EMS is dispatched to a 50 year old male in respiratory distress. En route, dispatch advises that the chief complaint is actually chest pain.
On arrival, the patient is found lying supine on the floor just inside the front door to his house. He is cold to the touch and pale but his skin is not diaphoretic. He denies falling and the head is atraumatic.
He appears to be mildly short of breath and admits that he is having chest pain.
Onset: 3-4 hours ago while walking
Provoke: Nothing makes the pain better or worse
Quality: He is unable to describe the pain (some language barrier)
Radiate: The pain radiates down both arms
Severity: The patient gives the pain a 10/10
Time: The patient does not admit to any prior episodes, although he does state the he was recently diagnosed with anxiety and is scheduled for a “cardiac exam”
He denies nausea or vomiting.
SpO2: 92 on RA
Breath sounds: slight rales bilaterally
A 12-lead ECG is captured.
The patient and his family request to be transported to the local (non-PCI) community hospital.
What is your impression?
What should the treating paramedic do next?
*** UPDATE ***
The treating paramedic was very concerned about the 12-lead ECG. Even though it technically did not meet the criteria for a STEMI Alert in his system, he persuaded the patient to request transport to the PCI-hospital across town.
It was his intent to capture a 12-lead ECG with posterior leads V7-V9 once the patient was loaded in back of the ambulance.
He didn’t get the opportunity because the patient went into ventricular fibrillation.
A precordial thump was delivered with no success (don’t pretend like you wouldn’t have enjoyed it).
Chest compressions were initiated while the monitor was charged. A shock was delivered at 150 J and chest comrpessions were immediately resumed.
Approximately 1 minute later the patient regained consciousness. He remained in sinus rhythm for the remainder of the transport.
An additional 12-lead ECG was obtained post-arrest.
Does this change things for anyone?
*** UPDATE ***
Here’s the exciting conclusion to the case!
The patient was taken straight to the cardiac cath lab at the receiving PCI-hospital (apparently the cardiac arrest got their attention).
The angiogram revealed a total (or near-total) occlusion of the left main coronary artery (limiting flow to both the left anterior descending LAD and circumflex LCX arteries).
The lesion could not be stented.
A balloon pump was placed and the patient was prepped for CABG.