58 year old male CC: Chest discomfort

Here’s another case from a faithful reader who wishes to remain anonymous.

No, these are not all from the same anonymous reader!

EMS responds to a 58 year old male complaining of chest discomfort.

Onset: 30 min ago while mopping hot tar on roof
Provoke: Nothing makes the pain better or worse
Quality: Dull pressure
Radiate: The discomfort does not radiate
Severity: 4/10
Time: Persistent with no previous episodes

The patient is found supine on the ground appearing acutely ill and diaphoretic.

The patient was moved to air conditioned room, skin dried.

Pt denies SOB, allergies, meds, history.

GCS: 15

Vital signs:

Pulse: 66
BP: 116/78
RR: 16
SpO2: 99 on RA

BGL: 92

Breath sounds: clear bilaterally

12-lead ECG was captured.

Crew initiates CP protocol to include O2, ASA, NTG.

The patient declines intravenous access.

Vital signs remained unchanged.

The patient stated that he felt better and did not want to be transported to the emergency department.

The EMS crew was concerned about the patient’s decision and spent the next 40 minutes persuading the patient to be seen at the hospital.

Finally the patient agreed.

The patient was loaded for transport, the monitor was re-attached, and en route other 12 lead ECG was captured.

Are you noticing a trend here?

8 Comments

  • Dan says:

    Still a noob here, but here's a try. Def. a pattern recently in posts advocating serial 12-leads to catch progression. As far as the 2nd 12, ST elevation in II, III, AVF clues in to an inferior infarct. IV access would be great to have in this patient in case of hypotension, and a V4R and a posterior view would be nice too to see if there is something else with that widespread depression in the other leads. Is the p wave considered biphasic? Does the first 12 show an incomplete LBBB?

  • Christopher says:

    Dan, I don't believe the P wave in III is biphasic but rather the limb lead placement may have changed between the two ECGs. Especially if this gentleman was diaphoretic or had hairy arms/legs!Outside of ectopic atrial activity (or maybe a Tp wave in 3AVB) you wouldn't normally see biphasic P-waves in III. Usually biphasic P-waves are appreciated in V1-V2.As for incomplete-LBBB, while the QRSd is 0.10-0.12, V1/I/V6 don't really fit the LBBB morphology. Note how "fast" the initial slope of the R wave is in I and V6 showing that conduction through the left bundle probably went as designed.I do agree: V4R, Posterior, line/labs, early STEMI notification!

  • G.W. says:

    I'm curious if there are any comments about the first 12 without the revealing knowledge of the 2nd. What clues, if any, are there that would lead one down the trail of developing MI?

  • Tom B says:

    Dan – You're right! The trend I was talking about is "serial ECGs". As for the ST-depression in leads V1-V3 I think it's safe to assume it's posterior extension.Incomplete LBBB is not present and I wouldn't get too caught up in the P-wave morphology.The P-wave in lead II looks a little long, flat, and notched, but as a stand-alone finding it's not particularly helpful.Tom

  • Tom B says:

    Christopher -You don't even need me anymore! Hahaha! Tom

  • Tom B says:

    G.W. -To be honest I don't see anything in the first ECG that would worry me.I'd call it non-diagnostic.Tom

  • Terry says:

    So I am not the only one to nag a pt into an MI. (-: Inferior wall. I bet with the second 12-lead the pts pain increased and he wanted to have something done for his pain. Be careful giving someone NTG with an inferior wall MI and no IV. Good job talking the patient in to going to the hospital.

  • Tom B says:

    Exactly, Terry! These patients need to cooperate! :)Tom

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EMS 12-Lead

Cardiac Rhythm Analysis, 12-Lead ECG Interpretation, Resuscitation
Comments
Jewel
53 Year Old Male: Severe Leg Pain
Hmm it appears like your site ate my first comment (it was extremely long) so I guess I'll just sum it up what I wrote and say, I'm thoroughly enjoying your blog. I as well am an aspiring blog writer but I'm still new to the whole thing. Do you have any helpful hints for…
2014-08-31 17:51:28
David Baumrind
All that wiggles isn’t Wellens’
@Gary, by all means, nitpick all you like. I agree with your assessment, and the post has been modified. Thank you for the feedback!
2014-08-30 17:28:16
Gary Huntress
All that wiggles isn’t Wellens’
Not to nitpick but is this really a "slightly leftward axis"? I and AVF are both positive. I put it at about +20 degrees, not leftward.
2014-08-30 11:49:35
Handsome Robb
87 YOM COMPLAINING OF CHEST DISCOMFORT AND DYSPNEA
CHF. 12-lead shows a sinus Tachycardia in the 120s with PACs, besides the anterior leads there's diffuse ST depression, the STE in the anterior leads can be explained by the LBBB, axis is good as well. I wish they posted the EtCO2 waveform so we could see but I'm assuming it's non-obstructive. The elevated EtCO2…
2014-08-30 08:08:22
Christopher Watford
“Bad heartburn” – 82 y.o. female without chest pain.
Brooks, Firstly, thank you for the warm welcome to the club. Secondly, the Glasgow algorithm's only published sens/spec for AMI is 51.6%/97.6% respectively (Tuscon STEMI Database). I've not been able to find any other publications. The GE Marquette 12SL algorithm has been widely studied, but is much older, and ranges in sensitivity from 48% to…
2014-08-29 16:50:14

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