64 year old male CC: Indigestion

One of our faithful readers, Nicholas Eisele, sent in this interesting case study. As always, changes have been made to protect patient confidentiality.

After a long night of car wrecks, you get dispatched right before shift change on a Sick Person call.

As you arrive, your partner states she may have been here once or twice, usually for chest pain. A woman is waiting for you outside.

You meet the patient's wife on the porch and she leads you inside to her husband, sitting in a recliner, holding his chest. He appears to be in mild distress with moist, pale skin. As you kneel beside him to begin your assessment he speaks up.

"I said don't call the ambulance, it is just indigestion."

Deftly you obtain a history while your partner grabs a set of vitals.

  • Bypass x 5
  • Stent placement, "last Christmas"
  • Hypertension
  • Hypercholesterolemia
  • Type 2 Diabetes

You nod your head while the patient explains his reluctance, "to miss a good tee time this morning". You coax a medication list from him as well.

  • Lisinopril
  • Metoprolol
  • Metformin
  • NitroTabs

His wife adds that he was up all night and vomited more than once. She also informs you he has, "serious morphine and PCN allergies."

Your partner taps you on the leg before she quickly runs down the vitals.

  • Weak radials, "barely palpable"
  • Pulse: 80, regular
  • BP: 88/46
  • RR: 24
  • SaO2: 95% on room air

The cardiac monitor is attached.

The patient remains adamant that he does not need to go to the hospital. However, he consents to a 12-Lead ECG.

Due to his diaphoresis, it takes multiple attempts to acquire a readable ECG.

What is the rhythm?

What does the 12-Lead show?

Should this patient be allowed to refuse?

20 Comments

  • alex says:

    - It’s a sinus rhythm but borderline 1st degree heart
    - Normal QRS axis
    - The occasional flipped T
    - Funny looking QRS complex – it’s slightly wide – so RBBB or something? It’s not my idea of a ‘classic’ RBBB but it’s not too far off.
    - Pathological Q waves in various places

    Everyone has the right to refuse, but with his signs and symptoms, I think it would be very unwise not to travel.

  • VinceD says:

    SR, RBBB, inferolateral Q-waves. I'm not seeing any signs of primary ST changes, so there's no way to tell if the Q-waves are new or related to an old MI that might have prompted his quintuple-bypass, but with no old ECG we have to assume they're new. I'm very interested in the duration of this patient's symptoms, and while I wouldn't be brash enough to try and decide the age of infarct based off symptoms alone, it would help with understanding the HPI and maybe shed some light on the ECG. Diaphoretic, with a low pressure, and this ECG, there's no way I'm leaving the house without this gentleman in my ambulance. While we cannot take someone against their will, I'm very confident his wife would be able to coerce him into going to the hospital if she were informed of what is likely going on. He's a very sick fella.

    Posterior leads will be a necessity in this case with ST-depression in V1-2 that is likely secondary to the BBB, but could also be hiding posterior ST-elevation and signs of viable myocardium.

  • allen winters says:

    sr w/ rbb…with history i would encourage him to go to be checked out!!…Cant kidnap him but encourage unless he pass out !

  • zmed441 says:

    I agree on the SR c RBB. its ever so slight but its there. He is certainly within his rights to refuse transport but i would sure start talking to the wife for support to transport. May have to go thru the whole time is muscle thing.  No time to sit and wait on him to pass out. not a good idea!

  • Chris T says:

    sinus rhythm, RBBB pattern, patholigical Q waves, possible brugadas syndrome additionally? With history, current symptoms with or without this 12 lead Im convinced if I cant convince transport ASAP and or leave him he will be code status check for the oncoming shift. I will use all my knowledge, experience and scary lingo to convince him to go with ambulance.

  • James says:

    Agree with Chris T but I'll add some more evidence that this guy really needs to go to the ED.  I'm fairly certain there is a bifascicular block in that 12-lead (RBBB + LPH).  This particular type of bifascicular block is notorious for deteriorating into a complete heart block.  

  • Nick Adams says:

    12 Lead – SR @ 68 bpm, RBBB, RVH, rightward axis (approx 90) (I'd say no to a left posterior hemi-block) (lead II is eqiphasic), old lateral wall MI (Q-waves V3-V6), Inf wall MI with pathological Q-waves in II, III, aVF (new?).
    Given the patients presentation of:  N/V, pain/pressure? (holding chest), hypotension and diaphoresis, I would do a 15 lead EKG with a V4R, V8 and V9 to check the RV and posterior wall.
    Reguardless of the EKG, the patient has lots of risk factors to include:  HTN, Diabetes, and Hypercholesteremia.  Not to metion a very poor PMH of By-pass x5, and recent stent.  It could be a stent failure.
    The patient has to go to the hospital.  I would also point out to the patient that indigestion does not produce theses symptoms.  therefore it is not just indigestion. 
    I would use his wife as a tool to get him to go.  Can call the ED med control to speak with the patient.  Lastly, you could inform him that by refusing, may result in his death…..today.  Ask him if that's what he wants.  If he says yes…….then he's suicidal, and loses his right to refuse…lol

  • Dave B says:

    i agree with earlier posts of SR with RBBB… Q waves inferiorly and laterally are troubling, because we don't know if they are new or old, but with the patient presentation, they are a concern.  inferior MI could cause conduction abnormalities with hypotension and symptoms of indigestion.  how are lung sounds?
    what also troubles me… with the very tall R in V1, i might have expected some j point depression, and a deeper T wave inversion… also, V2 has some ST depression, but with a positive T wave.. this is not normal for RBBB.  also, the rule of appropriate discordance is not happening here in V2-V6.  with positive complexes and no real S waves, the T waves should be inverted and they are not.
    either way, with the patient presentation and atypical RBBB, this patient needs to go to the ED.

  • Dave B says:

    also, forgot to add… i would absolutely want serial ECG's to look for any dynamic changes.

  • Alex B says:

    - RBBB and due to his other presenting symptoms, I would be worried he is headed into a complete heart block. He needs to go the ed and I agree with Dave B, he needs serial ekgs.

  • Earl Bookheimer says:

    i agree SR with RBBB..With a pressure like that vomiting IDDM i would also call Medical Command and transmit the 12 lead to them…  I would ask him to allow an IV due to his BP being low….I would not leave that patient…..i would tell him a IV bolus may help to bring up BP….get aa more detailed HX ….The patient has an extensive Cardiac HX and may nnot want to deal with all the procedures….I thought i saw T wave depression….?? on lead II….

  • Brandon O says:

    Did he take one (or ten) of those Nitrotabs?

  • Jon Eshbach says:

    Q-Waves in multiple leads. QRS is wide and bizzare and appears to have "notches" in some leads, evident of Benign Early Repolarization.
    If this patient is AO times 3, and not on ETOH or disoriented, he has the right to refuse, as long as he is certain of the consequences of his symptoms.

  • Jedi Master says:

    Q or QS waves are pathologic when they reach 0.04 sec in length (one small box) or at least 1/3 the size of the QRS complex …..
     
    I love that rule and it's right more than it's wrong…..
     
    Of course, he can refuse and of course, he speaks with my medical control via truck cell phone BEFORE he signs that refusal.

  • Mufaddal says:

    SR with 1st degree HB. RBBB with possible LPFB. Old inferlateral MI. ST depression in V1 -?V2.
    Nothing to suggest acute pathology from ECG, symptoms suggest otherwise.
    Overnight observation with ECG,BP, I/O monitoring. 
    Order routine labs, CXR, ECHO, troponins.
    He can refuse admission though.

  • The Yoda Medic says:

    QRS is 0.16-0.20.  r R1 in V1.  Right bundle branch block.  P-R .20-.22.  Signs and symptoms, say….right ventricualr AMI.  Do a right sided 12 lead and see where the ST seg elevation is.  My guess is a septal, right anterior. 

  • ToddB says:

    Certainly not a normal 12 lead (as others have indicated). I agree with the RBBB and borderline first degree block with obvious Q waves. I don’t really see anything there that would expain his poor VS though. What does jump out at me is a stated history of GI losses (vomiting) along with taking a beta blocker. That would explain a low BP with the expected tachycardic response blunted by the b-blocker…..hence no way to adequately compensate for the hypovolemia. I’d like some more history about onset, recent illness, etc. If he can stand I would do some orthostactics and listen to his chest. If he wasn’t wet I would hit him with a fluid bolus and see what that does. Maintaining a high suspicion for cardiac etiology is in order as well. Repeat 12 leads and be ready to handle any deterioration. Would also pull out all the tricks in the bag to get him to go.

  • Harrison says:

    I'm betting NSTEMI. Oh, that's because that's what it is. 

  • Koste says:

    SR , PR 20 ms, pathology Q w in II,III,avF,V4,V5,V6. Negative T w in III,aVF,V4 and flat in V5.i don't see any ST  elevation,there is ST depression in V1 due to secondary repolarization abnormalities.
    It's look like RBBB with prolonged QRS,tall R in V1 with ST depresion on it ,prominent S in I and AVL  but there isn't S  wave in V5 and V6 so this is not RBBB.

    RV or posterior MI should be ruled out.

  • Baqui says:

    Beside everything 'till now mentioned, I would consider pulmonary embolism as a possibillity.Pain, hypotension, RBBB, S1Q3T3, tachycardia is missing but beta blockers  are in the therapy …. Big help wil be  to see old ECG strip and after that give some more closer dgx.

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EMS 12-Lead

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Comments
Kevin
44 year old male CC: Palpitations
Why on earth would you risk VF, by giving Adenosine to rule out rhythms.. This is dangerous, and foolish. There might be a slight chance that this is WPW.. You might as well just give him Cardizem, they are both AV nodal blockers... I don't know why the AHA even added this stupid idea..
2014-10-22 13:31:06
Vince DiGiulio
The 360 Degree Heart – Part II
It is standard practice in electrocardiography to label the first 90 degrees counter-clockwise from "zero" that way. When you see a patient with "left axis deviation" you'll see that their measured QRS axis is somewhere between -30 and -90 degrees. Imagine if you saw someone with a mean QRS axis at 5 degrees. Now imagine…
2014-10-21 14:00:37
Bryan
The 360 Degree Heart – Part II
I don't understand why (-)III and aVL are be labeled -60 and -30 degrees instead of 300 and 330 degrees?
2014-10-21 13:43:29
The 360 Degree Heart – Part II | EMS 12 Lead
The 360 Degree Heart – Part I
[…] first post in our “360 Degree Heart” series attempted to visualize how the different frontal plane […]
2014-10-21 12:50:56
Eric Strong
Axis Determination – Part VI
This is a great discussion of axis determination. One minor suggestion: I think it's potentially misleading to refer to an axis between 0 and -30 as "physiologic left axis deviation", since "axis devitation" implies deviation from normal, and axes between 0 and -30 are perfectly normal, (depending on age and body habitus). It may be…
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