74 Year Old Male: Chest Discomfort

 

It’s a sunny winter afternoon when you and your partner are called to a local doctor’s office for an “adult male- possible heart”.

When you arrive, you are led into room #3 where you find a 74 year old male, in no apparent distress. His color looks good.

You introduce yourself, and find out that your patient was suffering from left sided chest discomfort, 4/10, that radiated to his right arm.

“I can’t believe I have to go to the hospital, I thought it was something minor”, he tells you.

He admits that he has had short episodes like this for the last couple of days, but that today’s is worse. It doesn’t seem connected to exertion, and nothing makes it better. He can’t quite localize the discomfort, and it doesn’t change with breathing.

He denies any shortness of breath, diaphoresis, lightheadedness or nausea/vomiting.

His past medical history is significant for: Prostate cancer, high cholesterol, peptic ulcer disease and chronic back pain.

Vitals are as follows:

  • HR: 84 and regular
  • BP: 152/84
  • RR: 18 and regular; SpO2 98% on supplemental O2
  • Skin: warm and dry

You acquire the following 12 lead ECG:

 

ECG1:8

 

You package the patient and acquire a second 12 lead ECG:

 

ECG1:8-2

 

Decision time: Community hospital is 20 minutes away by ground. PCI center is about 30 minutes away by helicopter. As you ponder your decisions, he tells you again that he “still can’t believe he has to go to the hospital !”

 

What is your interpretation of the 12 lead ECG’s?

What do you want to do with your patient? What are your transport and treatment decisions?

Are there any significant changes between the first and second ECG?

 

 

 

3 Comments

  • Caleb Seavey says:

    This is the real one.

    Interpretation: Normal Sinus Rhythm with a borderline 1st degree AV block (PR is slightly over 200ms…maybe), right bundle branch block (widened QRS with positive terminal deflection in V1) and, left axis deviation (possible LAFB). So to start out with he has a trifascicular block. Then to the glaring ST elevation in the anterior and precordial lateral leads suggesting acute anteriolateral MI. In addition, the T-wave morphology in the ischemic leads is wide and symmetrical, further confirming MI. The most important difference between the two EKG’s is that in the later EKG, the T-waves appear even more ischemic (tall, wide, symmetrical) and you can see the start of pathological Q-wave formation, suggesting the development of infarction.

    Treatment: Activate STEMI Alert, O2 NC 2L, Asprin 324 mg PO, IV 18 Gauge (probably 2), NTG .4 mg q 3-5 minutes x3 to complete relief of pain (if blood pressure holds), Consider Morphine if pain remains refractory and blood pressure holds, Transport Fast Lights and Sirens to PCI center.

  • Darren says:

    “Sir, I’m sorry. Not only do you need to be at the hospital, but you need specialized care, and you need it faster than we can get you there by ground. It will be in your best interest if we send you to a PCI equipped facility by helicopter.”

    Bifascicular block in the presence of an active STEMI equals a 4x greater mortality rate than an STEMI without complications. Regardless of how this patient presents or acts, it is our job to give him the best treatment and transport possible. Ultimately, the decision must be the patient’s, but our job is to educate him to make the best decision.

    If he consents, focus should be on rapid transport, aspirin admin, and relief of pain and anxiety. Nitro, morphine, and low-dose benzos are all indicated. In addition, this patient stands an above-average chance of going into VT or VF. Defib pads would be a good idea.

  • Justin Alberson says:

    NSR with borderline 1st degree AVB. RBBB. LAD with LAFB (borderline trifasicular block, definitely bifasicular). ST-elevation in V2-V5 and T-wave inversions in V1-V2. This patient needs to be flown to a PCI center based on his cardiac condition. He is a high risk of complete AVB or cardiac arrest.
    Treatment: Oxygen. Dual large-bore IVs. Aspirin 324mg. Nitro 0.4mg x3 x5 minutes depending on BP. Morphine if pain doesn’t go away. Add nitropaste 1 inch. Changes from 1st to 2nd ECG is the T-wave inversions in V1-V2 are no longer present.

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Comments
James
59 Year Old Male: Unwell
This is a ugly EKG. Wide complex irregular tachycardia around 150's. A-fib and a-flutter are possibilities. He's severely symptomatic. At this point, all treatment is same, electricity. If A fib, it may not want to "shock out" easily. This may be a case where initial cardioversion at max joules would be prudent. Pulmonary edema likely…
2015-07-01 22:00:13
Bryan
59 Year Old Male: Unwell
Calcium has little to no side effects, given the first EKG I think it is reasonable to consider it for first line treatment. Repeat EKG after 5 mins and reassess.
2015-07-01 21:14:40
Mike MacKenzie
The Trouble with Sinus Tachycardia
An absolute must read for all Medics. Great article. I am always trying to tell students to consider referring to these fast rhythms as a narrow complex tachycardia, then start looking for the cause, be it physiologic response or an electrical conduction issue. And as many have stated, I often hear that it must be…
2015-07-01 20:11:34
Josh
59 Year Old Male: Unwell
Looks like anterior lateral STEMI with BBB. Possibly LAD infarct. Positive Avr indicative of a Proximal LAD. Clear elevation to high and low lateral leads. I, AVL, V3,4,5,6. Reciprocal inferior ST Depression in II, III and AvF. Tachycardia could be secondary to hypotension, anxiety, pain or tachyarrythmia caused by hypoxic excitation. Descernable P waves, ST…
2015-07-01 16:19:15
Todd Ellingson
59 Year Old Male: Unwell
Being irregular argues against VT, though first glance it does look like that. This is likely afib with aberrancy. One could consider WPW with afib with antidromic conduction down accessory pathway, however WPW is usually dx'd when someone is younger - unlikely to be 59 and not know this. Electrolytes, especially high K, is a…
2015-07-01 16:02:58

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