This document summarizes a paramedic student's formal case review involving a patient with multiple blood clots. The 50-year-old male patient presented with shortness of breath, numbness, back pain, and blood in his urine. He was found to have blood clots in his lungs, legs, arms, back, and heart. The document reviews Factor V Leiden disorder, which causes a higher risk of blood clots. It also discusses thrombolytics, which are clot-busting drugs that can be used to treat blood clots in conditions like pulmonary embolism and myocardial infarction. The patient was ultimately diagnosed with multiple blood clots and a left ventricular thrombus.

1. FORMAL CASE
REVIEW
Chemeketa Community College
Paramedic Class Fall 06

2. Irina Bubnova & Jeff Johnson
West Valley Fire District
• Population 2,500
• HWY 18 & 22
• Spirit Mountain Casino
Metrowest Ambulance
• Headquarters in Hillsboro
• Serving all of Washington
county
• System status ALS division
• Wheelchair division

3. PRECEPTORS
• Irina
• Kim Torris
• Senior Paramedic
• Medic 56
• 1845-0600 2/2/3
• Jen Stanislaw
• Lieutenant for West
Valley Fire
• Medic 8
• A Shift (24 hours)
Holding Lt. Stanislaw’s son

4. PRECEPTORS
• Jeff
• Travis Schlegal
• Medic 74
• Oliver Mellor- EMT-P
• Tammy Schurter
• Medic 62
• Maria Roeder- EMT-P
• 1045-2300 2/2/3

5. THANK YOU ALL!!!!!!
• Family
• Friends
• Dr. Kirkpatrick
• Rhonda Woods, RN, BSN
• Justin Hardwick, NREMT-P
• Peggy Andrews, NREMT-P
• Gregg Landers, NREMT-P
• Erin Wheeler, NREMT-P
• Johnny Mack, Associate Dean for EMS

6. The Call…………
• Dispatch:
• “Difficulty Breathing”
• Code 3 at 1242
• Responding Units:
• TVFR ENG 67
• MWA 62
• Arrive on Scene:
• 1248
• TVFR Paramedics have
PIC

7. History
• 50 y/o Male patient complaining of shortness of
breath since 0730 this AM
• Pt is also complaining of leg/arm numbness,
back pain, and bright red blood in his urine!
• Initial Vitals:
• Pulse 130
• RR 32
• BP not obtained due to inability to auscultate or palpate
radial pulse
• CAO-PPTE
• SaO2- 100% on 15LPM NRB

8. History Continued
• PMHx (past medical history) HTN, Anxiety,
Depression, FVL (Factor Five Leiden)
• Pt on Warfarin for FVL but stopped taking it
one month prior due to financial/social
reasons
• All extremities are blue/cold to touch
(acrocynosis) cap refill delay of 10 seconds!!!!

9. TEACHING TOPIC
Factor V Leiden

10. FACTOR V LEIDEN
• Factor V is a natural and normal component of the
blood clotting cascade
• Helps to clot blood and works as an anticoagulant to
prevent clots
• Factor V Leiden was discovered as a gene mutation
in Leiden, Netherlands in 1994

11. Mutation!!!
• Not a disease
• Most common hereditary
coagulation disorder
• 5% of Caucasians
• 1.2% African-American
• Almost zero in indigenous
people of America, Asia,
Australia
• Less then .5% of Hispanics

12. Field Concerns
• Those people who have this disorder have a much
higher risk of blood clots (3-8 greater with one gene
mutation and 30-140 times greater with two)
• Most people will not have any clotting issues
• Those at a high risk will be on anticoagulants like
Warfarin

13. Now Where Did I Place That Clot?!?
• Lungs – Pulmonary Embolus
• Heart – Myocardial Infarct
• Brain – Stroke/Sinus Vein Thrombosis
• Intestinal – Mesenteric Vein Thrombosis
• Liver – Budd-Chiari Syndrome
• Legs – Deep Vein Thrombosis

14. EMS
• Where there is one there may be many!
• Pt that has Factor V Leiden disorder may have more
then one clot and will not always present with
symptoms of each………
• Back to the Patient………

15. Interventions
• TVFR established an IV (20G right AC)
• Three attempts
• Pt placed on monitor – NSR
• Lung sounds – clear and equal
• Patient packaged up and transported code 3 to
St Vincent Hospital
• Seems cut and dry…PE, right? Why are his
arms and legs blue though???????

16. More?
• Easy answer… one blood clot to the lungs and one
to the femoral/radial arteries….
• Chest Pn? Nope
• Jaw Pn? Nope
• H/A? Nope
• Back Pn? Yep, also hematuria…..

17. ST Elevation!?!?!
• Lead II is showing slight elevation
• (noticed by Tammy Schurter)
• 12 Lead EKG time…..
• ST elevation noted in Lead II and precordial Leads II,
III, V, VI
• Another clot…this one in the heart (AMI)

18. 12 Lead Strip

19. Treatment Again….
• Aspirin (ASA) – Contraindicated by disorder
• Nitro – He doesn’t have chest pain…….
• Thrombolytic checklist
• Treat with a little more diesel!!!!!!

20. TEACHING TOPIC
Thrombolytics

21. What Is It?
• Clot-busting drug
• “Thrombo” –
Thrombosis
• “lytic” – Destroy

22. What’s Going on Inside

23. How Does it Work?
• Converts plasminogen into the active enzyme
plasmin
• The plasmin acts on the fibrin to dissolve it
• This restores the blood flow in the occluded
blood vessels
• Must be done within a few hours because the
clot undergoes a hardening process, which
makes it resistant to breakdown by plasmin

24. Illustration

25. Indications
• Myocardial Infarction
• Ischemic Strokes
• Deep Vein Thrombosis
• Pulmonary Embolism
• Clear Blocked
Catheters

26. Contraindications
• Hemorrhagic strokes
• Active internal bleeding
• CNS procedure or CVA within 2 months
• Uncontrolled hypertension
• MI due to aortic dissection
• Aneurysm

27. Commonly Used Thrombolytics
• Streptokinase
• Alteplase
• Reteplase
• Tenecteplase
• Anistreplase

28. Streptokinase
• Inexpensive
• First thrombolytic available
• Converts plasminogen into
plasmin throughout the
circulation
• Causes some type of
allergic reactions in 5% of
patients

29. Alteplase (tPA)
• Expensive
• Binds to fibrin at the site of the thrombus
• Rate of re-occlusion is greatly decreased when tPA is
used with heparin
• Mortality was better for tPA in the US while no
differences were found between streptokinase and
tPA in other countries

30. Drug Administration
• Intravenous
• Within the first ninety minutes, up to six hours after
the start of symptoms
• Usually given in combination with an anticoagulant
(usually heparin)
• Usually administered for 24-48 hours.

31. Thrombolytics At Work
• 75% of patients will attain reperfusion
• Rate of re-occlusion is about 20%
• 5% of patients will have some problem with bleeding
• 1% of these patients will have a serious episode of
bleeding
• 0.5-1% will have an intracranial hemorrhage

32. Which to Use?
• Hotly debated topic
• Allergies
• Cost
• Drug availability
• Convenience in dosing

33. Why Thrombolytics Are Important
• Must be administered as soon as possible
• Potential 48% reduction in mortality if treatment is
received within an hour of onset of symptoms
• Within the next five years may become a common
prehospital drug

34. Prehospital Thrombolitics
• Used as a prehospital drug in many European
countries
• France, Netherlands, Belgium, UK
• There are currently studies in the US with
participating ambulance services who are giving
thrombolytics in the field
• Miami, Florida
• Atlanta, Georgia

35. Prehospital Thrombolytics in the US
• More difficulty in establishing, possibly due to
liability issues
• Pooled data from 8,318 US patients in published
series showed that prehospital thrombolysis was
associated with a 17% relative reduction in mortality,
compared with standard in-hospital thrombolysis

36. Sample Case
• Typical chest pain
• Over 15 minutes
• Less than 6 hours
• Not responsive to NTG
• Typical ECG changes
• ST segment elevation in two or more continuous leads
of over 1mm leads or 2 mm in chest leads

38. Sample Case Continued
• Absence of major
contraindications
• Expected benefit greater
than risk if “relative”
contraindication are present
• Candidate for
Thrombolytics

39. Monitoring the Patient
• 80% of patients have chest pain resolution
• 75% of patients have resolution of ST
segment elevation
• Arrhythmias (PVCs or brief V-tach) often
occurs as blood reaches ischemic
myocardium
• In patients with no signs of reperfusion
nearly 50% will have cleared the thrombus

40. Results
• 18% reduction in death
when thrombolytics
are used after a heart
attack

41. Call Continued……..

42. St Vincent ER!!!!
• Assessment for PE
• ECG repeated
• Lab workup (Troponin
level 8.2)
• Chest x-ray
• Medications given:
Ativan, Metoprolol,
ASA, Heparin Bolus
• Echocardiogram/Cath
Lab

43. ER Impressions…
• Acute Coronary
Syndrome
• Possible embolic
shower or apical
thrombus
• Pt sent to cath lab then
to Cardiac Care
Unit……

44. Follow Up
• Cath lab –
• Occlusion of proximal left anterior descending artery
• Mild proximal right coronary artery disease
• Pt not considered a candidate for Thrombolytics
therapy!!!!!!!

45. Discharge summary
• Left Ventricular Thrombus
• Embolic Phenomenon to
spinal cord
• Acute renal failure
• Possible Bipolar disorder
• Pt goes home with no
neurological or sensory
function deficits after 5
days in hospital

46. Questions?

47. Sources:
• www-admin.med.uiuc.edu/hematology
• www.factorfiveleidensupport.org/
• www.fvleiden.org/
• http://en.wikipedia.org/wiki/Thrombolysis
• www.rcr.ac.uk/index.asp?PageID=521
• www.strokecenter.org/pat/thrombolytics.html
• www.bchealthguide.org/kbase/topic/detail/drug/hw100
796/detail.htm