45 year old male with “numb hands”

This case illustrates both how good modern EMS can be at expediting emergency cardiac care, but also the challenges that still confront us. Yes, there is a “twist,” but only a small one.

Note: I never saw this patient, but the ECGs and outcome were brought to my attention by a colleague, Dr K. Thrace, who moonlights at a number of EDs in the region.  Paramedic Tim Y. also generously shared his recollections of the patient.

The Case

EMS was called for a 45 year-old man with chest pain. The patient was initially reluctant to talk with the paramedic, Tim, since “my girlfriend called for you guys, not me.” He was eventually persuaded to discuss his symptoms, however, and stated that he had been out shoveling snow when the chest discomfort started He rated it at a 5/10, and also described “numbness” in both of his hands, saying he couldn’t move them, but denied nausea or sweating.

  • PMHx: Anxiety, opioid abuse
  • Meds: Methadone
  • Shx: Smoker

Vital Signs:

  • P-70
  • BP-120/90
  • RR-30
  • SaO2-99% RA

Physical Exam:

  • Gen: Anxious, unable to sit still. Hyperventilating.
  • Skin: pink/warm/dry
  • Pulm: Clear lungs
  • Cardiac: No JVD, RRR
  • Chest: Tenderness over the precordium

An ECG was obtained:

D2B_pt_delay#1

The symptoms persisted, and and the chest pain worsened to a 10/10. A second ECG was obtained:

D2B_pt_delay#2

Upon seeing this ECG, the paramedic immediately notified the a local PCI center that the cath lab should be activated. There were no extrication issues, and the drive to the hospital took only 9 minutes. Because of the early activation, the D2B time was only 37 minutes.

Questions

  • First, what is the likely culprit artery?
  • Second, are there any early signs of MI on the first ECG?
  • Lastly, even though “time is muscle,” the very short D2B time probably did not improve his outcome. Why?

17 Comments

  • Muhammad k Abouhajar says:

    St elevation in inferior leads,ll,lll &vf
    Suggest acute inferior MI

    • Muhammad k Abouhajar says:

      St elevation in inferior leads,ll,lll &vf
      Suggest acute inferior MI, &
      Lvh

    • Mark says:

      I agree… The changes in the first trace are there and enough (with the symptoms) to raise my suspicions… Second trace simply confirms. As to which artery… I’m going to guess here… Somewhere along lower section of the Posterior Interventricular Branch?

  • Peter says:

    flipped t in avl would be concerning in first ecg and worthy of serial ecg and there are signs of st elevation starting ,RCA fo culprit lesion and symptoms ,damage because of drug use possibly would not affect outcome ???

  • John says:

    There is a small amount of elevation on the first ECG in leads II and more in III. That and the chest pain which has not eased with rest (I assume this because when a family member insists on calling and the patient objects there is usually a delay in making the call) would make me take the patient to hospital. The hand numbness is puzzling and does not fit in with anxiety and elevated resp rate. Mainly I’m puzzled as to why the crew were on scene for so long.

  • brooksw says:

    @John – Many patients with panic attacks will report paresthesias in their hands, as well as the circumoral area, due to hyperventilation-induced hypocapnia.

    Some people try to treat these symptoms using the old paper-bag trick. Good thing the medic didn’t do that in this case!

    • John says:

      Interesting. I’ve encountered pins and needles and cramping plus chest pain/tightness due to anxiety but not loss of sensation. Will read up on that. What was the patient’s temperature?

      • brooksw says:

        37.

        I’m just presenting the complaint, in quotation marks: “numbness.” It doesn’t sound like a lot of effort was made to refine this element of this history much further (e.g. altered versus absent sensation). Not sure it’s worth it, usually.

  • Fritz Fuchs says:

    Inferior MI, slight ST elevation on the first EKG. The numbness is due to hyperventilation. Culprit artery would be RCA. I have no idea why reprofusion wouldn’t help. Was there scar tissue from IV drug abuse?

    • brooksw says:

      Not exactly the question I asked. ;)
      Reperfusion therapy likely will be of some benefit. However, the impressive D2B time was not as helpful as it could have been.

  • Jp2134 says:

    The cold hands could be from shoveling snow in the cold.

  • David Cokely says:

    1. Whichever angioplasty shows narrowing.
    2. See above previous answers all essentially correct.
    3. Im guessing the twist is pt. Was doing cocaine and mi is due to vasospasm and thus early d2b time not helpful.

  • Lance Lynch says:

    Interesting case, sir… Lots of things to consider. The initial EKG seemed to show some J-point notching that I’d probably (initially) chalk-up an early repolarization pattern. Those inferior Q waves in the don’t appear to be very pathologic to me as a cold read (without knowing the outcome/progression).To a lot of folks, the EKG wouldn’t have shown anything earth-shattering. But investigating the situation further and scrutinizing the story/circumstance, I’d hope that the ST depression/T-wave inversion in aVL would have spoken to someone… Dr’s Smith/Mattu have given some great talks that have resonated with me regarding ‘subtle’ aVL changes in the presence of a ‘good story’ or chest pain. – And I think that the situation did ‘speak’ to the paramedics on scene. ..

    It’s easy to arm-chair quarterback these situations and argue that the medics should have transported more quickly – But it’s easy to forget how ‘stubborn’ some of these patients can be… Given his first remark relating to the fact that ‘he’ wasn’t the one that called should, I can understand why the scene time was so extended. Assuming that the second EKG presented wasn’t from a ‘second’ 911 call, I think that the medics need to be commended for waiting-it-out and being patient/persistent with this patient seeking care for his benefit… Great work on their part.

    I know and (have worked with) plenty that would have allowed this ‘stubborn/ignorant’ patient to stay at home after taking a quick set of vital signs and an initial EKG. I could see some other folks writing off the numbness/tingling as hyperventilation syndrome or simply a result of the cold weather.

    Regarding the EKG, I’d suspect the RCA; STE in II > III with STD in aVL > lead I. Despite the phenomenal DTB time from the PCI center, I’m curious to know how his myocardium made out… he was infarcting for a while prior to the CVL. Again, great case… How’d he do? – Did HE learn anything?? :-)

  • Chris says:

    Inferior STEMI possible with 1-1.5mm elevations in II, III and AVF, inverted T-wave in AVL and symptoms. Important to note that the STEMI guidelines are only guidelines and every patient will present differently. Additionally, just because the monitor doesn’t identify an irregularity doesn’t mean it isn’t there…clinical judgment is vital…treat the patient, not the monitor!

    Would go with RCA as culprit given inferior elevations.

    I’m thinking that an hour and a half passes between ECGs may mean that the guy refused or some other circumstance caused a delayed door to balloon.

    Additionally, ventricular function may be compromised as there was already hypertrophy noted in the lower precordial leads in the first ECG. Add hard working left with inferior infarct and there will be Lois of function the longer the condition persists.

  • B. Graham says:

    My observations:
    Likely culprit is the RCA
    Early signs noted on the initial ECG:
    First, he’s bradycardic (not necessarily significant on its own, but he’s also acutely anxious so a HR of 55 seems off)
    In the initial ECG there are approx. 2 mm ST seg elevations in 2,3 & aVF
    Small Q waves present in the same leads
    aVL shows STs dep w/inverted T waves
    The short D2B time is important but if the pts onset of sx was more than 2-3 hours before the procedure, the PCI won’t be of as much benefit, though onset isn’t stated in his hx here.

  • jessica says:

    pathological Q waves means irreversible damage has already been done

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EMS 12-Lead

Cardiac Rhythm Analysis, 12-Lead ECG Interpretation, Resuscitation
Comments
Christopher Watford
59 year old male: chest pressure – Conclusion
Tony, From the initial ECG it appears that the pattern of ST-elevation is suggestive of a proximal RCA occlusion. However, at cath it was instead found to be an LCx lesion. Good question!
2014-09-18 13:20:09
Tony
59 year old male: chest pressure – Conclusion
Please explain why you suggest that the inferoposterior is caused by RCA but the Left Cx has been stented. Thank you.
2014-09-18 06:17:03
Keren Levi
The 360 Degree Heart – Part I
Lately, a few paramedic-students arrived at my station. So i tried to explain that basics at my best simpliest way. After readinv your perfectly coherent "article", i couldnt stop smily for knowing we both thought of same phrases and associatives words. For me it is a great compliment! Thanks for writing! Cant wait for part…
2014-09-17 19:34:44
Richard Kenkel
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Cardiac arrest? Its a RELATIVE contraindication. You need to use clinical gestalt. Her blood pressure is quite high, and her heart rate is average, she would probably tolerate nitro quite well. Provided she's not on beta blockers or calcium channel blocker, orthostatic hypotension etc, from what I can tell she'd compensate just fine. While there…
2014-09-16 02:05:12
Stephen Smith, of Dr. Smith's ECG Blog
59 year old male: chest pressure
Inferolateral MI, not RV (T-wave down in V1)
2014-09-14 18:16:53

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