Snapshot Case- No Day at the Beach

It is a beautiful summer afternoon when you and your partner are called to the beach for a “swimmer in distress”.

Upon your arrival, you find a 48 year old male sitting on a beach towel, appearing to be in some distress.

You are told that he was swimming in the ocean when he began to struggle, and was pulled out by bystanders.

Patient tells you that he developed a constant sharp pain in his chest, along with pain in his right arm, probably from overdoing the swimming he thinks. He says he feels a little better now.

He has no history, takes no meds, and tells you this has never happened before. He denies shortness of breath, lightheadedness, and nausea. Diaphoresis is hard to assess because the patient is still cool and wet from the water.

 

You get a set of vitals:

  • Pulse: 78 and regular
  • BP: 128/78
  • RR: 18 regular, lungs clear
  • SpO2: 96% on RA
  • Skin: cool and moist (out of the water)

 

You acquire a 12 lead ECG:

 

ECG626

 

The community hospital is 12 minutes away by ground, and the STEMI center is 30 minutes away requiring Medevac transport.

For context, your system has had an issue with false positive cath lab activations, making activations from the field a little more difficult subject to system review.

 

Back to this call:

  • What is your ECG interpretation?
  • How will you treat your patient?
  • Will you take your patient to the closest hospital, or activate the cath lab?

 

12 Comments

  • BT says:

    Q-v1, pain resolved after rest. Transport to closest hosp. Anterior ischemic disease pattern.

  • JT says:

    Hyperacute T waves; PCI center

  • Paul says:

    I’m calling this a STEMI. Hyper acute T-waves as mentioned, but there is clearly defined ST elevation in V1-V3 relative to the amplitude of the QRS. Furthermore, the QRS is too wide for an otherwise previously healthy male in his 40’s. The QRS widening is secondary to acute ST changes.

  • Josh says:

    Meets Squarbossa criteria. Concordant ST elevation. Cath lab activation needed.

  • Tom says:

    There is a hyperacute T-wave (T-wave straightening with wide base) –> cathlab

  • Tom says:

    I would make another ECG arriving at the cathlab + hypersensitive troponin. Repeat in every 30 min until final diagnosis.

  • Alex says:

    Not a good ECG for a person with no history. The anterior T waves, the T wave inversion in aVL, the Q waves, are very suspicious but I don’t think my PPCI centre would buy those with some (more) ST elevation.

    Aspirin, GTN, etc and repeat ECGs while we head to the local hospital. If the ECG develops, we’ll change our plan.

  • Nicole says:

    3rd year ER resident here.

    I see 1mm of horizontal appearing STE in V3, none in V2 (but there’s not much of a QRS there) or V4. There are broad, symmetrical T waves that tower over the precordial QRS complexes.
    There are T wave inversions without ST depressions in 1 and aVL.
    I agree with the computer interpretation of LAFB, which explains the leftward axis and slightly prolonged QRS. This is the most common intraventricular conduction defect in acute anterior MI.
    Altogether, this is a patient who looks well, has some chest pain but is improving, with minimal or no associated symptoms, is young-ish, with minimal or no risk factors (but does he see a Dr?) with an EKG that is concerning for acute coronary occlusion but does not meet most cath lab activation criteria.
    I would treat like an MI and repeat EKG q15 min on my way to the cardiac center, while on the phone with the ED doc, and transmitting EKGs if possible.
    I wouldn’t fault any EMS provider for doing the same but going to the closest facility.

    • Nicole says:

      forgot to mention, as soon as the ST segment creeps up in a contiguous lead, which I think it will, cath lab activation would be appropriate.

  • Mel says:

    I’m going to agree with Nicole on this one.

  • Glenn Walmsley says:

    I agree with 3rd year resident on this one. 1 mv Elevation in V3 with hyper-acute T’s in V 3 to V6 with flipped T’s in LI & AVL. It currently does not meet STEMI in my region but I believe it is likely to evolve into one. I would head to a PCI Hospital (Not a STEMI Alert yet) and treat with ASA, NTG followed by MS if req’d. Repeat the ECG on departure and at hospital or if condition changes. I reading this on my phone but it appears to be bordering on a RBBB or (incomplete RBBB) so sgarbossa criteria does not apply. Regardless of lacking other risk factors this guy is only in his 40’s and deserves to be at a PCI Hospital and would be going their without hesitation if it were one of our family members.

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