On a Thurday morning, approximately 02:15 hrs, in a small rural town, your EMS unit is dispatched to a residence for an 87 year old male with difficutly breathing.
You arrive on scene before the fire engine and enter the residence. Upon entering the bedroom, you find an elderly male, sitting on the edge of the bed, vomiting. He is alert and oriented x 4 (person, place, time, event) and with a GCS of 15. He appears to be in moderate respiratory distress, diaphoretic, with rapid and slightly labored breathing and muscle retraction, but yet, he's smiling at you and tries to explain what happened. He tells you, he woke up 15 minutes ago because he could not breath while laying down.
- Patent airway
- Shallow and labored breathing with bilateral rales upon auscultation
- Weak and slightly irregular radial pulses
- Skin: cool to touch, pale and diaphoretic with >2 sec. capillary refill time
- No signs of external bleeding
He is also complaining of chest discomfort throughout his entire chest, rated 7/10, non-radiating which started at the same time he woke up from his sleep. Nothing makes this discomfort better or worst.
Past Medical Hystory:
- Hypertension (HTN)
- Amlodipine (Norvasc)
- Metoprolol (Lopressor)
- Levothyroxine (Syntrhoid)
- Atorvastatin (Lipitor)
- Daily vitamins
- No known allergies
Your partner places the patient on O2 at 15 lpm via Non-Rebreather mask with ETCO2 monitoring and a 12 lead ECG was obtained as well as vital sings and blood glucose.
The first 12 lead ECGs was "too dirty" to evaluate. The second 12 Lead ECG is shown below:
Pretty alarming, isn't it?
Vital signs as followed:
Blood Pressure: 230/125 mmHg
Heart Rate: 130 beats/min
Respiratory Rate: 36 breaths/min
SpO2: 71% on Room Air
ETCO2: 55 mmHg
BGL: 122 mg/dl
The closest initial receiving hospital is 30 minutes away.
What is your 12 Lead ECG interpretation?
What interventions would you perform next?
Would you activate the cath lab?
Case conclusion below: