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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58 year old female CC: Chest pain
I would be inclined to ignore QTC as rate is above 100 and unreliable to interpret less than 50 or more than 80. ST segments are interesting as is the history. PE was my first impression AnterioSeptal MI second impression but I'm inclined to consider LV Aneurysm as third Impression as no reciprocal changes?
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