Discussion for 70 Year Old Male: Short of Breath

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:

ECG4.14orig

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?

  • ACS
  • PE
  • Hypvolemia
  • Infection

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?

ECG4.14

We have LBBB present, so to look for a STEMI equivalent, we turn to our Modified Sgarbossa Criteria:

Sgarbossa

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.

Other abnormalities?

  • 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?

12 Comments

  • Lance Lynch says:

    I did a ‘cold read’ on this EKG before reading the scenario and noted what appeared to be a regular, sinus rhythm at a rate of about 120 with a wide-complex QRS that appeared to have a LBBB morphology. One thing that immediately stood out to me what what appeared to be ST depression in the inferior leads and (to use the authors’ adjective) an ‘abnormal’-looking aVL… (Perhaps a ‘TOUCH’ of elevation?) I also noted the depression in v3. – This appeared to be a ‘sick’ heart before the patient was introduced to the scenario; Reading his presentation confirmed.

    After ‘seeing’ this patient, I would have treated him as an acute cardiac (although I may not have used the word ‘STEMI’) and transported him directly to a PCI-capable facility. He doesn’t meet Sgarbossa’s perfectly, but I think that, given his presentation (I’d suspect L. Ventricular failure) and EKG abnormalities, we could make a good case for a stat cardiology consult at a PCI center. By the way, the history provided didn’t mention that the patient had an extensive ‘cardiac’ history… Perhaps we could have presumed this to be ‘new’?

    I understand that cases like these are easily ‘arm-chair-quarterback’ed’, but I think this should have been a fairly simply call to make. I work rural EMS currently and have to make this call all the time; This patient, without a doubt, would have taken the 46 mile trip to the PCI-capable facility rather than the 15 mile trip to the ‘nearest’ ED. For the patient’s sake, I think that the crew should have done the same. The patient, given the information provided, seemed more than stable enough for the trip; Simply my humble opinion.

  • David Baumrind says:

    Lance,
    Thank you for your insightful comments. I can say that the crew requested the trip to the PCI facility. In this system, that call is made by the Med Control doc, who opted for the nearest ED.

    • Lance Lynch says:

      It’s easy to forget that systems like that still exist; I’m blessed to NOT have to work in one any longer – although I got my start in one. I agree that this is NOT a good thing for patient care – as this case demonstrated, a clinician (regardless of their title, etc) is not able to accurately assess the ‘acuity’ of this patient remotely and needs to extend some trust to their ‘eyes and ears’ in the field…. What’s the answer? – Who knows… But I think that it certainly involves education or updates to hospital staff regarding what crews can do and their level of expertise (blanket statement, I know).

      I recall working in a system as a young medic and calling for ‘orders’ from our local hospital, who had been designated as ‘medical control’… In hind-sight, it was hysterical the things that we’d get orders for: “Give 20mg of labatelol” – “Doc, we don’t have labatelol”… In another instance it was suggested that I ‘try’ some ketamine or propofol before using versed/fentanyl… “Seriously doc? That’s not in my bag (or local scope)”.

      It’s clear that, in a lot of places, delegated medical control like this can be disastrous to patient outcomes and, to a greater extent, growth and acceptance of our profession by the rest of the healthcare world. I think it’d definitely be worth putting on the list of things to strive to improve with education and proper orientation to said EMS systems before ‘grabbing the wheel’.

  • Rob G says:

    I agree with the concern for CHF due to surgery. Another concern could also be endocarditis. It was not dental surgery (as bacteria causes this by traveling through one of the cranial fossa), but they are finding out more and more about the causes of this condition, especially after any type of facial procedure. I would wonder if a combination of endocarditis and CHF would cause ischemia in a coronary artery to the point of marked troponin levels, suggesting MI? Just a thought!

  • Paul Bishop, CCEMT-P says:

    I agree with Lance’s interpretation, and would just like to add the following comment. It concerns me greatly when the ability of a provider to make an executive decision in the patient’s best interests has been superseded by allowing online medical control (i.e. A physician at a remote hospital) to determine a destination on a patient who he/she clearly cannot lay their eyes on. The general function of online medical control is to provide guidance, not make destination decisions without the request of said consultation by the paramedic(s) in charge of the patient’s care. The patient clearly suffered deleterious effects as a direct result of the online medical control physicians choice to ignore the paramedic’s overall assessment and determination of the most appropriate facility and treatment strategy for this patient. Both parties are very lucky that this patient did not expire, as a result of this decision.

  • dawakhan says:

    My diagnosis in this case will be STEMI leading me to take the patient to cath lab or follow AHA guidelines if PCI facility not available at my hospital.

  • dawakhan says:

    STEMI. Primary PCI or will follow AHA guideline if PCI is not available at my hospital.

  • David Baumrind says:

    Paul,
    Of course, I could not disagree with you.
    After speaking with so many providers from different areas, you know as well as I do that system setup runs the gamut. Some Paramedics can activate and make the very decisions you mention, and some can not. Not to mention everything in-between.

    The variety that exists regarding implementation of patient care can not be a good thing, IMHO.

    -David

  • Peter Hammarlund says:

    As I mentioned in the last comments, I think this is ACS with a Sgarbossa positive ECG, but since the patient was having an infection I guess a reasonable differential diagnosis is a type II myocardial infarction. What was the level of the troponin?

  • David Baumrind says:

    Peter,
    Troponin level unknown. Follow up is, shall we say, challenging.

    -David

  • Yuya says:

    Looks like some mild hyperacute T waves. Maybe De Winter’s? Possible critical LAD occlusion? I wouldn’t call this a STEMI but a NSTEMI if anything. I would not activate cath lab especially without any chest pain.

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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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