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
Jessica
68 y.o. male with weakness: “Treat the monitor, not the patient?”
the bizzare complexes coupled with the fact that the patient takes a potassium sparing diuretic make me think hyperkalemia
2015-04-29 12:31:37
Aman
The 12 Leads of Christmas: V2
Thank you for your response. By all means, take your time! As for the source of the first figure, I got it from the book "Essential Cardiology: Principles and Practice - 3rd edition" by Clive Rosendorff - Chapter 7, Figure 7.3 (Page 97). It's one of the rare texts where I found a mention of…
2015-04-27 06:52:25
Vince DiGiulio
The 12 Leads of Christmas: V2
Your questions on this topic are some of the best I've encountered—no need to apologize! It makes me very happy to see this post reaching the right people. I'm working non-stop the next two days but I will get back to you soon with my full response. Two things to start: First, where did you…
2015-04-27 05:14:11
AJ
68 y.o. male w/ weakness: conclusion – “Treat the monitor.”
Very informative case! Thank you for sharing..... I will be using it to teach our paramedics and residents (if you allow me to)..... Keep the great working going guys!
2015-04-27 03:05:29
Aman
The 12 Leads of Christmas: V2
Thank you so much! I wonder why this information is not found in ECG texts. I have a query though. The critical information seems to be the fact that leads V1 and V2; V3; and V4-V6, each are physically located on a different transverse plane with respect to the theoretical electrical center. (Also mentioned in…
2015-04-26 18:24:06

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