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 â€œtwist,â€ 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.Â Paramedic Tim Y. also generously shared his recollections of the patient.
EMS was called for a 45 year-old man with chest pain. The patient was initially reluctant to talk with the paramedic, Tim, since â€œmy girlfriend called for you guys, not me.â€ 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 â€œnumbnessâ€ in both of his hands, saying he couldnâ€™t move them, but denied nausea or sweating.
- PMHx: Anxiety, opioid abuse
- Meds: Methadone
- Shx: Smoker
- SaO2-99% RA
- 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:
The symptoms persisted, and and the chest pain worsened to a 10/10. A second ECG was obtained:
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.
- First, what is the likely culprit artery?
- Second, are there any early signs of MI on the first ECG?
- Lastly, even though â€œtime is muscle,â€ the very short D2B time probably did not improve his outcome. Why?