50 year old male CC: Chest pain – Discussion

This is the discussion for 50 year old male CC: Chest pain.

You may recall that the patient started experiencing chest pain during sexual intercourse.

Many of you were appropriately concerned about the possible use of drugs for erectile dysfunction that would contraindicate nitroglycerin! Thanks for pointing that out.

In this case the patient was not taking any medication for erectile dysfunction.

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

This ECG shows an essentially regular rhythm with no clearly discernible P-waves and wide QRS complexes (but not > 180 ms) at a rate of about 90.

The morphology of the QRS complexes are somewhat unusual, especially in the right precordial leads. If this is a supraventricular rhythm I would call it a non-specific intraventricular conduction defect or atypical left bundle branch block.

Regardless of what kind of conduction delay is present (even if it’s an accelerated idioventricular rhythm) we know that the depolarization is abnormal. T-wave discordance is present throughout the majority of the 12-lead ECG.

So does anything look like an acute injury pattern? Absolutely!

Let’s take a look at high lateral leads I and aVL.

Here we can see significant ST-elevation that is concordant with (in the same direction as) the majority of the QRS complex. It is also concordant with the terminal (last) wave of the QRS complex.

That’s bad! We have already satisfied one of Sgarbossa’s criteria to identify acute STEMI in the presence of left bundle branch block (LBBB).

Another feature worth pointing out is that leads I and aVL show pathological Q-waves.

Now let’s look at inferior leads III and aVF.

Even taking into account the wandering baseline and artifact we can appreciate concordant J-point depression.

Is this concerning? Yes!

Why?

Because of the ST-elevation in the high lateral leads. In the words of Tomas Garcia, M.D., one must always consider the company an ECG abnormality keeps.

Lead’s III and aVF are reciprocal to leads I and aVL. So the fact that ST-depression (or at least J-point depression) is present in two inferior leads while ST-elevation is present in the high lateral leads is troublesome.

How troublesome?

Troublesome enough for me to call this an acute STEMI.

Now let’s look at the right precordial leads.

Once again we see concordant J-point (and ST-segment) depression in leads V1-V3. Is this concerning? Absolutely! In fact this meets another of Sgarbossa’s criteria.

Finally, we can appreciate ST-elevation in leads V5 and V6 in spite of the wandering baseline there.

I can’t tell you what heart rhythm this patient is in but I feel confident we’re looking at an acute injury pattern.

So what was the outcome?

Unfortunately, this patient experienced cardiac arrest on arrival at the hospital and was not successfully resuscitated (which is more evidence that it was an acute STEMI).

See also:

An unusual case of right bundle branch block

An unusual case of right bundle branch block – Discussion

5 Comments

1 Trackback

Leave a Reply

Your email address will not be published. Required fields are marked *

EMS 12-Lead

Cardiac Rhythm Analysis, 12-Lead ECG Interpretation, Resuscitation

JEMS Talk: Google Hangout

Comments
know it all parapup
83 Year Old Male: Shortness of Breath
@ Kyle I would question your authority to call out people for not having a license or being a know it all parapup when your tx basically entails "call medical control." I think we can both agree that his cardiac output is not great at all. I assume your reluctance to give him any other…
2014-10-30 20:26:11
Kyle
83 Year Old Male: Shortness of Breath
Well st elevation in avr and v1 associated with anterior and lateral depression would call for possible posterior wall MI. 15 lead would be in order. Also check all the leads for appropriate placing. If v7, v8, and v9 show the elevation i would treat as a STEMI per my protocol. Asprin only until medical…
2014-10-30 18:14:05
Tim
The most awesome STEMI test on the internet!
Thanks for the app. It made me think about all that one may see in the field. The only problem was I never got a score or saw the results of how I did other than saying I had completed the test. Anyway a great way to get the old brain working.
2014-10-30 13:14:27
Brian
83 Year Old Male: Shortness of Breath
I mostly agree with dustin. I believe this is may be an isolated posterior MI. The R wave in V2 points to it being a posterior MI. otherwise it is a 1st degree av block with a LAHB. I am somewhat concerned with the concordant t segment depression noted and in fact if you were…
2014-10-30 04:22:44
Karl Brennan
Understanding Amiodarone
Great article , however in VF caused by hyperkalemia it should be avoided along with lidocaine , Since it shuts down the K channels, the eiteiology of the arrest hyper K, K channels are needed to exchange K in the cell. Calcium , Bicarbonate, dextrose and insulin should be used to decrease K levels along…
2014-10-30 03:04:45

STEMI Expert?

  • Click here to find out!
  • 12-Lead ECG Challenge Smartphone App

    Photobucket

    12-Lead ECG Challenge Smartphone App - $5.99

  • Apple iOS
  • Android
  • Amazon
  • Web Based

  • FRN-TV video review
  • iMedicalApps.com review
  • Interested in resuscitation?

    FireEMS Blogs eNewsletter

    Sign-up to receive our free monthly eNewsletter

    Visitor Map / Stats

    Locations of visitors to this page


    LATEST EMS NEWS

    HOT FORUM DISCUSSIONS