Here’s a great case submitted by Nick Ciaravella of Grady EMS in Atlanta, GA.
66 year old male presents to EMS with chest pain.
- S – Chest Pain
- A – None
- M – Atenolol, HCTZ
- P – Hypertension
- L – meal, 7 hours prior to event
- E – Mowing his lawn
- O – Started while mowing his lawn
- P – Provoked while exerting himself, Palliated initially when he sat down to rest
- Q – Sharp
- R – Substernal, initially radiating to his jaw, when he rested the pain was only in his chest
- S – Initially 10/10, upon ems arrival 4/10, en route 8/10, 9/10, and 10/10 upon arrival at ED
- T – No previous episodes
- RR: 18
- HR: 72
- NIBP: 148/84
- SpO2: 96% on room air
- BGL: 103
The patient was placed on 3 LPM O2 via NC, given 324 mg Aspirin PO, given 0.4 mg nitroglycerin SL and 1 inch of nitroglycerin paste. The patient’s pain increased en route to the ED and began to radiate down his left arm en route.
12-lead ECG #1
Sinus rhythm with a rate of 68 and borderline first degree AV block. The R-wave in lead V4 is cut off by the top of the ECG paper. The prominent T-waves in leads V3 and V4 are probably due to early repolarization.
12-lead ECG #2 (15 minutes later)
The patient was taken to the cardiac cath lab. We do not know the outcome but there is little doubt this represents acute STEMI, mostly likely total occlusion of the circumflex (LCX).
Some ECG machines come with ST-segment monitoring and will automatically print out a new 12-lead ECG when there are changes. Whether the machine does it automatically or you do it manually, it’s important to obtain serial 12-lead ECGs when caring for a patient with signs and symptoms of an acute coronary syndrome (ACS).