47 year old male CC: Crushing chest pain

Here's an awesome case submitted by Phil, an Intensive Care Paramedic from Australia. Some minor changes have been made to ensure patient confidentiality.

EMS is called to a track and field event for a 47 year old male patient with chest pain.

On arrival the patient is found lying on the grass with a cold, wet towel on top of him. He appears pale and acutely ill. Otherwise he appears to be in excellent physical condition.

  • Onset: 30 minutes prior to EMS arrival
  • Provoke: Nothing makes the pain better or worse
  • Quality: He describes the pain as "crushing"
  • Radiate: He describes an ache to his jaw and left arm
  • Severity: 8/10
  • Time: No previous episodes

Past medical history: CAD, dyslipidemia, mild hypertension, stents x3 approximately 4 years ago

Medications: Numerous but not immediately available

Vital signs are assessed.

  • RR: 22
  • HR: 90
  • BP: 210/90
  • SpO2: 95 on RA
  • Temp: 36.9 C (98,4 F)
  • BGL: 10.8 mmol/l (194 mg/dl)

Breath sounds are clear bilaterally.

The cardiac monitor is attached.

A 12-lead ECG is captured.

A rhythm change is noted on the monitor.

The patient is still conscious.

What's going on with this patient?

What is your next move and why?

27 Comments

  • Brandon Hampton says:

    First, what is going on with this patient:   Acute STEMI antero-septal with lateral involvement.
    Second, my next move is to prepare to be working a full arrest.  No time for sedation, but I would check a pulse even though the patient is still conscious.  I have heard from a coworker of an incident that happened to her of almost 20 seconds of asystole with the patient still talking.  After pulse check, I would defibrillate, because the rhythm change went to what looks like a coarse VF.  I toyed with the idea of Torsades, but the deflection/direction change/flip is not pronounced.  I also would call for air transport if I am considerable distance from a PCI center.

  • Danny says:

    Looks like V-Tach to me. Follow V-Tach algorhym for your agency.  Lets not make this any more complicated than it is.. Save this one.

  • J says:

    Concur with Danny and Brandon.  Sedate if conscious (if time allows), cardiovert to a sustainable rhythm, treat the A-S AMI, and move rapidly to a PCI center.  Prepare for imminent arrest, looks like he is CTD.  Would love to see the patient's outcome on this.
    Does the patient know which arteries were previously stented?

  • William says:

    He is having the BIG one with ST ELEVATION in lead II and VI thru V6 as well as AVF.  I have not seen it in the field but I am going to say the rhythm change is Trosades de Pointes..looks like a constant twiting you would expect to see.  If I am right then IV and hang a IV Bag of NS 1000 TKO and bolus after each round of med.   Mag Sulfate 1 to 2 mg/kg IVP rpt every five to 10 min in 0.5-0..75 mg/kg to a max of 3 mg.  I would apply the pacer pads.  I would give ASA and hang a bag.  I would contact medical control for orders to give the nitro as I am not sure why giving it to a patient with this rhtyhm would do.  (Will as a doc if I cannot find it on my own looking it up).  Monitor Patient and be prepared to treat any new rhythm changes and intubate if necessary if patient crashs.  
      If I am wrong and this is Vtach with a pulse please tell me why.   Still a new medic and want to lean.  

  • TJ says:

    I’m fairly new to this gig(finished medic school recently and waiting to take my state exam), but it looks like torsades to me. It would be nice to have a longer strip to look at to be sure, but I understand there was no time to reach over and push print. I guess the pt could still be talking, but he won’t be soon. I would shock him and then move to a mag drip if electricity didn’t convert. Being new, I’ve never seen torsades in person, and every medic I’ve talked to tells me that they have never had that rhythm outside of an arrest scenario. So I guess that it is exceedingly rare to see torsades in a conscious patient, if it happens at all. But I would love to know for certain. Hopefully the treating medic was able to get the patient out of this rhythm and into a cath lab quickly.

    Also, I want to say thank you to everybody that ever shares on this blog. I read it pretty regularly, and I’ve learned a lot just in a couple months. Its really helped this newbie enhance his ekg skills.

  • Karen says:

    I'm just getting into this so I'm really stumped.. but just to piggyback on TJ, reading all your responses has been a big help. So thanks!

  • TJ says:

    To add to my previous post, I misread the end of the original post. I thought it was asking if the patient would still be conscious. Now that I read it again, I see that it makes a good portion of my reply look rather foolish. Sorry everyone!

  • Michael H says:

    Given the background information that it is at a track and field event, assuming in hot weather (is there anything else but hot weather these days?), and that the patient is still conscious,  I would lean toward torsades, too.  High con oxygen, Mag 2 mg, and fluid bolus with close monitoring and rapid transport would be my initial thought.  I would also be prepared to start working a code and contact med control for an early heads up.  I don't think cardioversion, (sync-ed or unsync-ed), would do much good from cases I have heard about.  I am looking forward to hearing your final report.

  • LAGCCMedicXV says:

    This is one massive MI that turns into Torsades De Pointes. As the previous people have said, this rhythm is almost NEVER seen in a conscious patient. Immediate Cardioversion is needed to convert this rhythm. Sedation may be out of the question do to the severity of the patient's conditon. A 1-2 gm Mag Sulfate Drip over 2 minutes (mixed with 10cc Saline in the case of my local protocol) may work to keep him out of this rhythm. Magnesium is a wonder drug for wide-complex tachycardia. Antiarrhythmics such as Lidocaine should be used with caution I think (he is having an MI after all). Let's consider the H's & T's while we're at it. This looks to be a Thrombus since most of the leads are severely elevated. However, put the other causes in the back of your head. This person was found on a track. His electrolyte levels could be off the charts, in addition to the Myocardial Infarction. This person needs immediate PCI. Can't wait to see the follow-up to this case.

  • saraswathi thangavel says:

    it s an acute  anterior wall STEMI … with poly morphic VT.. I would prefer defrillation AS THE PT S HAVING CHEST PAIN.. and immediate revascularisation with tenectiplase or retiplase  andantiplatilet  trasfer the pt to near by higher center   within 10 minand and call and inform them..and primary PCI and get ready for CABG..

  • Rescue_Monkey says:

    My almost educated guess is early repolarization due to electrolyte imabalance that lead to Torsades. Treat the torsades as indicated, 1-2 mg/kg  Mag Sulfate over a few minutes. If that stabilizes the PT he probably needs IV fluids due to dehydration. 

  • Troy says:

    Anterioseptolateral MI with reciprocal changes in II, III, and aVF. Distal LMCA culprit? Q waves in II, III, and aVF. QTC is prolonged but mildly (which I believe is due to the ischemia) so I’m gonna call it polymorphic VT. sedate and cardiovert

  • probie2 says:

    This guy is having a massive MI. As for the rhythm, I am going to call it polymorphic Vtach. I does look a little like torsades, but if you look at the QTc before the rhythm change, it is hardly prolonged. By defininition, torsades is polymorphic Vtach in the presence of a prolonged QT(c). Any pt with a QTc<500ms is very unlikely to be in torsades. 

  • Lance says:

    Can an electrolyte imballance cause a cornary artery spasm?  If this ACS isn't due to a thrombus it changes our treatment priorities.  Administer magnesium sulfate (MgSO4) and re-evaluate the patient.

  • Troy says:

    Probie2,

    According to Garcia and Holtz, anything QTc>440ms is considered prolonged. The main thing I look at is “the company it keeps”. In this case I believe the prolonged QTc is because of ischemia, not hypomagnesiumia. Plus there’s no other clinical findings of hypo Mg+ in the ECG

  • dr uzma says:

    this is polymorphic vt most likely torsede patient should be cardioverted whats about the patient current vital stillkj he has pulse or not.
    n
     

  • Oldmedic48 says:

    I'm struck by the concavity on the upswing of the ST segments in all the V leads as well as the height of the T waves themselves.  I'm leaning toward pericarditis, but the fact that the pain is constant and isn't relieved by any sort of movement/manipulation is troublesome along with the fact the patient is afebrile.  Still, the concavity and number of leads with elevation point in this direction.  It would be nice if ST segment was more horizonal and had a nice "dish" effect to them, but textbook stuff seldom reflects real life.  If you were to combine pericarditis secondary to an electrolyte imbalance such as hyperkalemia, you might see exactly what we have here.  Electrolyte imbalances could also be responsible for the multifocal V-tach (Torsades) noted in the second 12 lead.   Some people have suggested cardioversion or defibrillation, but I doubt if you could provide synchronized cardioversion since the polarity is changing too fast.  Unsynchronized cardioversion isn't going to do anything for the electrolyte imbalance and would be capable of producing some very negative results.  (You must have a viable myocardium to effectively convert the rhythm)  As long as my patient has a pulse and is talking, I'm leaning toward 2 Grams of Mag in 10-20 ml of NSS over 2-4 minutes, followed by 1 mEq/Kg of Bicarb via a second line, followed by another 12 lead.  If nothing else, this approach should be diagnostic.  It might just lead me down a second road, but this is where I'd go first.

  • LAGCCMedicXV says:

    Very well put, Oldmedic48. I suggested this before. This patient was found on a track. Doesn't say how long he was running, whether or not he was properly hydrated, etc. There's a lot of factors that can go into this. And Magnesium Sulfate is the wonder drug. Premixed bags come in real handy at a time like this lol. I didn't consider pericarditis before, but I will now :-)

  • Jordan Schooler says:

    Those are the hyperacute T waves seen in a very early STEMI, followed by torsades. If you don't think it's convincing, it will look much more classic on the repeat EKG after you get him back from his arrest. I've seen this twice in the last two months. The first patient came back after one shock, the second one took a few more. Both turned out to be 100% LAD occlusion, and I'll bet this is too. 
    As for all this stuff about "electrolyte abnormalities" and the track and field event, OK, what abnormalities? Track and field to me means short distance events. Yes, marathon runners are at higher risk for hyponatremia, but that's not going to explain these findings. Mg and K aren't affected by exercise in a healthy person. 

  • Christopher says:

    I will eat my shoe if somebody can find me a case of pericarditis with STE and T-waves like that (and recip changes to boot)!

  • Taz Rundle says:

    I'm going to go with Torsades (I've witnessed two such cases that both arrested and one shock got them back), in the back of a truck on in the field it doesn't much matter it's a Vtach. I'm not an ICP but in that flowing motion of treatment, Pads cause in 5-10 secs I'll be shocking, large IV with fluids (TKVO) and depending where I am, scoop and run with maybe a volunteer from the location, or any level of backup for hands or maybe some ICP's. My protocols only have lignocaine but I'm not authorised.

  • Stephen NF says:

    Agian im just out of medic school about to take regristry.. but i would immediately cariovert at 150J Bi phasic. recheck the monitor/pulse. if pulseless have my partner start compressions. soon after protect my airway, if apneic begin intubation, but if Pt. could protect his own airway give him high flow O2, start a line and administer the drug that goes with the rhythm, if cardioverted to normal sinus – TKO fluids then code 3 to nearest hospital, if still in torsades w/pulse 1-2mg of mag-sulfate IVP, if torsades/v-tach/v-fib  w/o pulse 1mg epi IVP…. TREAT WITH DIESEL! 

  • SpankyMedic says:

    This is clearly a polymorphic VT, as for TdP…that can be argued both ways. If you’re going to TX this electrically, you’ll need to defibrillate, not cardiovert. As for the other mentioned TX modalities, I agree. All very good insightful commentary.

  • AW says:

    I think this pt is most likely on a Class III antiarrythmic or anginal control medication that prolongs his QT and as a result of demand (his activity at the track) or new ischemia and the long QT he has gone into Torsades.  I would check for a radial pulse with the onset of Torsades and if he has one quickly asses him for change in pain level and LOC.  By our treatment guidlines we are to call in if we can to discuss if he gets sedation and synchronized cardioversion or Mag Sul 2 gm over 2 minutes first.  Pts that continue to have a palpable pulse follow this path, we are left with the justification of consultation time based on presentation.  If he only had a carotid pulse I would certainly begin action on my own and which of the two I put up first might simply depend on how set up in the call I was to that point.  Since I have had time to obtain a 12 lead already I might also have an IV already so Mag could be happening faster than therapy pads and synchronization.  If I did not already have an IV it might go the other way.  Regardless if the Torsades sustains it needs treatment.  My partner has seen Torsades come and go in runs on a pt and the pt not get significantly worse in those runs.  I have only see it come and stay till I did something about it.  Cardioversion has always got rid of it for me but it tends to return without Mag.  Treating with Mag first seems to lower the number and J of shocks from the discussions I have had with other staff.  Always a Class III drug seems to be involved when we see Torsades.

  • ToddB says:

    Are the leads still attached? That’s the first thing I would check. Treat the patient…..not the monitor (I know…..we’ve all heard that ad nauseum….but it seems to apply here). If the rhythm is indeed accurate the stated treatments above seem plausible. Looks lime he’s have a quality MI on the 12 lead…

  • BigWoodsMedic says:

    I'd suppress the OH *(^% at the second rhythm which I'm calling that torsades, it looks like a duck so I'm calling it a duck. Then direct an EMT to place the defib pads, start an IV and hope he remains conscious for the mag. I've only seen this in cardiac arrest and was defibrillated to asystole and never returned. Provided he remains conscious, treat further for ACS, emergent to the cath lab.

  • chase says:

    Load and go. Alert nearest PCI that your enroute with a 47 year old male presenting early signs of STEMI..

    Treatment:

    IV-100ml NS iv bolus, with Mag. sulfate drip. with 0.5mg Atropine
    -Administer Nitro sl (suspect ACS)

    -sedate, dfib

    -place advanced airway if needed otherwise place on O2 via NC.

    (Future medic (BLS/ACLS certified only))

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