Snapshot Case: 44 Year Old Male – Chest Tightness


Here's a new "Snapshot" case courtesy of Dr. Bojana Uzelac from Serbia…

A 44 year old male presents with a chief complaint of tightness in his chest x 1 hour. He was on his way to a conference when it started and states:

"It feels kind of like asthma. I've never been diagnosed but I imagine this is what it would feel like. Maybe I'm just nervous about speaking in front of everyone."

Vitals: HR 85 bpm, RR 20/min, SpO2 97% on room air, BP 157/84 mmHg, and temp 37.1 C.

The patient's skin is cool and dry and he appears mildly anxious. The following EKG is then captured.

2014.02.03 - 0000 - 01 - Bojana Uzelac - Blog Case - EMS 12-Lead

Is this patient experiencing a STEMI? If so, where would his occlusion be located?


8 Comments

  • Shalom says:

    Looks like a STEMI, very probably of the Proximal LAD (Anterior ST elevation with elevation in V1, AVR + possibly Incomplete RBBB)
    Elevation in III makes me think that the LAD may wraparound the apex. (Considering limb leads are properly placed) 

  • ren says:

    I would call STEMI anterior ST elevation. With aVR also being elevated this is a LMCA until proven otherwise (could also be prox LAD).  

  • John says:

    I am thinking pericarditis or possibly BER. I am not calling this STEMI.

  • Joel says:

    Anteroseptal MI with ST elevation in V1-V4, reciprocal depression in Leads I, II, aVL. Likely Proximal LAD occlusion. 

  • sanchopanza says:

    ECG: Sinustachycardia 75/m, normal heart-axis, normale PQ en QTc duration, slight intraventricular conduction delay, significant ST elevation in leads V1-5 and aVR, depression lateral (aVL, V6) and slightly in II, sharp T-waves V2/3.

    Combining this with the complaints and duration (1 hour) I would seriously consider CAG. Possibly proximal LAD/ left main as said by Ren.

    Any cardiovascular riskfactors? Any recent illnesses? (diarrhea, respiratory infection last 2 weeks?)

     

  • Chris says:

    STEMI -anterior.. not sure how any Paramedic can not call this a stemi…. Jon , please explain why you would not call this a stemi?? Chest discomfort-st elevation -new onset . Im hear to learn

  • Matthew says:

    Lots of ST elevation.  To the cath lab!  But maybe pericarditis??

  • P Lem says:

    My quick guess would be Early Repolarization with Hyperkalemia, but tangentially, I'm rather intrigued with the morphology of the anterior lead P waves; is there atrial pathology of some sort as well?

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EMS 12-Lead

Cardiac Rhythm Analysis, 12-Lead ECG Interpretation, Resuscitation
Comments
Jeff
Rate Related VS. Primary ST-T Changes:
He's complaining of 10/10 chest pain that coincided with palpitations with a HR of 206 that is probably A-Fib. I am guessing that if you correct his rate you will allow his myocardium to become perfused again and his chest pain will subside. I would pre-sedate him with Midazolam 2mg and electrically cardiovert starting @…
2014-09-21 19:17:36
Michael
Rate Related VS. Primary ST-T Changes:
I just don't see adequate evidence for WPW. I would be confident administering this PT Cardizem at .25mg/kg based on his hemodynamic stability. I'd also like to know more about PT history, like does he have AFIB at baseline and, if so, what does he take for it. I would also ask about a history…
2014-09-21 12:06:31
Tony
59 year old male: chest pressure – Conclusion
Thank you Christopher. I am wondering if this particular patient is one of the minority where the LCx is the dominant artery supplying the Posterior and Inferior regions. I believe this to be the case in only about 15% of the population. Whereas approx. 80% are Right dominant.
2014-09-21 08:39:21
John
Rate Related VS. Primary ST-T Changes:
ECG is a rapid atrial fibrilation with ventricular rates approaching 300 beats per minute suggestive of WPW. Widespread ST segment depression is most likely rate related ischemia; elevation in aVR is not a reliable finding with a rapid heart rate point away from LMCA occlusion. Slow the rate before looking for ischemia, injury, or infract.…
2014-09-21 01:49:03
Sean V
Rate Related VS. Primary ST-T Changes:
Also forgot to mention decrease the FiO2, 3LPM is getting us a SpO2 of 98%, titrate down so we staying at or above 94%. No need to hyperoxygenate & create all those fun free radicals. I would also include using an EtCO2 nasal cannula, lets get another measure of our cardiac output.
2014-09-20 02:32:20

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