81 year old male CC: "Cold and shaky" – Conclusion

Here is the update to 81 year old male CC: “Cold and shaky”.

Let’s take another look at the 12-lead ECG.

2010_06_03Bwm

At first glance the ST-elevation in the inferior and low lateral leads isn’t that impressive, at least when compared to some of the other cases we’ve seen. However, this is an impressive amount of ST-elevation when compared to the small size of the QRS complexes! This is known as the rule of proportionality and it’s critically important when it comes to STEMI recognition!

Perhaps more impressive is the ST-depression in the right precordial leads (V1-V3). These are reciprocal changes to posterior extension of this acute inferior STEMI. If this was the only abnormality on this ECG I would still call it STEMI! If you want to get really good at identifying acute isolated posterior STEMI, pay attention to the right precordial leads whenever you have an acute inferior STEMI. These changes will often be present.

Of course, you already knew that the ST-elevation in the inferior leads indicated STEMI. Why? Because of the downsloping ST-segment in lead aVL! This is the “go to” lead to “rule-in” acute inferior STEMI! It is so sensitive and specific that absence of this finding should make you question the ECG diagnosis of acute inferior STEMI.

So what happened?

The patient was sent to the cardiac cath lab where angiography revealed 100% occlusion of the right coronary artery (RCA). A stent was successfully placed and the patient is doing well.

Before

 

Balloon inflation

 

After successful stent placement

 

Diagnosis: Acute Inferior ST-Elevation Myocardial Infarction

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Comments
michelle
68 Year Old Male: Chest Tightness – Part 1
i see some depression and slight elevation in the st segment in the avr. i would alert the stemi crew to stand by.
2015-07-27 17:15:03
sean morrison
68 Year Old Male: Chest Tightness – Part 1
It's the big one Weezy! LAD
2015-07-27 12:48:03
Brooks Walsh MD
Computer misses it, but the medic catches it.
Well this blog is a great place to start! We cover most every aspect of emergency electrocardiography, with a variety of authors, and multiple perspectives, usually in a clinical context. If it is a book you are looking for, I prefer Ken Grauer's. I started with Dr Grauer as a paramedic student and I still…
2015-07-27 01:45:18
michelle
63 Year Old Female, CC: Neck and Arm Pain
looks like stemi . o2 , fluids, monitor and transport to nearest facility.
2015-07-26 16:24:04
The Six-Step Method for 12-Lead ECG Interpretation | EMS 12 Lead
Axis Determination – Part I
[…] 2.) Axis determination […]
2015-07-26 13:08:05

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