59 Year Old Male: "Lifting Boxes"

This is part one of today's case study. As usual some information has been changed to protect patient confidentiality.

EMS is called to the residence of a 59 year old male, who's chief complaint is chest discomfort. 

As the crew enters the kitchen, they find the patient sitting in a chair surrounded by family members. He is not happy to see the crew.

He tells them he was doing some lifting of boxes all afternoon, and developed some chest pain, slightly left of center.

He took a break, and it started to get better. Now, 3/10 on the pain scale. He states he has no significant medical history.

The crew ask who called EMS, and he tells them his wife called because she thought he did not look good. He makes it clear that he is not happy with the EMS presence.

As they continue to speak with the patient, they put him on O2 and give him 4 baby ASA just in case. He tells them the discomfort happened earlier in the day when he was lifting boxes, and totally went away when he took a break. He expects nothing different this time. The discomfort does not move anywhere, no shortness of breath, no dizziness or lightheadedness. His wife tells them he was sweating, but he states that of course he was because he was lifting heavy boxes!

The crew takes a quick set of vitals:

  • HR:       90 and regular
  • BP:        148/86
  • RR:       18 regular
  • skin:      unremarkable
  • Lungs:  clear bilaterally
  • Spo2:    98% on O2

The patient's wife convinces him to go and get checked out for her sake. He relents. The crew decides to get him into the rig before he changes his mind, and defers further assessment until then. The patient is ambulatory, and insists on walking to the rig. On the way, he insists on going to the bathroom. Then changes his clothes for the hospital. The crew protests, but he states he will not go otherwise.

Once in the rig, the crew acquires the following 12 lead ECG:

 

The crew does not note anything too concerning, and considering the patient's story and lack of history, they transport him to the community hospital, without any additional ECGs.

CRITICAL QUESTIONS:

  • What are your interpretations of this ECG?
  • What if this was your patient? What would you have done differently?
  • Do you agree or disagree with how this call was handled?

29 Comments

  • Francesco Cassano says:

    Hello everybody, i don't know if i'm right, but i can see slight (1 mm) ST elevation in DIII and aVF and ST depression (as reciprocal image) in V4 and, slighter, V5; moreover negative T waves in V1 and V2. V3 is not very clear… but i would be kind of worried about this EKG.

  • johnny says:

    I think i see a little A Flutter. 

  • johnny says:

    Overall I would have done the same thing with getting him to the ambulance.. AFter that, not so much.. 
    V3-V5 Show some ST Depression with what im gonna call Hyperacute.. I remember reading a thing on Dr Smiths Blog and an Anterior LAD. LEad I shows the same pattern. Also in the percordial leads shows what looks to be some Aflutter with 4-1 conduction. Because of this Id confirm or definatly stop the bus or when at a red light immediately run a 2nd 12-lead.. definatly need serial EKGS. 
     
    Needs ASA, Os, and IV.. Prolly wouldnt hurt to call ahead. I prolly would have attempted to get a 12 lead before he started to move around. although i know its not always possible. Wasnt there so cant judge. 

  • David says:

    Pic not very clear.
    p-r prolonged perhaps?
    BBB pattern, without QRS widening…
    Ischaemic changes inferior, as well as lateral leads.
    I'd love to hear other oinions.

  • Peter says:

    Posterior changes and st elevation slight with flipped t in avr I would be concerned this is abnormal possible posterior mi

  • Rogue Medic says:

    Are the flutter waves causing the appearance of ST depression in V4-V6 and aVL, or are they masking ST depression on some beats? I can't decide. More 12 leads might help. A continuous V4, rather than the usual Lead II might help.

    Does he normally have atrila flutter?

    His lack of history would suggest that atrial flutter is not normal for him. 

    What was his room air oxygen saturation? 

    Oxygen is a drug which we should not be routinely giving, except for specific indications – a low sat on room air or difficulty breathing. 

  • Christopher says:

    The "F-waves"  visible in V2/V3 are irregular and at ~420 bpm, making them more likely to be artifact than either flutter or atrial fibrillation. The ventricular response is regular, meaning if fib or flutter were present there would have to be a complete heart block and an accelerated junctional escape at ~85 bpm.
    I think we can take atrial fibrillation and atrial flutter off the table.

  • kyle says:

    positive mirror test, v4 v5 depression… Get a 15 lead and if it confirms posterior MI, activate cath lab.  

  • Jay says:

    I agree with Christopher; I don’t think those are flutter waves. It’s much more likely that it’s artifact.

    I see depression in V1-V4, with possibly the start of some depression/T-inversion in aVL. I wouldn’t say this patient is in the clear until I get a look at the posterior leads. The R-progression seems intact, but I’d be keeping an eye on those T-waves with serial ECGs.

    I agree with getting this patent into the rig before he changes his mind, but I’d of done a bit more for monitoring and reassessing enroute. It would be silly NOT to give ASA and IV to this patient, but I’d like to get a better OPQRST to rule out musculoskeletal causes, too, which seems like another easy cause in this case.

    As for transport, that would depend on travel time and what my posterior/serial ECGs tell me.

  • David Baumrind says:

    Great comments so far…

    I would also follow Christopher's lead regarding A-Fib/Flutter (hint lol.)

    Would anyone activate the cath lab?

    Why or why not?

  • Faith says:

    I agree with the actions to the unit, sometimes we all have to play along with the pt to get them to go. Afterwards though, I would have monitored the pt better, you can always toss the “extra strips” if there are no changes but you can never print what you didn’t monitor. I would definitely have transmitted the 12lead to a capable facility for the Dr to see and transported past a community hospital.

  • Francesco Cassano says:

    @David Baumrind: to me, activate cathlab asap for infero-posterior stemi.

  • Kyle says:

    Yes I would activate (as stated above) provided my 15 lead backed up my findings on the 12, for the reasons stated above (positive mirror test, st depression in 4&5)

  • ANNA says:

    In my opinion there is ishaemia – ST depressions in V3-V6, so cath lab but before…because of history of lifting I would check if it isn't a dissecting aneurysm of aorta – so echo, if it's clear and there are positive TnI, CK-MB – cath lab.
     

  • Danny says:

    I definately see the ischemia that everyone is talking about, I believe that this is sinus with some artifact. I wish it was a better tracing. I do see the depressions in V1-V2, so possible posterior involvement, but I do not see the inferior changes that some people are noting, if anything I see lateral changes.  I'm not quite sure about activating the cath lab at this point. Interesting 12 lead
     

  • Jan Waldorf says:

    A difficult one. V7-V9 could be interesting…
    Would not yet activate cath lab, but a community hospital without intervention possibility seems not to be approproate for this patient.

  • Kindle says:

    This pt. doesn't sound like the type to see a doctor regularly, so the lack of history doesn't mean too much to me.  Wouldn't activate cath lab based on this EKG. Repeat, hopefully with a cleaner tracing. Also want a 15-lead…the ST depression doesn't look like that seen with a posterior MI, but it's a consideration. Could also be anterior ischemia or a repolarization abnormality from A-flutter. Thinking a clean tracing will show A-flutter, regular R-R interval indicates constant conduction ratio. Increased chest pain with exertion, goes a way with rest points me towards the ischemia or decreased cardiac output from hastened A-flutter as his heart rate increases with the exertion.
    Serial EKG's, treat as chest pain with ASA, O2, Nitro as needed. IV of course.  
    Good job by the crew getting this guy into the truck! 

  • Nicky G says:

    Hi all, thoughts from australia.
    Posterior STEMI
    Hx consistent with evolving MI and manage for ACS. Not allowed to call this a STEMI and activate cath lab in my service (only inferior/anterior/lateral) however would take serial 12 leads and transport to PCI capable facility (I would call interventionalist and advise of pt even if pain and STD resolves as this guy needs diagnostic angio hopefully sooner then later).
    Rx – take off 02 unless hypoxaemic – aim for sp02 >93%. GTN prn, IV access and opiod prn. Hold off on further antiplatelets/coagulants/fibrinolytics as not indicated in protocol unsless inferior STEMI pattern presents.
    Cheers

  • Ivan says:

    I see a sinus rhythm with normal axis and no ectopic beats. However, Hyper acute T waves in inferior and lateral leads with minor reciprocal depression in I & aVLindicating early ischemia with predominant negative QRS in septal leads which is normal, but the septal leads also have almost concordant T wave depression indicating posterior ischemia/infarction or septal ischemia. There is good R wave progression in V1-6 and the QT interval seems fairly normal for now. I think if they understand this changes, this could be a save!!!

  • firemedic24 says:

    Interpretations – artifact… poor quality ECG
    What would I have done differently?  -  Take the time to get a clean ECG
    I have seen more and more poor quality ECGs.  Medics need to learn to go back to basics and get clean ecgs.  Poor electrode placement, not prepping the skin, poor positioning, and dried out ecg electrodes make crappy ecgs like these.  Please take the time to get a real ECG instead of a bunch of artifact.
    That being said the depression in AvL is concerning as well as depression in the precordial leads which would lead me to do a 15 lead ecg to check for posterior MI.  I am not going into further detail in my interpretation because the ECG is aquired very poorly.  Paramedics won't get much respect if they keep bringing patients in with a differential dx based on crappy ecgs like this one.

  • Mike M says:

    Also consider atrial enlargement with biphasic p wave in V2.

  • Darren says:

    I agree with firemedic.  This ECG is the result of not using a razor and a washcloth.  I will further state that some hospitals also have this problem; it's not just isolated to EMS.
    I would be interested to see what the ACTUAL T wave looks like in V3 to assess for Wellen's, especially considering the patterns exhibited in the anterior leads.  This is sinus rhythm with noted depression in anterior and lateral precordial leads, as well as some possible slight depression in I and avL.  I don't see any ST depression in V1 or V2, but that does not necessarily rule out posterior MI; a 15 lead is definitely in order, with skin prep for it as well.
    So far as treatment is concerned, definitely IV and ASA along with nitro and other ACS protocols.  Serial 12 leads are also indicated, as well as obvious reassessment of the patient.

  • Paul E. Morris - CMA RMA MST EMT BDLS says:

    Not too clean of an EKG.
    Some Visible Artifact.
    Do an Echocardiogram at the Hospital.
    Maybe, even an ETT Treadmill…
    ….BOTH Carefully monitored be an MD Cardiologist.

    NREMT would disagree with allowing CP Patients to walk to the Aid / Medic Unit…

  • Paul B says:

    This EKG is useless and of unacceptable quality for the purposes of diagnosing anything. Whoever said razor and washcloth, ditto. Also, don’t put the limb leads on the chest; they are called limb leads for a reason. The chest is not an arm or a leg.

    Based on this atrociously acquired EKG, I see strain pattern in V1-V3 with reciprocal high-lateral wall ischemia. I would do a posterior 12 lead and suspect a posterior wall injury/infarction until can be proven otherwise. Absolutely activate the cath lab, and treat as above plus judicious use of nitrates and morphine.

    I would also be strongly inclined to give 5mg of metoprolol IV due to the patient’s relatively inappropriately high resting HR and hypertension. Enzymes or not I would cath this patient. There certainly isn’t anything to lose by doing so, and early intervention is key.

    Bottom line is get a quality 12/15 lead before doing anything.

  • Paul B says:

    I forgot to add, the other reason I would have for doing a cath post haste, would be the fact that the patient was so hell-bent on not going to the hospital, and only conceeded because his wife had the huevos to give him an ultimatum. What do you think the likelihood of him being willing to A.) Call 911 again, and B.) Be willing to go back to the hospital a 2nd time is? Cath this man. He clearly didn’t want to go to the hospital to begin with, and if he gets sent home, will in all likelihood have another MI at home and not summon an ambulance or go to the hospital. Risk vs. benefit.

  • gbards says:

    I agree, need to get a better 12 lead and curious as to what 3 lead looks like. The ST Depression in anterior leads would lead me to check leads v7,v8,v9 to rule out posterior infarct, other than that Tx done by crew was good, consider NS lock and serial 12 leads.

  • arnel says:

    The limb leads seems nothing to worry but the precordials I think are saying something. Despite showers of artifacts there are T wave invesrions noted in V1,V2 and V3 (?). Though it is not so common, this can be an isolated posterior wall MI (prob LCx).  So more convincing is needed and a PCI-capable center could be a wise choice.

  • WVHillbilly says:

    15 lead posterior, should have gotten a 12-lead in the kitchen.  I can't help but think that maybe the leads are poorly placed or not connected well.  I'd like to see the initial rhythm strip.  ASA, O2 4L NC, Tx.

  • Jeff says:

    I would like to see a posterior EKG, with the depression seen on the 12 its very likely ST elevation will be present or soon to come.  It could have been the difference between the "community hospital" and a STEMI activation with crucial heart muscle for this patient.  Why not take the extra 30 seconds for it.

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