***Update: The conclusion for this case is now posted here.***
Most of our cases here at EMS 12-Lead are designed to strike a balance between challenging experienced prehospital providers while also highlighting a couple of specific teaching points for those seeking to learn. It’s a difficult line to walk. We want to showcase EKG’s with specific findings that are apparent enough to make good teaching tools, but we also want them to be subtle enough to make our practiced readers work.
At this point I’m sure there are a few folks out there who have been following us (and related blogs) for long enough to be familiar with a lot of the major tropes we often discuss, so to keep things challenging I’m starting up a new case series: the Masters Cases. These ECG cases are designed to challenge even our most advanced readers, with no limit to how subtle or multi-faceted the findings can be. While no-one here at EMS 12-Lead claims electrocardiographic mastery (holo-chat us in 30 years, maybe…), this series will feature some of the toughest diagnosable EKG’s we’ve come across after collectively reading tens-of-thousands of tracings.
To kick things off, here’s our first “Masters Case” courtesy of Dr. Bojana Uzelac from Serbia…
A 50 year old male presents with a chief complaint of sudden-onset severe chest pain x 45 minutes. The pain began at rest and has been constant, if not worsening. He is pale, diaphoretic, and fairly lethargic; although he still answers questions appropriately. He states he feels weak, short of breath, and just can’t find the energy to move. His radial pulse is weak but present and you hear rales in the lung bases bilaterally. Past medical history is significant for type II DM, heavy smoking, obesity, and hypertension. He has never been diagnosed with COPD, coronary artery disease, or MI.
Vitals: HR 90 bpm and irregular, RR 22/min, SpO2 94% on room air, BP 90/50 mmHg, and temp 36.5 C.
The following EKG is captured upon first EMS contact.
Here’s the rub: your job is to read this EKG as completely as possible. If you leave me a one-sentence comment I’m just going to delete it. Whatever abnormalities you find should be supported by reasoning. If you think the patient has pericarditis, you’d better list the findings supporting your diagnosis. If this patient is having a STEMI, I want to know where the lesion is and your rationale. I’d also like a brief overview of your treatment plan, though not as in-depth as the interpretation. Take your time and be thorough; these aren’t spot-diagnoses.
As a final general hint, when it comes to these Masters Cases you can rely on the EKG to tell the story. We aren’t going to try and trick you by slipping small clinical clues in the case description. For example, in the above case you would be right to consider aortic dissection if you met this patient in real life, but this is an ECG blog and I promise you the patient is experiencing acute coronary syndrome. Don’t over-think the descriptions but do dive deep into the ECG.