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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EMS 12-Lead

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Comments
Alex
100 yof CC: Rib pain and intermittent spasms
>>Too perfectly lined up with the T-waves, while the isoelectric line is relatively stable, to be strictly movement artifact. Can these spasms be sync-d with (or caused by) mechanical movement of the heart walls?
2014-11-25 23:20:19
Erich
What it Looks Like: Cardiac Arrest
Fantastic post, must see stuff for junior paramedics, medical students, residents and nurses that could potentially see cardiac arrest on a regular basis.
2014-11-25 16:22:28
LITFL Review 156
83 Year Old Male: Shortness of Breath
[…] ischaemia? Check out this case from the EMS 12 Lead blog. For more effective learning, read the original case first. […]
2014-11-25 09:09:03
ECG Axis Interpretation
The 360 Degree Heart – Part I
[…] http://www.ems12lead.com/2014/09/11/the-360-degree-heart-part-i/ […]
2014-11-25 09:01:37
LITFL Review 152 - LITFL
The 360 Degree Heart – Part I
[…] you understand axis as well as you’d like? The EMS 12-Lead blog gives us the first in a new series on understanding axis on the ECG. […]
2014-11-25 08:55:15

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