81 year old female CC: Chest Pain

Here is a great case from NYC Medic, hopefully you'll enjoy it as much as we did!

It's a hot summer's night in the city when the tones drop to Assist Police reference a 10-34 (assault in progress) at a large apartment complex. You arrive and find two cruisers parked, with no officers in sight. A quick check with dispatch reveals they're on the 11th floor in room 1108.

A sign on the elevator politely informs you that it has seen better days and you'll need to use the stairs.

As you exit the stairwell onto the floor you have a good idea as to the location of the scene. Shouting is audible down the hall where an officer stands outside the doorway with his arms across his chest. He motions you inside, letting you know, "they don't speak English, we think it's Russian."

An officer inside gives you a quick report, "we think he wants her to go to the hospital, but she does not want to. We haven't been able to get them to calm down."

Inside you see a large man yelling at the officer and his wife, gesticulating wildly. The wife is seated in a chair and is yelling back, their conversation unintelligible. After exchanging glances with your partner, you yell the only Russian you know, "ROSE-DEST-VOM KHRIS-TO-VIM!" (Merry Christmas!) 

The couple stops, turns to you and begins laughing. You introduce yourself and walk towards the wife, who upon closer inspection is clutching her chest. You point to her chest and ask her if it hurts; she nods her head.

Your partner spies a bag of medications on a counter and begins going through it. You place your hand on her wrist to get a pulse while he reads off the medications: "Lasix, digoxin, simvastatin, some vitamins, and coumadin."

One of the officers places her on the monitor while you get a blood pressure.

  • Skin: cool, dry
  • HR: 40, regular and weak
  • BP: 142/64
  • RR: 20, unlabored
  • SaO2: 92% on room air

The first 3-Lead print is handed to you:

Your partner ask one of the officers to go get the stair chair from your unit.

A 12-Lead is acquired:

  • Rate: 39
  • RR: 1538 ms
  • PR: *
  • QRSd: 160 ms
  • QT: 571 ms
  • QTc: 460 ms
  • P/QRS/T Axis: * / -82 / 91

What do you think is going on?

Given the patient's medications, what medical history do you think she has?

What treatments should the patient receive and should they be started in the apartment or enroute?

14 Comments

  • TC says:

    Alright, I’m new but will take a stab at this. The patient is right now in a tolerated bradycardia (no p waves, wide qrs, regular r to r, rate of 39-40, I am thinking junctional brady). I say the patient is tolerating the rhythm for now because she is alert, conversing/ yelling, sitting upright, with an adequate blood pressure.

    As for what the patient’s history is, I am going with chf afib and high cholesterol. The language barrier is going to make treatment difficult as there is no way of verifying this, verifying allergies, and asking if she has been taking medications regularly. What is the cp caused by, the rhythm, or cardiac event/ ischemia? Has she unknowingly taken more digoxin than necessary?

    As for treatment, on the 11th floor and waiting for a stair chair I would do a lot more than if a quick extrication from a sfh. First off the quickpads/ pacer/defib pads go on. O2 via nc, iv w/ a lock for ease of transport or bag if you are going to try atropine. With the “stable” nature of our patient I am going to just VOMIT-G12 as my instructors loved to say (vitals q5, o2, monitor, iv, treat/transport, glucose, 12 lead). Hopefully that’s all accomplished and I have explained to the patient or gotten some sort of agreement for transport by the time the stair chair comes back up. The ems provider asked the cop to get the stair chair which leads me to believe he cant ask for another crew/fd assistance or it will not be available. Hopefully the officers will also be willing to carry your bags as you and partner operate stair chair.

    If no interpreter via police officer/ language line is available I will just monitor and transport, no asa if I dont know allergy status, no nitro due to the hr. Plus, if I cant talk to her she may be clutching chest due to anxiety or something that isnt CP. Be prepared to give sedation and pace if pt condition changes.

  • Ben says:

    My interpretation is: no p waves visible, with the patient being on digoxin I expect she is known to be an AF pt. QRS >0.12ms so some form of conduction problem. Left axis deviation with negative deflection in II so LAFB. Increased R/S ratio in v1 and v2, however the s wave in I and v6 doesnt look like RBBB (I am not 100% on this as there is 'slight' slurring there) so IVCD. Other explanation for the R/S ratio is RVH, LPFB and posterior MI. With the hx err on the side of caution and treat for the MI. Do posterior leads to double check.
    Possible ddx is angina pectoris with RBBB and bradycardia. I would try her on GTN spray to see if it alleviates the symptoms.

  • Troy says:

    I’m gonna call it a 3rd degree block with a junctional escape rhythm in RBBB and an underlying AF rhythm. Deep T waves are symmetrical. Could be Adam-Stokes Criteria but probably due secondary to ischemia from rate problems. Possible digoxin OD as well. Push 0.5mg of atropine. Although BP is ok I bet she’s usually hypertensive

  • Will says:

    My stab is Junctional Bradycardia with RBBB. My suspicion is raised with the language barrier and use of digoxin that this could be related to digoxin toxicity. My treatment would be geared toward keeping the patients oxygenated. Start an iv and transport. Unless the pt becomes hemodynamically unstable there is no reason to perform in the field interventions. If the shoe is on the other foot however you can consider TCP.

  • marionurse44 says:

    Yes Junctional Brady and RBBB, LAD, Poss Inf. wall MI. Dig Toxiticy is a poss. and lasix with no K+ replacement will account for this rhy. Consider Atropine, O2.

  • Eldon says:

    Patient medications spell out cardiac patient snd this should be treated as an acute coronary syndrome (ACS) event. Patient is possibly having an MI which is affecting the AV node.   We should treat rate, rhythm and hemodynamics. She acknowledges she is experiencing CP so we go that route till proven otherwise. O2, ASA, NTG establish IV and administer bolus NS or LR at 20cc/kg if no change in rate we go to atropine which may or may not have an affect on the rate.  Women are known for atypical MI's so I'm treating this one as such and calling it is a nonSTEMI MI and will transport to a facility with cath capability and she'll probably end up with a pacemaker being put in as well.  I'll have her set up for pacing if her BP begins to drop and she becomes symptomatic.  I'll contact med control to see if they think additional atropine should be given.  I hold on MS until I'm sure of allergies.  I'll run a 12 lead every few minutes to monitor for any changes in rate and rhythm and ST segent changes.

  • Terry says:

    I am going to clutch my chest at the bottom of the stairs and call for another unit. Junctional Brady serial EKGS O2 to keep sats 95% apply pacing pads just in case. Try to keep her calm. Pmhx CHF A-fib old inferior wall MI. “ROSE-DEST-VOM KHRIS-TO-VIM!” actually means GO BRONCO’S!!!!

  • Robert (Las Vegas) says:

    12 Lead Interp: Idioventricular Rhythm, LAD. Wide, regular, with no apparent p waves… v1,v2 kind of have some p waves going on but it could just be artifact.
    She appears stable and there is a language barrier. IV, 02, Transport.
    Would be careful with asa since we don't know her allergies. Another consideration is an electrolyte imbalances which is common with lasix/digoxin combination particulary hypokalemia.

  • Andrew (Wayne County NY) says:

    AB Block Type III, technically an unstable bradycardia due to the chest pain, but vs are fine.  Alot of potential causes and with language barrier not alot of treatment options.  Would treat for possible Dig Toxicity and Hypokalemia due to meds.  Give the pt oxygen, place pacing pads on in case, Saline lock, and transport.   Guessable PMH:  A-fib, CHF, HTN, Hypokalemia. 

  • Nick says:

    I see a lot of people are saying there's a complete heart block/3rd degree AVB. However this cannot be the case. A 3rd degree AVB involves regular P-P intervals and regular R-R intervals, however the two are "completely" disassociated. The strips displayed here show no P waves at all. The underlying rhythm is either junctional with a BBB or idioventricular (more likely due to obviously wide QRS in all leads)

  • Nick says:

    As far as the problem at hand, I'm gonna go with a non-STEMI. Also possible is dig toxicity. Treat with O2, IV (or 2), Give 0.5mg Atropine so the rate is high enough to actually circulate oxygen, see if any change in CP. Transport to PCI facility.

  • ikynchik says:

    I'm agree that have to exclude right ventricular infarction ( RBBB and bradycardia, hypotension is possible ) and AV block with AF ( when RR is regular)

  • Corey Younger says:

    Acutely negative for STEMI, RBBB+LAFB=Bifascicular block, A-fib with complete AV block resulting in junctional escape. Control measures and transport.  Agree with : r/o dig-tox, hypo-K, etc. 

  • Brian L says:

    rhythm strip shows regular rhythm, HR in the 30's, flat baseline. 12 lead shows flat baseline except in V1. Regular rhythm and flat baselines rule out A Fib. Would call rhythm IVR. Assuming VS taken in sitting position. How does patient status and complaints change when attempting to stand? Would definitely start tx in apt w/ O2, IV access, combo pads in place and atropine IVP. T wave inversion in V1-V3 indicates evolving anterior MI. Digitoxicity and hypokalemia also considerations. Agree with witholding ASA due to language barrier. Transport to hosp. with PCI capability.

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