37 Year Old Male- CC: Chest Pain

This excellent case comes to us from Paramedic Jack Buckle. Thanks Jack!

You and your partner are in the middle of a busy shift, when you are dispatched to 37 year old male complaining of chest pain.

It's almost 2pm, and a balmy 78 degrees.

You arrive to a well kept house and find your patient sitting in his kitchen. He looks pale, but you don't notice any obvious distress.

"How can we help you today?"

"I just haven't felt well for a couple of days. No energy. Chills.  And I've been nauseous."

"What made you call 911 today?"

"Well, to be honest, I started having some chest tightness today and I got really scared."

His discomfort, 6/10, is poorly localized and non-radiating. He describes it as "intermittent". It started when he was at rest, and began about 2 hours prior to calling 911.

After talking with your patient, you understand that he suffers from depression stemming from a rugby accident that left him with a severely painful back condition.

In fact, he has previously undergone L5-S1 fusion surgery. He takes several pain meds for this chronic condition.

Although he states that during a recent hospital stay (related to back pain) he had to be on the cardiac monitor (he doesn't know why), he denies any history of cardiac problems, and no allergies.

Vitals:

  • Pulse: 78 regular
  • BP: 141/90
  • RR: 20, unlabored
  • SpO2: 99% on high flow O2
  • Skin: pale, cool and dry

You acquire the following 12 lead ECG: 

 

You are 14 minutes from the community hospital, and 22 minutes from the nearest PCI center.

 

YOU MAKE THE CALL:

What do you think is going on with this guy?

Where should you take him?

How should you treat him?

 

 

29 Comments

  • Danny says:

    Certain Elivation in 2-3 & AVF, Off to the Cath Lab with this one & Agressively Manage His Pain and Follow the Local Chest Pain Protocol.
     

  • Travis says:

    This is a complex case. I think the most likely cause of the ST-Elevation being seen on the EKG is an early Pericarditis. That is based on the evidence we have, he has been sick recently, he has had surgery recently, which is a source of exposure to IV pathogens. I'd like to know what his temp is, specifically what his meds are for depression (tricyclic) and find out about his compliance…did he vomit them up and then take a double dose thinking that would help? …and heart tones.
    However, he is certainly at risk for other problems. Electrolyte imblance secondary to decreased kidney function, poor fluid intake while sick etc. I would treat him for an MI and give him some fluid, ASA and I would consult for NTG. I am not sure how NTG given in the pressence of a developing Pericarditis would play out. I would also consider and consult for NTG paste so if a trending decrease in blood pressure developed I could wipe off the dose and give some fluid.
    This has been developing over a long period, but since the cx pn just started, I would transport to the PCI capable facitlity. Its obvious that I am not going to diagnose this patient in the field, but the pts stable. I can spend the extra few minutes to transport to the more capable facility. I would consult with the ED doc on this case for the Cath Lab Activation and put that decision on him. If I had no consult available, I would call the cath alert. Better to have the cardiologist call the time out then me. I'll take the heat if I was wrong at run review.
    Also, I think a PE deserves an honorable meantion for an acute onset of non-radiating chest tightness post surgery. This pt is not tachycardic and there is no S1Q3T3 for what thats worth. There was no RA sat but my feeling from the case is that this pt is not having a PE.

  • Brooks Walsh says:

    Great ECG! I wonder what the computerized interpretation is, and how it may have affected the real case.
    If this ECG were sent in from EMS, I would hold on the cath lab. First off, the clinical story is weak – a non-radiating pain without any apparent associated symptoms. Second, the ECG shows a fair amount of STE in the inferior and lateral regions, without corresponding depressions, and with arguable PR interval depressions.
    However, before jumping to pericarditis, I'm going to *treat the patient, not the monitor.* (Too soon?) A recent study in the NEJM about treating pericarditis indirectly supports the utility of the history and physical exam over the ECG (http://www.nejm.org/doi/full/10.1056/NEJMoa1208536#t=articleMethods). (I'm lumping ultrasound in with physical exam, I know…). I'd like to ask a few more question about the quality, (e.g. how positioning or breathing changes the pain), and I would find a quiet spot to listen for a rub.
    Of course he warrents testing with troponin, but I'm not calling the alert at this point.

  • Pat Moran says:

    Although pericarditisis is possible would expect to see changes in every lead with a coresponding cardiac rub. Would treat as stemi and transport to PCI as st elevation is more typical for a inferior-lateral wall MI 

  • Ironmedic says:

    I would keep early onset pericarditis in the back of my mind due to the symptoms of nausea, lethargy and chills and the pattern of ST segment in II. However, elevation in two contiguous leads gets this guy a trip to the PCI center and a STEMI alert. I can suspect pericarditis all I want but I would rather alert the cardiologist and let them make the final diagnosis. Aggressively treat chest pain en-route, trying to bring the pain down to zero while I maintain NaCL on a KVO rate and monitor vital signs. At least one more 12-lead en-route and early activation of the STEMI team. 

  • Brian Behn says:

    If this is a double post please delete the other posts by me:
    This appears to be Pericarditis. There is diffuse ST segment elevation and no reciprocal changes noted.
    There is PRs egment depression in many leads.
    Spodick's sign is present in lead III and V3-V6.
    Knuckle sign ( not sure if that is epynonomous or not) is noted in aVR ( PR elevatyion in aVR)

  • Andrew y says:

    I would definately fax the EKG and let the decision fall on medical control. There is obvious elevation in 2, 3, and AVF; however I don't see any reciprocal changes.   With recent Hx I would be concerned with pericarditis due to the lack of reciprocal changes.  However, I definately would transport patient to a facility CAPABLE of PCI.

  • Andrew y says:

    Also, the qt appears greater than 400. My phone isn't detailed enough to give me a good picture of it but that does indicate cath lab criteria.

  • Brian Behn says:

    Man, I am blowing it on teh internetz forums today – I was hoping to be able to edit my post…if there is any way to merge this with my above post, please do..and if not, sorry for acting like an interwebz noob.
    As far as what I would do with this patient? I would do some more assesment. Does the pain change with position? is the patient more comfortable leaning forward? I would check a temperature and I would listen to heart sounds to see if I could hear a pleural friction rub.  
    I would titrate his high flow oxygen, (hopefully) down to a more resonable level on a cannula and I would take him to a hospital. establish an IV, repeat 12 lead and vitals, some fentanyl for pain if the patient is so inclined.
    I should say that it is possible to have an MI with ST elevation and no reciprocal depression, as in the case of an InferoLateral AMI with a "wrap-around" pattern of coronary circulation. So could this be an inferolateral MI with a wrap around circulation pattern and the Lateral Elevation is essentially canceling out the reciprocal depression?  I guess that is possible, but with the Hx suggestive of pericarditis, the PR depression, PR elevation in aVR and Spodicks sign I would lean strongly towards pericarditis over an inferolateral MI.
    No STEMI alert, no Cath lab. 

  • Aaron says:

    Prinzmetal angina?

  • Paul says:

    I see PR segment depression and concave elevation with the evaluation being greater in lead II than III- paracarditis. I would give this patient fluid and return to him to which ever hospital he was previously at with his medical records.

  • Jim says:

    this patient presents as a normally healthy 37 y/o male with onset of substeral non-radiating chest pain coupled with symptoms of nausea, pale "COOL", and diaphoretic with a PSQ of 6/10. PMH states the hospital staff had him on cardiac monitor for what he states as "unknown reasons." While I understand the pathogenic response due to previous hospital stay, I would be more comfortable with more of a febrile, diaphoretic, nauseous response. Fact remains patient presents with symptomology and a EKG consistent with an Inferio-Lateral MI. It would be nice to see reciprocal changes, however they don't always present. This patient gets continuous 12L monitoring, reprofusion therapy, ASA, NTG until max dose, IV, transport to a PCI facility. Contact Med Control, send initial 12L to receiving facility to prep for Cath Lab

  • Jason says:

    I really don't see this as being an MI…however, I'm going to prepare for the worst.  His elevation in II, III, AVF definitely has me concerned…but without reciprocal changes…I'm not convinced.  I think Pericarditis as the issue here based on history, exam, and strip.  However, still treating for the worst.  O2, IV, Monitor, NTG, Fent, ASA.  Just no STEMI Alert called enroute.  

  • Pelagic says:

    Pericarditis

  • Matt says:

    You don't need reciprocal changes for it me be an ami!

  • Wyatt says:

    I'm going with pericarditis.  He has wide spread st elevation with pr depression, pr elevation in AVR.  Also his CP for 2 days intermit along with having "chills".  Transport local hospital no treatment.

  • VinceD says:

    With a frontal ST-vector of ~75 degrees and such diffuse precordial ST-elevation I'm calling it pericarditis, but that's always so much easier to do from desk than in actual practice. Serial ECG's are definitely indicated, especially with his waxing and waning symptoms. Tough case Jack.

  • abdullah says:

    i Dont think hes going to have an MI >>  yet should have serial EKGs .  close monitoring> csrdiac enzymes . .. more assessment of  quality and radiation of pain., relatioon to posture, respiration ..  thnx

  • Mike M says:

    1. I think this is Pericarditis. Recent chills (fever), nausea, lethargy. Intermittent for 2 days. Would like to assess his pain positionally. Elevation looks concave throughout, no cardiac history, and he's young.
    2. Take him to local hospital.
    3. Pain management en route. 

  • FLMedic311 says:

    @Brian Behn  I like your call, on top of H/P many signs pointing to Pericarditis!

  • Steve says:

    Obvious elevation but no noted reciprical changes.  I would want to do a posterior EKG just for due dilligence.  Is the pain reproducable?  Coughing?  Recent surgery with sickness and vomiting, dehydration is to be considered with the subsequent rubbing / pericarditis. 

    While I can activate the cath lab solely off my decision, I wouldn't for this.  I'd send my 12lead, I'd give some ASA, but that's about it.  Transport to the PCI facility and let them do the final determination.   If you even think there could be a cardiac component (which obviously you do since you did a 12lead) no reason to not transport to a facility capable of handling it in the off chance it is cardiac.    (While I can give NTG down to 90 systolic, I personally only give it if the patient is hypertensive after a discussion I had with my medical director and what he does in the ER)

     

  • James says:

    Agree with St elevation in II, III, AVF, V5, and V6. I don’t see any reciprocal changes (avl may have some st depression, but I think that is baseline wander)
    Is this a STEMI? My call, no. I don’t see any reciprocal changes. I don’t see obvious change to the qrs axis.
    Plan: ASA, nitro by protocol. Serial 12 leads enroute, if possible transmit 12lead to medical control and discuss case (?avl depression, lack of T wave in avl). I’d probably do a R sided 12 lead even though elevation in II>III leans against R sided MI. Transport to cath center probably best idea here. Probably over triage here, but I feel it is appropriate here.

  • deezy says:

    UPWARDLY CONCAVE ST ELEVATION!!! Low probability of STEMI with this morphology alone, let alone the ST-E is nearly global.

    No cath lab. Complete the prehospital assessment by obtaining a temperature in pertinent cases. Now a temperature is not needed for a drunken bar fight, but for this instance, it is, due to the high suspicion of pericarditis as detailed upon the questioning.

    Have the pt lean forward and see if there is any change to the ECG and/or pain.

    And treat per protocol.

     

    Take him to the hospital of his preference. Not wrong for going further to the cardiac hospital, but whatever.

  • Kyran Vale says:

    I am going with Pericarditis as well. Have to consider the fact of his cardiac history and age – both working in his favor. I would treat for pain and take him to the local hospital for treatment.

  • Alexander Labak says:

    Infero-lateral STEMI! ST elevation in II, III, aVF, V5, V6, flattened ST in AVL. Off to the cath lab.

  • J. Collins says:

    Pericarditis is my initial diagnosis.  The wide-spread ST-elevation, depresse PR-segements indicate that.  General illness, intermittent chest pain. Like Kyran said, age is in his favor.  Unless his family all died from early-age heart disease I'm going to go with an extremely-low probability of MI.  The upward concavity of his ST-segment also goes against an MI.  Support ABCs, IV, normal saline KVO, temperature(if my service had them).  Facility of his choice. 

  • Chau Son says:

    I can say that this is a pericarditis EKG with diffuse concave-upward ST-segment elevation with concordance of T waves; ST-segment depression in aVR and V1, PR-segment depression; low voltage; absence of reciprocal ST-segment changes. Clinical symptoms suggested a pericarditis. The chest pain is atypical.

  • Sarah Wilson says:

    With the inability to rule out a STEMI in the field (due to inability to check CK, CKMB, Troponin levels), I would treat this as if it were a STEMI and call a STEMI Alert/Cardiac Alert. Treatment plan: oxygen (maintaining sats 94-99%), cardiac monitor, IV (NS TKO or titrate to BP), 4 baby ASA, nitro (titrate to BP), vital signs q5 mins, consider morphine, and monitor EKG/cardiac monitor for any EKG changes. Also, treat the patient, not the monitor.

    I have seen many different presentations of AMI's, from no pain and "just not feeling right" to crushing chest pain radiating into the left arm. I have seen slight ST Elevation on the monitor and it turns out to be an early repolarization pattern. I have seen patients as young as 23 years old that have had a confirmed heart attack and were taken to the cath lab. I like to resort to the CYA Protocol we were all taught in paramedic school, the hospital/patient is not going to dock you or get mad for over-treatment and being cautious. I have screwed up before with that, luckily the patient outcome has always been good, but some day it may not.

    Treat your patient, CYA protocol, give excellent patient care. I love the discussion answers I've seen, and it's nice to see what other people think, I learn a lot.

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