, obtunded
  • Work of breathing: Shallow respirations
  • Circulation: Mottled extremities, cool skin

Vital Signs:

  • Heart rate: 42 bpm, irregular
  • Blood pressure: 78/50 mmHg
  • Respiratory rate: 8 breaths/min
  • SpO2: 88% on room air
  • Temperature: 36.1C
  • GCS: 10 (E2V4M4)

Primary Survey (ABCDE)

Airway:

  • Patent but tenuous due to altered mental status
  • No stridor or obstruction
  • Jaw thrust performed, improved air exchange

Breathing:

  • Shallow, slow respirations
  • Clear bilateral breath sounds
  • No accessory muscle use (concerning - may indicate fatigue)
  • Bag-valve-mask ventilation initiated

Circulation:

  • Weak central pulses, absent peripheral pulses
  • Capillary refill >5 seconds
  • No external hemorrhage
  • Two large-bore IVs placed
  • 12-lead ECG obtained immediately

Disability:

  • GCS 10 (E2V4M4)
  • Pupils: 4mm, sluggishly reactive bilaterally
  • Glucose: 142 mg/dL
  • Moving all extremities, no focal deficits noted

Exposure:

  • Cool, clammy skin
  • No trauma, rashes, or obvious abnormalities
  • Warm blankets applied

Resuscitation Priorities

Immediate Interventions:

  1. High-flow oxygen via BVM
  2. IV access x2 (18-gauge)
  3. Continuous cardiac monitoring
  4. 12-lead ECG STAT

ECG Findings:

  • Third-degree AV block with ventricular escape rhythm at 38 bpm
  • ST elevation in leads II, III, aVF (inferior STEMI)

Working Diagnosis: Cardiogenic shock secondary to inferior STEMI with complete heart block

Secondary Survey

SAMPLE History (from coworker):

  • Symptoms: Chest pressure this morning, "didn't think it was serious"
  • Allergies: None known
  • Medications: Metformin, lisinopril
  • Past Medical History: Type 2 diabetes, hypertension
  • Last Meal: Coffee 2 hours ago
  • Events: Complained of chest discomfort, then became unresponsive

Focused Physical Examination:

  • Neck: JVD present, no bruits
  • Cardiac: Bradycardic, no murmurs
  • Lungs: Clear, no crackles
  • Abdomen: Soft, non-tender
  • Extremities: Cool, mottled, no edema

Diagnostic Testing

Point-of-Care:

  • Lactate: 6.2 mmol/L (elevated - tissue hypoperfusion)
  • Troponin: Pending (treatment not delayed)
  • ABG: pH 7.28, pCO2 32, pO2 68, HCO3 16

Labs:

  • CBC: WBC 12.4, Hgb 14.2, Plt 245
  • BMP: Na 138, K 5.1, Cr 1.8
  • Initial troponin: 2.4 ng/mL (elevated)

Management

Immediate Treatment:

  1. Atropine 1mg IV - no response to heart block
  2. Transcutaneous pacing initiated - capture at 80mA
  3. Dopamine infusion started for blood pressure support
  4. Aspirin 325mg given (crushed, via NG)
  5. Heparin bolus administered
  6. Emergent cardiology consultation

Disposition:

  • Cardiac catheterization lab activated
  • Successful PCI to RCA with stent placement
  • Temporary transvenous pacemaker placed
  • ICU admission

Teaching Points

  1. The "sick" gestalt: This patient's vague complaint of "not feeling right" combined with abnormal appearance triggered immediate high-acuity response
  2. Primary survey saves lives: Systematic ABCDE approach identified cardiogenic shock requiring immediate intervention
  3. ECG within 10 minutes: Door-to-ECG time is critical - identified STEMI and complete heart block
  4. Shock classification guides treatment: Cardiogenic shock requires different approach than hypovolemic - cautious fluids, focus on underlying cause
  5. Clinical decision-making under uncertainty: Treatment began before definitive diagnosis based on clinical picture

Clinical Image

Image Description: 12-lead ECG demonstrating third-degree atrioventricular block with slow ventricular escape rhythm and ST-segment elevation in leads II, III, and aVF consistent with inferior STEMI.

Attribution: Image from Wikimedia Commons, ECG demonstrating complete heart block. Licensed under CC BY-SA 4.0. Source: https://commons.wikimedia.org/wiki/File:Complete_heart_block.png

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