62 year old male CC: chest discomfort

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

Vital signs:

Resp: 20
Pulse: 62
BP: 84/48
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.

See also:

Acute inferior STEMI – RCA or LCX?

19 Comments

  • Rogue Medic says:

    Where are my right sided leads?Any STE (ST Elevation) in lead II, I want to look at the rest of the inferior leads and the right sided leads, before giving any NTG. With this guys pressure (84/48), love the palindrome, nobody should be racing to give any NTG, but the best treatment for the pressure should be dumping fluid into the body a few liters at a time, if it is an RVI (Right Ventricular Infarction).What would be the most typical vital signs for RVI? Hypotension and bradycardia. At 64 BPM, he is just avoiding the text book definition of bradycardia.From the first strip, I was looking for RVI, because STE in lead II can be a lot of things, but the worst case that I can do something about is RVI.Nice pre-arrest SpO2. It means nothing for this patient. ;-)8/10 = 747?10/10 = ?

  • McTerzlins says:

    Not that it would change my tx, but I would like to fire off v7-9 if time permits. The depression in v1-v3 are likely reciprocol to a posterior injury pattern.

  • Leigh says:

    inferior MI, in my mind, means I would be immediately doing a 15 lead ecg (V4R, V8, V9).when you look at V1, I'm suspecting some posterior extension there. That's why that 15 lead is crucial. you get the view of the right side, and posterior! chew some ASA, let's bring him into the cath lab!

  • Tazambo says:

    Nice EKG.As per Rogue, and given enough transport time, a V4R would be good but I'd also wouldn't mind V7, V8 and V9 to confirm my diagnosis of posterior involvement.I see:STE in II, III, aVF, V5 & V6STD in V1, V2 & V3reciprocal depression in I & aVLOver here he'd get 2 x big cannula, fluid, Morphine, Maxolon, Aspirin, no GTN, pre notification of the cath lab and rapid transport.

  • Tom B says:

    Thanks to everyone who replied! We're off to a great start.@RogueMedic – Good news! I've got your right sided ECG. :) As for the 747 on the chest, I also wondered what it would take to elicit a 10/10!@McTerzlins – Another astute comment! I don't have the posterior leads to show you, but I agree with your assessment.@Leigh – You're right, a 15-lead ECG would cover all the bases.@Tazambo – I'm on board with your treatment plan, and that's exactly what this patient received (minus the Maxolon, although we're in the process of adopting Zofran).Stand by the the update!Tom

  • Shaggy says:

    Does the update tell us more than we already figured out. Do we really need to do a 15 lead EKG. We already know we have at least an RCA occlusion with possible posterior involvement. We know this pt. needs IVx2, labs (coags, chems, and CBC), ASA, O2, fluids, and maybe fentanyl for pain. Most of all we know the patient needs to go straight to the cath lab or at least the cath lab activated and pt. going to ED until the cath team gets in. What difference will the additional information of a 15 lead provide us? Sure it would be nice if I had transport times greater than 20 minutes or so, but the key is IT WOULD BE NICE. Not necessary. If I am wrong, please correct me for I am all ears.

  • Tom B says:

    Shaggy – I'm with you! Acute inferior STEMI, particularly with borderline bradycardia and hypotension should be treated as RV infarction until proven otherwise! Even though leads V4R and V5R look pretty negative for ST segment elevation, what does it matter? I agree with you that the culprit artery is the RCA.The patient needs a fluid bolus regardless! In my book, the reciprocal changes in the right precordial leads represent posterior extension (not anterior ischemia). However, this finding is far more important in the absence of obvious inferior STEMI! See also:Anterior ischemia or posterior STEMI?Tom

  • Scott T says:

    great post,I agree 12 lead is good enough and im sure we are all agreeing posterior infarct for various reasons. I like the rule if lead 3 has a larger STEMI then lead 2 its posterior infarct(is that right tom?).Also another question, our protocols in australia is that morphine is contraindicated in pts with a systolic less then 100mmhg in cardiogenic chest pain…what are your thoughts on that? Did the crew give the morphine post fluid bolus to raise systolic bp?oh and one more, how much fluiddo these pts typically recieve?cheers

  • Shaggy says:

    Scott, I missed in the post where the patient was given morphine. I read through it a couple of times but did not see it.One of your cohorts from down under, Tazambo, stated the patient would get morphine if treated there. I cannot speak for others but around my region, we opt toward fentanyl in the case of hypotension or borderline hypotension, for obvious reasons. As far as fluid goes, we have a protocol which states 500cc, but of course we have clinical judgement that comes into play, such as when the patient presents with signs of CHF.BTW, I mentioned drawing labs in a previous post. I should have stressed drawing the light green tube for the troponin and CK-MB. That is an important one for any chest pain patient.

  • Scott T says:

    sorry shaggy i was refering to tazambo post with the morph. (I cabt read his profile for some reason to see where he is from)…However, in Queensland its BP over 100systolic for cardiogenic, regardless of clinical judgement etc.. I guess its cause of the hypotension and morphine blocks the rate of AV conduction (especially if the SA node is supplied via RCA).Shaggy your luid is the same amount as us, as far as i am aware, however i have not learnt that yet.Also we definately don't carry fentanyl, maybe in the future hey (any negative side effects in cardiac pts? apart from the resp depression?). We carry ketamine for severe musculoskeletal pain after morphine admin. Thanks for your comments shaggy

  • Tom B says:

    Shaggy – This patient did receive morphine after a fluid bolus.Tom

  • Tom B says:

    Scott T – The rule of thumb for inferior STEMI: when ST elevation in lead III is > ST elevation in lead II, then it's probably a RV infarct.Any time I've seen this ECG finding, there's also a downsloping ST segment (reciprical ST segment depression) in lead aVL suggesting occlusion of the RCA.I'll be interested to see exactly where the occlusion was in this patient's RCA.Tom

  • Shaggy says:

    Tom, what is your take on using Morphine in this situation? We have discretion between fentanyl and morphine, but I always liked morphine for ACS patients due to vasodilatory effects, but see its limitations in the treatment of RCA occlusions. Do you think it wiser to wait until after bringing the pressure up to give morphine or treating early with fentanyl? What do you think of fentanyl in treating patients who are bradycardic like this patient may be?

  • Tom B says:

    Shaggy – I don't have any experience with fentanyl, so I'll defer to Rogue Medic on this one.As for using morphine when the patient is bradycardic and hypotensive, probably not a good idea! I'd at least correct the pressure with a fluid bolus (that's what the paramedics did in this case).I've also read that 12.5 mg of diphenhydramine prevents the undesirable hypotensive side effect of morphine (but I've never tried it).Tom

  • Tom B says:

    Well, I was wrong! The culprit artery was the LCX in a patient with a very non-dominant RCA.I'm trying to figure out how to upload videos of the angiogram, but I'm running into some technical problems.If all else fails, I'll post still images. Give me a few days.Tom

  • William R. says:

    Awesome comments. Yep always be careful with that Nitro. I agree nothing less then 100 systolic and only after a IV is established. Can see why you would think RV infarction with this one. Works as very rural Paramedic (1 hour plus to nearest hospital with a cath lab). This would be a clear cut flight patient for me. Time is muscle!!

  • Matthew says:

    Obtain V4R before any NTG. given to rule out a Inferior wall MI, as for the B/P 2-IV’s fluid challenge, Dobutamine or Dopine, Apply the combo pads, Pain manag. once you have a systolic pressure of 100. Transmit the 12 and 15 leads.

  • dr khurram says:

    lovely comments im a student doing my training in cardiology unit and i really keenly read all comments thanks 2 allllllll

  • Michelle says:

    The first chart you posted came from "The ECG in Emergency Decision Making" written by Hein J.J. Wellens and Mary B. Conover, Saunders publication, 1992. It comes from page 7. This is an excellent advanced 12 lead textbook and I used it heavily in the 1990s when I was teaching a lot of 12 lead courses at a local community college.
    Michelle (a nurse who enjoys your website)

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