Discussion for 51 Year Old Male: Chest Pain

Here is the conclusion to 51 year old male: Chest Pain. You may wish to review the case.

Here is the ECG again:

 

There is a regular sinus rhythm at a rate of about 70. The QRS is narrow. The axis is normal, at about 15 degrees.

Let's take a look at the constellation of ST changes:

There is ST elevation in leads I, aVL, V2-V6. There is slight ST depression in III and aVF (and arguably in lead II) with ugly looking T wave inversions. Some of you also noted the suspicious looking Q waves in III and aVF.

Pericarditis and Early Repol were put forth as possibilities. Remember though, that neither of those will have reciprocal changes (excepting myocarditis, which may present as STEMI). Here, we have reciprocal changes inferiorly. If you were inclined to be thinking about STEMI mimics in this case, those changes should put ischemia at the top of the list.  In addition, as some of you pointed out, the ST changes do not look like Early Repol, and the amount of ST elevation here is alarming.

The crew in this case, along with the physician, decided this was STEMI. The patient was given Heparin, ASA, anti-emetics, and Morphine. His condition improved enroute, and his BP climbed to 124/75.

Upon arrival at the hospital, he was taken directly to the cath lab. There was a complete blockage of the LAD.

 

Here is the cath lab image showing the blockage:

Here is the image after revascularization:

 

I don't know about you, but I always find these images amazing. Fortunately, our patient was discharged from the hospital to cardiac rehab a few days later. He was expected to recover nicely. 

Enjoy the holiday!

 

 

 

 

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EMS 12-Lead

Cardiac Rhythm Analysis, 12-Lead ECG Interpretation, Resuscitation

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Comments
Sharon Sinclair
The 12 Leads of Christmas: V3
As a technician, I absolutely love how comprehensive these posts are. Although I do not have the advanced knowledge or understanding of a licensed provider, I try to absorb as much as I can from posts like these. Maybe one day I will muster the courage to transition to a more advanced position in cardiac…
2015-02-28 20:40:17
A visit to Johns Hopkins #EMSToday2015 | EMS 12 Lead
Episode #11 – Are we harming patients with oxygen?
[…] might remember Mike from one of our most popular EMS 12-Lead podcasts Episode #11: Are we harming patients with oxygen? We finished up the night with food and adult beverages in the […]
2015-02-25 14:33:03
Rollo
The Trouble with Sinus Tachycardia
Had a pt today with a rate @ and around 160, it was indeed sinus tachycardia. The tachycardia was secondary to a stimulant which caused over stimulation of sympathetic nervous system ie sympathomimetic O.D. The treatment was fluid and a benzo. Problem solved.
2015-02-25 00:14:18
Jeff Reader
The 12 Leads of Christmas: V3
When looking at how the heart sits in the chest and how things are named remember they were probabily named during autopsys when the cadaver was on its back.
2015-02-24 16:55:04
darren
58 year old female CC: Chest pain
I would be inclined to ignore QTC as rate is above 100 and unreliable to interpret less than 50 or more than 80. ST segments are interesting as is the history. PE was my first impression AnterioSeptal MI second impression but I'm inclined to consider LV Aneurysm as third Impression as no reciprocal changes?
2015-02-24 04:01:24

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