63 Year Old Female, CC: Neck and Arm Pain


Good morning. It's 7:45 am on a sunny winter Monday, and you are just finishing up your holiday shopping list– it is getting down to the wire after all!

The tones go off, and you are dispatched to the residence of a 63 year old female, "sick". 

You arrive to a well kept two story suburban home. You are met by a well looking gentleman who directs you and your partner into the living room, where you find his wife sitting on the sofa looking slightly uncomfortable.

"How can we help you today?"

"Well, i'm having strange pain in my neck and both arms… feels like pins and needles too.."

"Any chest discomfort?"

"A little bit… a little tightness across the front of my chest."

As you continue with the history, she denies any difficulty breathing, lightheadedness, or nausea. She tells you the discomfort woke her from her sleep at about 6 am… she thought it would go away, but it didn't so her husband called 911. Nothing seems to change the discomfort, and she tells you that she is generally in good health–this has never happened before.

Her past history is significant only for hypertension. She was a two pack a day smoker, but she quit 5 years ago.

Your partner acquired the following set of vitals:

  • Pulse: 54, irregular
  • BP: 122/68
  • RR: 18 regular, lungs clear
  • SpO2: 99% RA
  • Skin: slightly pale, warm and dry


You acquire the following 12 lead ECG:



Your patient tells you the discomfort is "not that bad", and asks if you could give her something for it now–she doesn't want to go to the hospital.

What do you tell her?

You are 15 minutes from the local hospital, and about 50 minutes from the nearest PCI center.


  • What is your field diagnosis (yes, I did use that word)?
  • What are the significant findings on the 12 lead ECG?
  • What is your treatment plan?
  • To which facility will you transport your patient and why?
  • Are there any other treatment considerations for this patient?


Thanks for reading, and looking forward to your comments!


  • mike says:

    Inferior wall STEMI. She's getting some ASA, possibly cautious use of NTG and IV with fluid bolus ready to go. I always err on the side of caution with the ladies due to their not so normal presentations with cardiac issues.

  • Jacob Lesher says:

    ST elevation in Leads II, III, aVF. Reciprocal changes in lateral leads. Pt having inferior MI. Consider right sided ECG to confirm, 324mg ASA, IV, hang a bag of NSS tko, supplemental O2 via NC @2Lpm. Continue monitoring pt vitals to nearest facility. Transmit ECG for cardiac alert, contact med control enroute.

  • Bob Barker says:

    Inferior, and depression in V1 & V2 suggest posterior. I’d move V4R over too. Obtain IV access, asprin. Rapid transport, 02. What’s everyone’s thoughts on nitro right now? I’m a paramedic student.

  • Dustin Mills says:

    i belive the patient is having an inferior mi. I think i will be calling code STEMI!!


  • Donald Coffield says:

    ST elevation II, III. and. aVF. 324 mg asprin, Oxygen NC 2 Lpm, IV bolis NS 200cc, NTG 0.4 mg SL, transport To Hospotal with Cath lab for possible STEMI

  • Alex Kroeze says:

    Huh, this is very interesting.  I want to preface this with saying that I haven't read any of the comments yet as I would like to test myself and not be influenced by others.  I also want to say that I'm often guilty of looking too deeply into things and soemthings seeing things that aren't actually there.  With that in mind here are my thoughts.

    As to the rhythm:

    At first glance I was going to call this sinus rhythm with a few PJCs in there.  Looking deeper however I am a bit more concerned.  Looking at the sixth complex it is obvious it is a premature beat.  If you look in lead V3, you see what appears to be a funny hump in the very end of the ST/beginning of the T-wave.  It has an almost P-wave type appearance to it.  Could this be a P-wave?

    Well when I took a piece of paper and drew some lines and mapping it out on my computer screen I see that that little funny hump is EXACTLY half of what is the CONDUCTED P-P interval.  I will call this half distance the "Non-conducted" inteval.  Further, when there are not those premature beats then the non-conducted interval would put the non-conducted P-wave buried in the T-wave of the conducted p-waves.

    My interpretation is that this is a Second Degree AVB with 2:1 conduction and PJCs.

    If those PJCs weren't there, we would have no idea that this person was in an AVB!  (Assuming I'm right that is).



    Second Degree AVB with 2:1 conducation and PJCs
    Inferior, Right Ventricular, Posterior STEMI

  • Dustin says:

    Inferior AMI.  Probably posterior involvement with T-wave inversion in V2 and right sided involvement with elevation greater in III than II.  15 Lead is a must.  She is slightly bradycardic so preparing for a complete heart block is a necessity. RCA feeds Sinus node so V fib arrest or complete heart block can occur.  NTG only after 15 lead, 2 large bore IVs with NS bolus (at least 1 liter cautiously with lung sounds).    She gets a quick ride to closest PCI facility, assuming she allows us.

  • Matthew says:


    STE II III AVF, STD I AVL. Inverted T Waves in V1 and V2 are critical indicators.

    IV, O2, ASA. What are my Air Options? My first thought is Air Intercept at closest facility. If air is not possible, I will seriously consider dieseling to PCI, as long as we can sprint straight through the ER and go straight to the cath lab quick fast and in a hurry.

  • Jason says:

    Sinus rythem, 1st deg block.  Elevation in II, III, aVF and depression with in I and aVL, Pretty straight forward inferior MI.  Need to get R sided leads…but treat with ASA, Nitro (depending on R Leads), O2, Possibly some Fent for discomfort as needed. Call this one in as a STEMI alert.  I would consider Flying her to the PCI if that was an option.  Otherwise, get moving to PCI facility.  

  • BigWoodsMedic says:

    I'm going with inferior STEMI, immediately doing a V4R and V8/V9 for my next capture. Treatment then following our ACS protocol. I would be very interested to see any right side involvement, since I have not seen that in the field yet, and I do V4R on almost every patient that I do a 12 lead on. 

  • DJ says:

    ~~Right inferior wall MI. Confirm diagnosis with a right side 12-lead. ASA 324 mg PO. IV NS KVO. Due to ‘chest tightness’ 0.4mg NTG SL. Second IV access with a saline lock. Scene alert to cath lab, transmit 12-lead, and transport patient to intervental cath capable facility. Hold off on oxygen due to good SPO2 level. Serial 12-leads.

  • Patrick Guziewicz says:

    Call ALS for intercept, rapid transport, 324 mg aspirin, assist with nitro, high flow O2. A little simpler for me as an EMT. Sick patient however, and I can at least say the 12 lead is quite abnormal.

  • Darren says:

    My field diagnosis is an inferior STEMI with some lateral extension in V6.  There is also some more investigation to be done to determine whether there is right ventricular and/or posterior involvement, so a 15 lead with V4R, V8, and V9 is a crucial next step while administering ASA (providing I can convince the patient to be treated.)  Significant findings include ST segment elevation in II, III, and aVF, with reciprocal depression in I and aVL.  Also significant is the depression in V1 and V2, which could point to posterior involvement (V8 and V9 will confirm). 

    Having said that, prepare for worsened bradycardia, AV nodal blocks (possibly one already there), and hypotension.  Be ready to pace and get them to a cath lab. Fluid bolus if RV involvement with possible low dose titrated IV nitro.  Morphine is relatively contraindicated in RV involvement as well due to the decreased preload.  If possible, an anxiolytic might not be a bad idea either to calm the catecholamine sea.

    (1.) Probable sinus tachycardia (rate about 105/min) with . . .
    (2.) . . . acute inferior infarction complicated by . . .
    (3.) . . . Type I A-V block manifest as . . .
    (4.) . . . 3:2 Wenckebach periods and . . . 
    (5.) . . .  2:1 A-V block.

  • Ironmedic says:

    Dx: 1st degree AV block with inferior STEMI. Tx: Immediate transport to PCI facility, while en-route, ASA 324, early activation of Cath team. IV, NaCL KVO and NTG as long as systolic remains greater than 100

  • emad says:

    inferior and posterior stemi give aspirin nd send for pci

  • Jason Roediger, CCT says:

    Was there any follow-up or conclusion to this case???

    Inquiring minds want to know!

  • Robyn P says:

    Posterior MI with reciprocal change. IV access, Aspirin, opiates and PCI.

  • T. Smith says:

    Inferior MI, reciprocal lateral depression, depression V1,V2, doe a 15 lead. STEMI alert, TRX the 12 lead, serial 12’s during transport, fast patches, 324 ASA, O2 as needed, 2 large bore IV’s, labs, nitro drip start 5mcg/min titration to pressure relief, heparin…our agency has a kit with specific pump tubing, IV’s, blood tubing etc. To ready the Pt. for the cath lab. This is also with a check off sheet that documents onset time, meds and time given, this also includes the pre-lytic check list from the AHA. Be cautious with a right sided or inferior, watch pressures and be ready for the next thing that will kill your patient. Think ahead and think it through, if unsure call med-control.

  • Vikas says:

    St elevation in inferior lead suggesting of inferior wall MI. Pt needs thrombolysis.

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EMS 12-Lead

Cardiac Rhythm Analysis, 12-Lead ECG Interpretation, Resuscitation

JEMS Talk: Google Hangout

Conclusion to 59 Year Old Male: Unwell
Great discussion on a difficult 12lead! I follow these very closely and based on pt presentation and 12lead tracing, this was a difficult or to treat with impending heart failure, hypotension, and trouble breathing. Thanks for the follow up and look forward to next week!
2015-07-06 20:53:35
Conclusion to 59 Year Old Male: Unwell
Hmmmm, I was fairly close. Sounds like most of the treatment occurred IN Hospital. Love case studies, and that one was good.
2015-07-06 20:28:25
59 Year Old Male: Unwell
There's the point! There is are no P waves, and the rhythm is irregulary-irregular-atrial fibrillation. If you look, it is rsR phenomen-RBBB, BUT there are huge ST elevations on all leads from V1-V5 (that's why the QRS complexes look so broad). I and aVL is clearly ST elevation suggesting STEMI. In limb leads you can…
2015-07-06 10:12:16
Vince DiGiulio
Conclusion to 59 Year Old Male: Unwell
I'll expand on this in the next post but unfortunately I actually wasn't present for this case so I can't give my direct account of how things happened. That said, from the notes I read and word-of-mouth from those involved (which I suspect painted things in a better light than I would have viewed them),…
2015-07-06 04:09:22
Matt King
Conclusion to 59 Year Old Male: Unwell
Hey Vince thanks for the through follow up with this case. I am curious how his rate was controlled since he was hypotensive and maybe an unknown onset of when his A-Fib stated(thinking anticoagulation first)? As you know the wrong approach could be devastating in this PT with risks of further infarction, stroke, or death…
2015-07-05 14:10:57

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