EMS is dispatched to a 62 year old male with a chief complaint of chest discomfort. On arrival, the patient is found sitting at the dinner table. He appears acutely ill.
Onset: Fairly sudden after sitting down for dinner 20-30 minutes ago
Provoke: Nothing makes the pain feel better or worse
Quality: Dull pressure/ache
Radiation: The pain does not radiate
Severity: 8/10 "feels like a 747 is sitting on his chest"
Time: Feels slightly better since the onset
Skin: cool, pale, diaphoretic
SpO2: 99 on RA
Breath sounds: clear
The cardiac monitor is attached.
A 12 lead ECG is captured.
The paramedic trouble-shoots the loose electrode. The data quality looks good to me, but the computer disagrees!
Three's a charm!
*** UPDATE ***
The paramedic in charge of the call elected to perform an additional 12 lead ECG using modified leads V4R and V5R.
Here is the result.
Here are some charts from my series on right ventricular infarction for reference. I don't remember where the first chart came from, but it shows the ramifications of various ST/T configurations in lead V4R.
Also consider Eskola et al. How to Use ECG for Decision Support in the Catheterization Laboratory – Cases With Inferior ST Elevation Myocardial Infarction. Journal of Electrocardiography Vol 37 No. 4 October 2004.
Question: Does this change anything? Why or why not?
See the update, including angiograms HERE.