“You Make the Call” — 86 Year old Female: Dizzy

 

It is a beautiful September morning when the tones go off for a 86 year old female, “altered mental status”.

“Guess breakfast will have to wait”, as you and your partner head towards the residence.

As you enter the one level home, you are directed to a back bedroom where you find your patient lying in bed.

She is alert and oriented, but her color seems pale. She seems uncomfortable. Her radial pulse is strong, and she is breathing normally.

You ask what happened…

” I was sitting at the kitchen table having some tea when I got really dizzy. My friend helped me to bed, but it hasn’t gotten much better over the last hour so my friend called 911.”

She denies any chest pain or shortness of breath, but she says has been nauseous and has vomited twice.

  • HR: 66 and regular
  • BP: 164/78
  • RR: 16, Lungs are clear
  • SpO2: 96% on RA
  • Skin: Cool and moist
  • BGL: 108 mg/dl

Her history is significant for hypertension and lymphoma.

  • A: No known drug allergies
  • M: She takes a beta blocker for hypertension, and meds for chronic lymphoma
  • P: As stated above
  • L; Eggs and toast for breakfast
  • E: Having tea

You acquire a 12 lead ECG:

ECG9:10

You are 15 minutes from the local ER, and 1 hour from the PCI center by ground. Medevac to PCI is available.

  • Is there anything else you would like to ask the patient?
  • What is your interpretation of the ECG? Are you concerned about a STEMI?
  • Where are you going to take your patient?

YOU MAKE THE CALL!

 

 

 

12 Comments

  • iliyas says:

    LAD
    LAHB
    1’av block
    Lvh with strain
    Conductint tissue disorder

  • Holter Green says:

    what are signs of LVH that present here ?

  • Chris Gage says:

    The criteria in V1-V3 of STE/(R-S) is <25%, and this should be considered normal elevation for LVH. Treat her symptoms, which seem to be very little and drive her to the local ER.

  • Chris Gage says:

    Holter Green: The signs of LVH here are r-wave in aVL >11 mm and r-wave in lead I >12 mm.

  • anthony says:

    LVH for new onset CHF would still start an iv and alert hospital to possible stemi but would make sure to tell them the EKG shows signs of LVH.

  • Jessica says:

    I want to get to the bottom of what the friend means by “altered mental status” and attempt to get an understanding of what the patient’s baseline is, determine whether or not patient is reliable. History of HTN supports possible LVH, and the ecg criteria may be there, but I’m also concerned about new LBB. I would ask, in terms she can understand, if she’s ever been told she has a heart block. I’m also interested in when she was diagnosed with lymphoma, how long she’s been on treatment for it/what the treatment is, and how she generally tolerates it. I may need expert advice on this one, especially if I can’t obtain reliable history of present illness. I’d bring the patient to the closest hospital, where people smarter than me can decipher what exactly is going on and request air transport to PCI center if needed.

  • Stian says:

    Bare with me, I am still trying to catch on with ECGs. Isn’t that anterior Q’s with the STE?

    Suggestion for ruling out STEMI – V7, V8, V9 looking for reciprocal depression?

    Heart sounds would help support any cause of LVH…

  • Stuart says:

    There is no LBBB as QRS <120ms.
    Diagnosing LAHB in a patient with LVH is difficult. ST elevation is appropriate for LVH.
    1st degree HB rarely causes symptoms, but when combined with a betablocker could be problematic.
    I'd want her to have 24 hours telemetry monitoring to rule out cardiac causes of dizziness.

  • allan says:

    Sinus Rhythm, Mutiple LVH criteria, 1st degree block. Would ask patient if she has a history of dizzy spells; if so, if this episode is similar to previous episodes she has had in the past. The fact that this episode occurred at rest is concerning, as is her age and sex (elderly females can present with atypical symptoms). As far as her symptoms and clinical context, an ill appearing elderly female with an acute onset of symptoms is concerning. I also would be careful chalking this EKG up to simple LVH; simply because criteria for LVH are present does not mean an infarction can be ruled out. The absence of an R wave in V4 is concerning, as is the lack of ST segment elevation in V6. In my mind, this ECG is highly concerning in the context of her symptoms and presentation. If you use Dr. Smith’s (From Dr. Smith’s ECG blog) app “Subtle STEMI”, her score indicates STEMI. I would give her aspirin, if possible transmit a 12 lead, and speak to a command physician regarding my findings. If transmission and a consult are unavailable, I would absolutely transport her urgently to a PCI center, treat her nausea, and provide supportive care.

  • Andreas says:

    STE in V1-V4 plus the descending ST with upright T waves in I and aVL could be an MI.

    Any update on this? Conclusion was never posted

  • cs1245 says:

    Would consider LV aneurysm (from old MI) due to deep, well formed Q waves in V1-V3 and no reciprocal changes seen. If pt was having a new STEMI with those deep Q waves in V1-V3 and visible STE of 2 mm, there should be reciprocal changes seen and I don’t see any reciprocal changes.

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