Here is a great case submitted by a faithful reader who wishes to remain anonymous. As usual, details have been altered to ensure patient and provider confidentiality.
Hurricane Irene has kept your night shift wet, windy, and you've bounced from one stranded motorist call to another. Dispatch chimes in and puts you out on a chest pain call, 68 year old male at a convenience store, no other information.
You arrive to a neighborhood grocery store and see a small crowd in the doorway. An older gentleman is seated on the ground, in no apparent distress.
You introduce yourself and ask what is going on while your partner acquires vitals.
- Onset: 45 minutes ago he awoke with some chest pain, but went to the store anyways for supplies
- Provocation: nothing makes the pain better or worse
- Quality: "it's like somebody keeps punching my chest"
- Radiation: he localizes the pain to the left side of his chest
- Severity: increased to an 8 of 10, "sometimes I can't catch my breath"
- Timing: constant
Your partner turns and gives you his vitals:
- Skin: cool, dry
- HR: 130, irregular but strong radials
- RR: 26, yet unlabored, too windy to hear lung sounds
- BP: 138/86
- SpO2: 95% on room air
- Temp: 36.9 °C
- BGL: 195 mg/dL (10.8 mmol/L)
Your patient reports a general "cardiac" history and is unable to remember what medications he is on, stating only that they, "are numerous."
With some help from the bystanders you assist the patient to your stretcher and move him to your unit to get out of the elements. Your partner places him on the cardiac monitor while you place him on a nasal cannula and listen to his lung sounds.
You note that his lung sounds are clear and equal bilaterally as your partner hands you the initial 3-Lead. Your patient denies any history of arrhythmias and says at his last checkup he was, "healthy as a horse."
A 12-Lead ECG is acquired.
With Irene still pummeling the Eastern seaboard, it will be at least a 20 minute ride to the closest facility, 30 minutes to the closest PCI capable center. Your partner asks if you'd like him to request a driver.
What is your patient's rhythm and what treatments should your patient receive?
What does the 12-Lead ECG show?
Does the patient need a PCI capable facility, why or why not?