49 year old male CC: Chest pain

From the archives.

EMS is called to the vacation residence of a 49 year old male complaining of chest pain.

On arrival the patient is found sitting at the kitchen table. He appears anxious and acutely ill.

Past medical history: Healthy
Meds: None
Allergies: NKDA

Skin is cool, pale and diaphoretic.

He confirms that he is experiencing chest pain.

Onset: Sudden while moving furniture 30 minutes prior to contacting 9-1-1
Provoke: Nothing makes the pain better or worse
Quality: “Crushing”
Radiate: The pain does not radiate
Severity: 10/10
Time: No previous episodes

Breath sounds are clear bilaterally.

No JVD or pitting edema.

Vital signs are assessed.

RR: 20
Pulse: 50
NIBP: 138/79
SpO2: 98 on RA

The cardiac monitor is attached.

Sorry about the fading but this is what happens to ECGs over time (which is why they need to be copied or digitally scanned to preserve them for posterity).

A 12-lead ECG is captured.

A second 12-lead ECG is captured with lead V4 in the position of V4R.

Do you think this patient is having a STEMI?

Why or why not?

Describe how you would treat this patient and why.

See also:

49 year old male CC: Chest pain – Conclusion

21 Comments

  • Daanny says:

    Yes I do this this is a STEMI.

  • Gus says:

    STEMI for sure in II,III, and AvF. I just had the same call recently.

  • Gus says:

    Treatment would be IV, asa 324mg, call Med control before nitro. In this case they are gonna deny nitro because he is Brady and will bottom out.

  • Nick says:

    Inferior wall MI w lateral ext. 02 ASA NITRO

  • ryan says:

    Yep, call it like I see it an I see an Inferolateral MI that is probably evolving in front of us. Going with MONA as usual, early PCI activation, forward those 12 leads on, bilateral IV’s of saline, o2, rapid transport..and..if I have time, a right sided EKG.

    Gus, why would you say he will bottom out with the nitro at the rate he is at? Nitro has a very rare side effect of paradoxical bradycardia and his pressure is acceptable as is. If anything we’d see reflex tachycardia. While he, or anyone for that fact, may have significant vasodilation, nitro should not be witheld in this case. Doing so would only cause further harm. We can assume with the rate as is that it is of an RCA local blockage which is why we are seeing the rate. Open that up and I bet the rate increases…just saying.

  • ryan says:

    Also, if you were thinking he would bottom out due from the nitro being an inferior wall, then yes, I’d say that would be a concern. But, thats why we give fluids for pressure support.

  • Jmorrison349 says:

    Ryan
    I think caution with nitro is an appropriate concern.

  • Greg says:

    Caution is definitely warranted. I wouldn’t be afraid to give nitro because of the rate itself but inferior mi’s are generally the ones associated with hypotension and bradycardia. Besides you get more bang for your buck with the ASA. Fluid is the treatment of choice but nitro isn’t important enough to risk it. I might consider a nitro drip but most of us don’t have that. This is the reason that I do not give nitro without an IV and a 12 lead. Also I would want a V4r.

  • ryan says:

    Totally agree, especially in this patient, or any for that fact.. I’d opt for an inch of nitro paste, instead of the instant shock of the sublingual delivery personally speaking. If his pressure was 100/50, I’d be really concerned at that point, but, we’ve got a good pressure right now and he needs it.

  • ryan says:

    Greg, I’d argue that nitro is only ineffective in complete occlusions. We cannot determine level of blockage in the field, so I don’t understand why you are suggesting that it be withheld just becuase the patient could experience some hypotension.

  • Wes says:

    Elevation II, III, avF, v5, v6. Inferolateral MI. No elevation in v4R and lead III does not seem to have more elevation than II, so I am not too worried about right ventricular involvement. Activate cath lab. 02, bilateral IV’s, ASA, nitro, morphine/fentanyl for pain. Serial ekg’s and keep blood pressure in check. Use caution with nitro, but I don’t see a problem using it in this scenario.

  • VinceD says:

    Clinical picture + ECG = STEMI. There’s likely infero-lateral involvement with elevation in II, III, aVF, V5, and V6, along with maybe 0.5 mm in I and V4. The morphology of III is what really has me sold on this being a pathological ECG with its convex shape and terminal T-wave inversion. I’m torn on whether those q-waves in I, II, aVL, and V3-V6 are due to the infarction or not because they’re normal in depth and duration, but there’s just so many and they reach so far across the precordial leads. Oh well, it doesn’t change my interpretation or actions aside from making MI slightly more likely.

    For treatment, I’d call a STEMI alert, give him 12L NRB as required around here (although titrated O2 via NC would be a nice option), 325 mg ASA, max him out on nitro, and if he’s still symptomatic, finish with morphine (fentanyl is just as good but we don’t carry it). Serial ECG’s en route.

  • Meg says:

    I’m a recent reader but new poster, so I’ll throw my thoughts in too. As soon as the first EKG printed out I’d be faxing it to the ER over our data line and activating the STEMI alert. It seems pretty strait forward and presentation fits the picture of a STEMI, inferior/lateral MI. I’d consider doing a V8 or V9 as well. (in fact I’d cover V4R and V8/V9 on the second EKG) ASA, IV plus 2nd if I have time, THEN the nitro with caution, but I would still give that first dose. Is he really that bradycardic though? Low 60′s might be his normal rate if he’s otherwise healthy.

  • amine says:

    very happy to participate here :
    ECG shows electrical signs of antero-lateral acute MI.
    i think the per-hospital treatment should include:
    2 venous line
    250Mg of aspirine per os or IV if patient vomiting
    4 tablets of clopidogrel 75 mg (plavix :300mg )
    Morphine in titration (personally i use Temgesic in IV) in iv
    0.3 g of Lovenox in IV if age less than 75 years old otherwise 5000UI of sodic heparine in IV
    Thrombolysis (streptokinase actylse or metalyse) if Kt room no available

    that’s the pre-hospital STeMI treatement in my country

  • hard to bet against it.

  • akroeze says:

    @amine

    Aspirin IV? Not doubting you, just never heard of it before.

  • Paramedic1052 says:

    Let’s see… sinus mechanism… no atrial abnormalities… No inter-ventricular conduction abnormalities… ST segment elevation >2mm in II, III, and aVF… no ST segment depressions… hyperacute T waves in V2, V3, and V4.

    I’m not 100% sold on STEMI… with the lack of radiation and the lack of ST depressions on the 12-lead, I’d look for another cause before I started treating. Any difference in radial pulses? Is there a difference in blood pressures between the two arms?

    Also, it says “NIBP”… how about a manual pressure? I’d also like a 15-lead while we’re at it.

  • Tony says:

    Inferior and lateral involvement. Probable depression in V1 and V2 so beware posterior involvement as well, wise to avoid nitrates in the presence of a right sided infarct, stick with Mso4, aspirin and O2, avoid unnecessary fluids in a failing heart like this one, worth a right sided ECG and posterior view with V8 and V9. Time critical patient for bypass straight to PCI.

  • The Jarvik 7 says:

    The T-wave morphology is suggestive to me of hyperkalemia (somewhat peaked rather than rounded, concave sides) — this does not fit the clinical picture but it may be worthy of mention.

  • Greg says:

    ryan,
    I’m not saying nitro should be withheld. I’m saying it should be used with caution. Younger pt’s tend to crash hard and fast.

  • Jarvik: sorta reminded me of hyperacute T-waves. But I see what you’re saying. Concomitant mild hyper-K due to binge drinking on vacation? :)

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EMS 12-Lead

Cardiac Rhythm Analysis, 12-Lead ECG Interpretation, Resuscitation
Comments
Dan
“Bad heartburn” – 82 y.o. female without chest pain.
I'm on board with most of the convents so far. No need to elaborate. I would add maybe a dissection into the aortic root causing RCA occlusion. Not going to know without imaging. Call cath from the field regardless.
2014-08-21 07:41:17
Dan August
“Bad heartburn” – 82 y.o. female without chest pain.
Correction S* and T wave.
2014-08-21 01:53:14
Dan August
“Bad heartburn” – 82 y.o. female without chest pain.
ST elevation in all leads is caused by early repolarization. That's why the Q and T are mashed together. Could be a stemi, but you can't tell with this going on.
2014-08-21 01:51:45
Brooks Walsh MD
“Bad heartburn” – 82 y.o. female without chest pain.
Very interesting discussion - I had not anticipated the degree to which giving/not giving nitro would be controversial! I had my own agenda in presenting this case, but I think it would be better to follow the interest of our readers. I'll add a few pearls about ACS, nitro, and inferior STEMIs in my discussion…
2014-08-21 00:14:19
Sassy
“Bad heartburn” – 82 y.o. female without chest pain.
Our local protocols prevent administration of GTN to RVI, Inferior STEMI with BP less than 160 systolic or HR less than 50bpm. As more than 50% of inferior MI's have RV involvement you walk a very fine line between preload and none. The HR could possibly indicate RCA occlusion so there's one side of your…
2014-08-20 22:23:14

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