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

Cardiac Rhythm Analysis, 12-Lead ECG Interpretation, Resuscitation

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Comments
Jared
59 Year Old Male: Unwell
Field Dx: Uncompensated cardiogenic shock. Tachycardia caused by compensation mechanism. Probable cause: Complete heart block due to the global nature of the changes. Tx: O2 @ 15 lpm NRB and possibly CPAP if pressure rises enough, 324 ASA, amio drip, possible norepi, and diesel. Put pads on in case he tanks. Definitive Tx: Needs cathed.
2015-07-02 17:46:57
Jonas
59 Year Old Male: Unwell
CPAP. IV. Nitro if BP can be controlled. Kidneys may be in acute failure causing extra fluid, or CHF, or both. Big ole triangular looking t-waves would have me thinking calcium. Monitor to see if conditions improve with CPAP. Place pads on patient, and have help with you in the ambulance.
2015-07-02 17:17:30
Brian Brubaker
59 Year Old Male: Unwell
At a quick glance it looks like tombstones (R on T). At closer look without calipers, it appears to be accelerated ideoventricular rhythm due to complete heart block. Not enough information to go off of, so cardioverting or pacing might just kill the patient quicker than anything. Transport immediately since his sick heart could stop…
2015-07-02 05:49:02
Holden
59 Year Old Male: Unwell
I've only studied cardiology for a few months and have read Dubin's book 1.5 times so I'm not an expert by any means. However, can a possible interpretation be a junctional tachycardia with aberrant ventricular conduction and a STEMI? No P waves and aberrancy causing a slightly wide QRS (but not wide enough for V-Tach).
2015-07-02 00:50:22
James
59 Year Old Male: Unwell
This is a ugly EKG. Wide complex irregular tachycardia around 150's. A-fib and a-flutter are possibilities. He's severely symptomatic. At this point, all treatment is same, electricity. If A fib, it may not want to "shock out" easily. This may be a case where initial cardioversion at max joules would be prudent. Pulmonary edema likely…
2015-07-01 22:00:13

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