Here's an interesting case submitted by a faithful reader who wishes to remain anonymous. As usual, some details may have been changed to protect patient confidentiality.
You are called to the residence of a 90 year old male. Prior to your arrival, he was met by a BLS crew, walking around his apartment in no obvious distress. Upon questioning, he admits to some sub-sternal "chest discomfort" starting four hour prior to calling EMS. As your partner starts to get vitals, you continue your history and learn that the discomfort started while "sitting in a cab on the way home". The discomfort is non-radiating, and not reproducable.
Your partner obtained the following vitals:
- BP: 130/90
- Pulse: 100+, very weak
- RR: 18 regular
- Skin: "unremarkable"
- Lungs: clear bilaterally
- SpO2: 99% on high flow O2
The patient receives 162 mg of ASA (per regional protocol), and as you get additional history your partner starts to put the leads on:
- Discomfort began while at rest in the cab
- Nothing makes the discomfort better or worse
- Pt can only describe an uncomfortable feeling in his chest
- Discomfort does not travel anywhere
- Pt rates it as 7/10
- Discomfort began four hours prior to calling EMS
The only medication he admits to taking is Plavix. His history is significant for DVT (for which he says he takes the Plavix) and Previous MI with CABG (time unknown).
You acquire the following rhythm strip and 12 lead ECG and begin your transport:
While the "data quality prohibits interpretation message" is given, you attempt to get a better tracing but this is the best you can get. In addition, you are unable to get IV access.
The nearest hospital is a community non-PCI center about 10 minutes away, and the closest PCI center is 20 minutes away.
WHAT ARE YOUR IMPRESSIONS ABOUT THIS PATIENT?
WHAT IS YOUR INTERPRETATION OF THE ECG, AND WHAT ARE THE DIFFERENTIALS?
HOW WOULD YOU TREAT THIS PATIENT?
WHERE WOULD YOU TAKE THIS PATIENT?