This is the discussion for “70 Year Old Male: Short of Breath“.
Tough case. Lots of excellent comments and observations from our readers.
Right off the bat, the patient’s presentation offered a major distraction: the recent eye surgery resulting in the old “eye patch presentation”. Confounding the situation further was the lack of any cardiac history, and lack of chest pain.
Let’s review the 12 lead:
Sinus Tach, 115 bpm. Physiologic left axis deviation. Left Bundle Branch Block.
Clearly, the moderate dyspnea and basilar crackles were red flags, as was the sinus tach at about 115 bpm. What are we most concerned about?
This is not an exhaustive list to be sure, but these seemed to be the most likely concerns.
While ACS was a primary concern, how about PE? I wouldn’t think it likely from cosmetic eye surgery, but stranger things have happened. What about subendocardial ischemia due to hypovolemia? Could the patient be dehydrated? He hadn’t had much to eat or drink since his surgery. How about infection? He denied recent illness, but post-surgery an infection is on the table too.
Even so, when a patient with no history of respiratory disease experiences the onset of shortness of breath with crackles severe enough that he can not speak in full sentences, this is highly concerning. Throw in the family’s description of “wheezes” (no asthma/COPD history remember) and we should be concerned about CHF.
What can we tell from the 12 lead?
We have LBBB present, so to look for a STEMI equivalent, we turn to our Modified Sgarbossa Criteria:
Any concordant ST elevation?
- Probably not, although aVL is very close (blue arrows). At the least, it looks abnormal. There should be discordant ST depression, and that is not there.
Concordant ST depression in V1, V2, or V3?
- I would say yes, in V3. I have drawn a line from the J point in V1 that is most visible down to V3 to if and how much ST depression there is. By my eye, it is at least 1 mm.
How about excessively discordant ST elevation?
- I do not see anything that meets this criteria.
- There are concordantly depressed ST segments in leads III and V4 (blue arrows). While these do not meet Sgarbossa, they are abnormal and concerning. The depression in lead III may be reciprocal to the abnormal finding in lead aVL.
It seems to meet Sgarbossa. It is still possible that it is subendocardial ischemia, but transport the lab is a reasonable course of action. Some comments referenced that thought that the LBBB may be new, but this is not really relevant any longer. The AHA has removed presumed LBBB from the list of STEMI equivalents. Nevertheless, the abnormal ECG findings in this case were found and noted by the Medic.
What happened next?
This was called in to Med Control for consultation about cath lab activation (in this system, activation must come from a Med Control physician). Although the ECG findings were shared, the decision was made to transport the patient to the local hospital due to the closer distance and the “equivocal” findings. A line was started, but no fluids given due to the crackles (debatable, small NS bolus may have helped).
Some will ask about NTG or CPAP. In this system, they are not options if the SBP < 120.
The patient was transported without a change in status to the local hospital. Another serial ECG was mostly similar.
Upon arrival at the local hospital, the Medic reported his ECG findings to the ED physician in charge. The ECG changes were not appreciated in the ED.
The patient was moved to a room for observation and labs. After a time (exact time lapse unknown), troponins came back markedly elevated. The staff determined he was having an MI. Concurrent with these results, the patient experienced flash pulmonary edema and had to be intubated and put on a vent. Transport to the PCI center was arranged.
However, it was also discovered that the patient also had an infection. Due to this finding, transport to the PCI center was postponed, and the patient was admitted to ICU. No further follow up is available.
What are your thoughts about this case?
Do you agree with the ECG findings?
Would this case have been handled differently in your system? How?