71 year old male: Chest Discomfort

 

This very interesting case comes from Bryan F, a Paramedic from Long Island.

A 71 year old male is cooking breakfast when he experiences sudden onset of 10/10 chest discomfort. He waits 20 minutes or so for it to subside, but it does not and he calls 911.

EMS arrives to find him lying in bed, stating the chest “pressure” has subsided somewhat (6/10), but he now feels some discomfort in his left shoulder. He has never experienced this before.

He denies any shortness of breath, diaphoresis, n/v, or numbness/tingling.

His Vitals:

  • HR: 74, slight sinus arrhythmia
  • BP: 178/96
  • RR: 20, regular, lungs clear,  SpO2 97% on RA
  • Skin: Pale and dry

He has taken 324 ASA prior to EMS arrival, and SL NTG and 50 mcg of Fentanyl are additionally given.

Here are two of the 12 lead ECGs:

 

 

In the time between ECG #1 and #5 shown above, approximately 30 minutes, there were no obvious changes or evolution. You are about 25 minutes from the hospital.

Would you call a STEMI alert?

Why or why not?

 



 


 

13 Comments

  • Bryon says:

    Yes

    Clinical picture + Q waves and ST elevation in v1-v2 is AMI until proven otherwise

    • Jeff B says:

      The use of Sgarbosa or modified sgarbosa criteria is not indicated here since there is no LBBB or other STEMI mimic.

  • Katlego says:

    I definately would call a STEMI alert, i highly suspect anterioseptal MI. v1 and 2 def. V3 and 4 using modified sgarbossa criteria.

    Willing to be corrected.

  • Darren Earley says:

    Q waves and 1mm in v1 & 1.5 mm in v2 with history is suggestive of AMI but not cath lab activation criteria; but i doubt anyone will criticise you for activating on this ECG.

  • Rhys says:

    With the clinical picture, pain, pale. I would transport via pre-alert to the nearest ED not Cath lab. Have a bed and Dr waiting get bloods and if they want to go through ppci that’s their choice. My choice at this time given the ECG I have along with the Hx post pain relief is rapid removal to definitive care. As the ppci pathway isn’t open the only option we have is ED.

  • goran says:

    STEMI until proof otherwise

  • John McCarty says:

    Looks like Septal STEMI with Anterior involvement to me… some evidence of a BBB trying to form

  • Tron says:

    Q-S complexes v1-v2 poor lead placement?
    Anterior STEMI…

  • Greg says:

    I would offer that yes, he is having an MI. Albeit early. His HR has slowed significantly, plus his axis has shifted further to the left, indicating to me that his septal region, and possibly the anterior wall (Lead-placement specific) may have some sort of defect/infarct. The incomplete BBB may also be an early sign of Anterior hemiblock.

  • goran says:

    Abnormal QRS in V2.Any ST elevation in abnormal QRS is significant.T wave in V3 is proportionally huge comparing with QRS in V3

  • goran says:

    3-variable LAD formula = 22.057
    4-variable formula = 18.95
    (because of Q in V2 there is no need for formula)

  • goran says:

    Sadleback ST elevation -maybe Brugada tip 2

  • Jim Todd says:

    The peaked T waves and clinical presentation would be enough for me to advise ER of a possible MI although probably not a definite STEMI.

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