57 Year Old Male–Chest Discomfort

 

It is a bright Sunday morning when you and your partner are dispatched for an “adult male-chest pain”.

You arrive at a well kept residence, noting a ladder and paint cans as you enter.

You find your patient, a 57 year old male, sitting on the sofa in mild distress.

“I was doing some painting, and about 20 minutes ago I felt some pressure here (points to central chest just left of sternum), and my arm started hurting too (rubs left bicep area).”

He rates the discomfort at 7/10. He also says he became very sweaty and nauseous at the time of onset. Oh, and just for good measure, he tells you he had some trouble breathing as well. He denies being nauseous at the moment, and his skin is warm and moist. PD had given him O2 via NRB, and he says his breathing is “better”.

He has not taken anything for this episode. In fact, the reason he called so fast:

“I just saw a show on TV where a guy had a heart attack and waited too long to call 911. I figured I better call fast.”

Pt hx is significant only for hypertension and hypercholesterolemia. He denies ever experiencing this before. He takes Toprol, and has no allergies.

Vitals:

  • Pulse: 74 regular
  • BP: 180/104
  • RR: 20, mild distress
  • Spo2: 97% on O2
  • Skin: warm and moist

 

Your patient is a heavy set gentleman, and you acquire the first 12 Lead ECG:

ecg720

 

Here is a second 12 Lead ECG taken several minutes later:

ECG720a

 

Destination options:

  • Community Hospital: 20 minutes by ground
  • PCI center:  50 minutes by ground

 

What is interpretation of the 12 Lead ECGs?

Are there any changes between #1 and #2?

How do you want to treat your patient, and where do you want to take him?

 

 

 

17 Comments

  • Chris says:

    IWMI that is evolving. Second ECG shows more elevation in III, both show ST depression on AVL with inverted T. Second ECG showing a notch on the R wave in some leads. Would go to PCI, call STEMI alert, ASA, cautiously use NTG and watch BP closely. Hope this is not over simplifying the case.

    • Chris says:

      IWMI though I can’t decide whether it is evolving, already happened or intermittent blockage. Second ECG shows more elevation in III. First ECG shows ST depression on AVL with inverted T. Second ECG showing a notch on the R wave in some leads. Possible intermittent blockage or an MI that happened in the last 24 hours. Regardless, as I do not have cath lab vision, I would go to PCI, call STEMI alert, ASA, cautiously use NTG and watch BP closely.

  • Brian says:

    Everything that Chris said ( inferior wall MI, slightly more elevation in inferior leads on 2nd ecg) and I’d do a v4R and some fentanyl titrated to pain.

    I would take off the NRB and do a trial of a nasal cannula and see if he could have an spo2% of 94 or better on less oxygen.

    Go to PCI.

  • Alan says:

    I agree with the treatment plan above, but I think there may be a possible left bundle branch block. I do see ST elevation in inferior leads that suggest an acute MI. I am just a Paramedic Intern so this is learning for me. I would repeat another 12 leads, ASA and nitro to chest pain and go from there. I would be looking at possible paint fumes as a hypoxia or toxin that may be showing pulmonary and heart problems. I would keep 02 on NRB because of the paint fumes especially if he was in a closed environment. That is my take. If I am incorrect please point my mistakes. Peace!

  • Lakshay says:

    IW STEMI
    ECG 1: STE in II,III, aVF + Reciprocal changes
    ECG 2: STE in II, III, aVF + Reciprocal changes (may STE in V6)
    Peripheral Pulses? Diastolic murmur?
    Quick ED Echo – looking for Dissection (High BP)
    Pain Relief – Antiplatelets – Activate cathlab

  • yasin yıldız says:

    İnferolateral STEMI.
    STE in III > II, maybe see V4R but not hypotensive
    No clue for posterior STEMI
    There is Q wave in III; maybe STEMI is not new :)
    And also S1 and Q3; maybe PE

  • Mike says:

    Inferior MI,

    More elevation on second 12 lead

    Preform a right side 12 lead to confirm, two liters of NaCl through bilateral IV’s, ASA, no nitro or beta blockers, O2 to maintain sat of 94%.

    Transport to PCI.

  • tyson says:

    just with his risk factors, and the fact that he’s having ongoing chest pain, with nausea, diaphoresis and dyspnea i believe qualifies the patient to go to the nearest hospital with PCI placement capabilities. if you took this guy to a hospital with no cardiac cathlab you should be fired. treatment should include m. o. n. a

  • John says:

    J point is only barely elevated above the TP segment & where there is elevation could be attributed to baseline wander. Not really seeing reciprocal changes either. That being said, It’s not a completely normal ECG either. Given his history and symptoms I would elect to transfer to the PCI center and introduce this man to MONA.

  • William says:

    Inferior MI with AVL depression and inverted T wave. Inferior MI is evolving in second 12 lead. MONA and to a PCI center.

  • Scott says:

    Definitely seeing elevation in both 12 Leads in the inferior leads. No history of a BBB, so presuming the LBBB that is seen here is new, and the elevation would be considered, in the AHA’s eyes, a STEMI. Possible Pathological Q wave with this as well so add on the elevation this would be an acute/iin progress MI. Also noting the Left Anterior Hemi Block with a pathological LAD. I would drop to a nasal cannula if sat’s support it, use fentanyl for pain management. Give ASA and be vary careful with a nitro spray given the fact this is an inferior wall MI with unknown R sided involvement. I’d start a nitro drip at 5 mcg/min titrated to response due to distance to cath lab, trend the 12 lead/vitals in en route, watch for any respiratory issues with the narcs on board, and manage any nausea that may reappear with Zofran. Call the doc with any other concerns and Code 3 to the Cath Lab.

  • Jason says:

    IWMI for sure. ELevated in II, II, AVF. Depression in I, AVL with inverted and sloped T waves. Would get a R Side view as well…we have the time. I might consider meeting a Chopper in route as well to cut on that 50 min PCI transport. FONA…we use Fentanyl instead of Morphine. Keep an eye on the BP with the Nitro…transport fast.

  • JJ patrick says:

    Inferior/lateral MI – good spot on the pathological q wave in III yasin – concur, could be subacute :) local protocol here says closest facility – MONA and closest ED, we can always evac to cath lab.

  • Geo says:

    There is no reciprical changes, no LBBB, althought concerns are mainly focused on the inferior leads. I see elevations only in leads ll and lll with significant q waves. I would withold Nitro, and my course of treatment will be O2, 324mg of ASA, 18 g IV cath, right sided 12 lead, find weight of patient and administer 1mcg/kg bolus of Fentanyl up to max of 150 mcg fetanyl and transport to PCI center activate Cath lab and monitor for any significant changes.

  • rick says:

    STEMI in inferior leads with inverted T in avl and avr. Would do v4r and 15 lead to check right and posterior involvement. Oxygen to spo2 over 94%. IV with lab draw. Nitro sparingly unless confirmed right side then fluid bolus 20 ml per kg. Aspirin. Consider helicopter for PC I facility. If Pt worsens go to closest facility to stabilize. If stable PCI facility is most appropriate as exam and transfer at non PCI would take considerably longer than 50 minutes.

  • CB says:

    Given what he was doing (paint fumes on ladder painting) I would first question if the pain is reproducable. Yes his ekg isn’t normal but looks like old inferior MI. And he is hypertensive. 02 a must. Def. would give ASA. First would give morphine and see how his cp and bp are. If still elevated would give 1 nitro regardless to get his pressure down but have IV access and fluids ready (systolic 180). Would actually transport to closest facility due to time because if it really was an MI he needs aniplatelets and asa won’t cut it for a 50 min drive… I think would cause more necrosis if anything if it was an acute mi. You have 2 hours to Cath lab they can run some quick diagnostics and air transport to meet that timeframe.
    I kinda feel the nausea and pain are from what he was doing… And would want a better exam/history.

  • Alex Beerling says:

    Would treat as a STEMI, and call in a STEMI alert and take patient to PCI. I would be sure to call ahead and inform them this is either an acute, evolving MI, or a new onset LBBB. Either way, the patient should be aggressively treated with PCI, so prehospital decision should be the same. If local protocols (such as the ones I work under) do not allow for STEMI activation for LBBB, I would at least let the receiving hospital know ASAP what we were looking at. I would probably hold off on nitro due to the appearance of inferior infarct, and would hope to keep the pain at bay with fentanyl.

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