Chronic Pain Part 2: Medication
Chronic Pain Part 2: Medication

This is part two of a two part series on chronic pain. Pearls: Set realistic expectations when treating patients with chronic pain. For the vast majority of patients, antidepressants are the first-line pharmacologic choice for the treatment of chronic pain. Patients who present after the acute phase of a painful condition, whether it’s 1 week or 2 […] - Emergency medicine podcasts, reviews and curbside consults

59 Year Old Male: Unwell

It’s the middle of the afternoon when you are dispatched to the residence of a 59 year old male with a chief complaint of general illness.

When you arrive on scene you encounter a middle-aged man in obvious distressed lying on a couch. He is pale, gray, diaphoretic, and drowsy. He states that he has felt drained for the past 8 hrs; unable to catch his breath or get up off the couch with a heavy sensation in his chest. 30 minutes prior to your arrival he vomited and felt like he was going to pass-out so he decided to call 911.

His radial pulse is faint, rapid, and irregular while his skin cold and moist.

  • HR – 150 bpm, irregular
  • SpO2 – Unable to get a clear waveform
  • BP – 72/42 mmHg
  • RR – 26. labored
  • Temp – 36.6 C (97.9 F)

Breath sounds reveal crackles bilaterally.

Multiple 12-lead ECG’s are performed but suboptimal due to the patient’s increased work of breathing and inability to stay still. This is the best of the bunch:

Initial 12-Lead

BGL is 156 mg/dL.

He is a bit lethargic but properly oriented and answers questions appropriately, albeit slowly.

  • S – As above
  • A – No known drug allergies
  • M – None
  • P – Appendectomy @ 24yo
  • L – Soup 45 min prior, which he vomited soon after
  • E – Can’t recall—states he has felt terrible “all day.”

Regarding the chest heaviness…

  • O – Gradually through the morning
  • P – Nothing makes it better or worse
  • Q – Heaviness
  • R – None
  • S – Unable to quantify
  • T – Worsening x 8 hrs

What are your management priorities for this patient?

What is your interpretation of the ECG?


 ***UPDATE (2015/6/29/ 14:00 EDT)***

After carefully transferring the patient to the ambulance and finding him a position of comfort (head-of-bed at 60 degrees—he doesn’t like to lie flat), you succeed in obtaining a cleaner EKG. Does this change your approach to the case?

02 - 12-Lead 02




Filed under: SMACCUS Tagged: 2015, airway, SMACCUS