81 YOM with Chest Heaviness

It’s approximately 2000 hrs, right as you get comfortable in bed, when you are dispatched to a residence for Chest Pain (CP). You arrive on scene to find an 81 year old male, semifowler’s in bed, complaining of chest heaviness, 8/10, which started 2 hours ago, while in bed, watching tv. The patient also advised he has vomited twice since he called 911 less than ten minutes ago.

He is alert and oriented to person, place, time and event, GCS of 15, denies dyspnea with clear bilateral lung sounds, strong and regular radial pulses, warm to touch, diaphoretic and normal skin color.

Medical history:

  • Hypertension (HTN)
  • MI
  • Hyperlipidemia

Medications:

  • ASA
  • Metoprolol
  • Plavix
  • Pravachol

Vital sings:

  • BP: 160/87 mmHg
  • HR: 96 beats/min
  • RR: 18 breaths/min
  • SPo2: 94 RA
  • BGL: 104 mg/dL

You administer O2 at 2lpm via nasal canula and placed him on your cardiac monitor, then obtain the 12 lead ECG shown below:

subendo1edit

  • What is your ECG interpretation?
  • What would be your treatment?
  • Any concerns?

4 Comments

  • Doug says:

    Sinus tach (approx 100bpm) with 1st degree block
    ST depression in leads I, AVL, II with significant ST depression in precordials V2-V6
    Right axis deviation with poor R wake progression.
    Suspect a posterior MI, transmit ECG, obtain IV access, administer 162 mg ASA, nitro, antiemetic ( IV gravol), narcotic pain control ( morphine currently). On route posterior ecg V7-V9 with second transmit, serial ecg’s, vials q 5 mins transporting to a PCI facility. Prep for a potential arrest and dysrhythmias (VT).

  • Eric L says:

    With the diffuse ST depressions significant enough to cause ST elevation in aVR, significant L main disease or 3 vessel disease are likely, and could indicate CABG rather than PCI. In a plavix naive patient, I would consider holding off on loading plavix since the patient might need CABG. I’m not sure what I would do in the case of this patient, who is already on plavix.

  • Alex says:

    1st degree AV block.

    We’ve got ST elevation in the right facing leads (maximal in aVR, some in V1) and ST depression in the left facing leads (I, II, V2-V6) making me think severe 3 vessel disease or proximal LAD or LMCA occlusion but I get very unsure at this point!

    Whichever, it’s not a good ECG to have.

    I would discuss this with the cath lab because I’m unsure how these patients are managed. Do they benefit from bypassing local hospitals to get to PPCI or would they normally be assessed in a local resus room?

  • Reni says:

    Sinus rythm,RBBB,LAFB,ST-depressions I,AVL,V2-V6

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EMS 12-Lead

Cardiac Rhythm Analysis, 12-Lead ECG Interpretation, Resuscitation

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Comments
Nick
100 yof CC: Rib pain and intermittent spasms
Can't be a potassium imbalance. The TW's wouldn't change and then change back. If it was coronary spasm, I would expect some ST segment elevation. The TW'S are also not hyperacute (peaked). Does she wear some sort of electronic stimulator?
2014-11-19 01:05:43
Anterior T wave inversions and PE. | EMS 12 Lead
Not just S1Q3T3: Look at the other 10 leads!
[…] Last week, I described the case of a middle-aged male with a vague history of heart failure who had been having progressive shortness of breath for 4-5 days. On the day he called 911, he had been walking a short distance when he syncoped. EMS obtained an ECG: […]
2014-11-18 18:33:47
Christine
100 yof CC: Rib pain and intermittent spasms
I believe this may be coronary artery vasospasm.
2014-11-18 11:02:45
Ian Fudge
What it Looks Like: Cardiac Arrest
this is really interesting because something similar happened to a patient as I sat them up in bed after delivering them to a community hospital in fact I even turned to his son and said "does dad suffer with epilepsy?" And then turned back and realised he wasn't breathing
2014-11-18 07:59:13
Dustin
100 yof CC: Rib pain and intermittent spasms
External interference? Something like a bladder stimulator or spinal stimulator.
2014-11-18 00:32:54

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