Weakness, nausea, and inferior-posterior-lateral STEMI

You are dispatched to a report of a disoriented man on the beach.

On arrival bystanders direct you to a 49 year old male who is sitting on a bench. An elderly couple states they were taking a walk and saw the man sitting on the bench and became worried about him due to his appearance.

The patient is pale and diaphoretic. He is lethargic and states that he doesn’t feel well.

He admits to slight chest discomfort on inspiration. He denies any significant medical history.

You place him on the gurney and load him in the back of your ambulance for a more detailed exam.

Vital signs are assessed.

  • HR: 50
  • RR: 16
  • NIBP: 82/54
  • SpO2: 94% on RA

Breath sounds are clear bilaterally.

The cardiac monitor is attached.

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A 12 lead ECG is obtained.

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What is your plan of treatment?

This is an impressive STEMI! Every single lead shows an ST-segment deviation.

This is a good case to show the difference between monitor mode and diagnostic mode. Look at the difference in lead II between the rhythm strip and the 12-lead ECG! In the rhythm strip the low frequency / high pass filter is set to 1 Hz. In the 12-lead ECG it is set to 0.05 Hz.

I did not receive the angiograms for this case but we can surmise that the culprit artery was either the RCA or LCX. When STE III > STE II it suggests RCA occlusion but in this case STE III = STE II (they look identical) so that’s no help!

Regardless, we can certainly say this is an inferior-posterior-lateral STEMI. Could there be right ventricular infarction? It really doesn’t matter because we should be withholding nitroglycerin based on the initial blood pressure.

It’s worth noting that we often see bradycardia and marginal blood pressures in the setting of acute inferior STEMI which is often a manifestation of the Bezold-Jarisch reflex which induces a state of hypervagotonia.

One interesting feature of the ECG is that the rate is 50 with narrow QRS complexes but the patient is not in sinus bradycardia. If you look at leads with the most isoelectic T-waves (lead I and lead V4) you can see a blip about 240 ms after the QRS complex. Is it a P-wave? Quite possibly. But this arrhythmia is likely to resolve following successful reperfusion.

Updated 11/23/2015

57 Comments

  • walma says:

    Let’s do the right side chest leads. Then let’s do the posterior leads because there is BIG ST depression in anterior leads together with positive R so probably there is posterior wall involvement also. From this ecg there is for sure inferior, lateral and for 95 % posterior and RVI AMI. Then fluids a lot of fluids, some analgesic (no morfin, use fentanyl), Aspirin and rush to the Cathlab. Beware of significant bradycardia because there is junctional rhythm (no of P) so he can deteriorate in more lethal brady arrhythmia. If so use the pacer, if there is no pacer on your rig. Use drugs, some Atropine or Epi drip, but only if he significantly deteriorate (drop BP despite aggressive fluids infusion)…PS. Great educational blog, keep it that way.Maciek from Poland

  • Tom B says:

    Awesome response, Maciek! Thanks for the encouragement.Tom

  • Hillis says:

    The rythm is junctional in origin. STE is seen in the inferior ( ii,iii, aVL ) and lateral leads V5and V6 deep ST depression in the anterior suggesting posterior STEMI so i would perform the posterior leads V7-9 also perform V4R for right ventricular involvement which is commonly accompanied with inferior STEMI .Rush the patient to the cath lab.

  • Brian H. says:

    I don’t understand the recent emphasis on doing right sided or posterior leads in the setting of clear cut STEMI. If there is criteria for reperfusion, move down that protocol. If there is profound ST depression in V1 and V2, that is diagnostic for STEMI as well. Right sided leads have diagnostic value when there is no overt ST elevation, especially when there is bradycardia, hypotension, or AV block in the setting of left lateral depression. I will suggest that right sided and / or posterior leads when STEMI is already present is an academic exercise – acceptable only if it does not delay any care for the patient. JMO.

  • in this case with hypotension, it arguably is an academic exercise to do R leads. i can see your point.

    but it is always a good habit to do R leads in inferior MIs because RVI is often seen with inferior MIs. for RVI, even with normotension, NTG is potentially very dangerous and large fluid boluses may be necessary. the R leads helps determine which treatment path.

    i think delaying care to determine a more appropriate treatment plan isn’t a bad thing. it takes so little time to run V4R.

  • Aharon Oppenheimer says:

    I give him O2 60% and make posterior and right AKG after I give him a 200 CC sline check agin his BP and if is not change I start with Dopamin Dreep 5-20 mkg/kg/min and transfer him to PCI hospital

  • Maria Dulce says:

    @ Brian H – very well, i agree with you.

  • Igor says:

    walma, why not morfin bur fentanyl ?

    I know that fentanyl is very, much more powerful then morfin (+- 100x). and also morfin is a central nervous sistem depressor, and the patient has hypotension which could worse a lot…right ?

  • Dr Zeeshan Ahmad says:

    junctional rhythem with infero-postero-lateral MI..he is very much prone to bradyarrythtmias,,,check RV4 for RV Infarction..take the pt to cath lab for further management

  • samantha says:

    EKG suggested inf- lateral with posterior MI, give O2, Asprin and clopidogrel. if patient complaint of chest pain can give SL GTN. done right sided for confirmation RV infarct. if RV infarct occurred, and patient develop hypotension fluid challenge of 200mls. send patient to cath lab for primary PCI should be can help the patient. if cath lab not available, fibrinolytic therapy should be can help.

    • Ex-para says:

      SL GTN contraindicated due to low BP and possible posterior involvement.. will only reduce preload further and increase risk of greater bradysrythima

  • Jukka says:

    I agree with interpretations. I would do AT LEAST V4R to determine if the right side is involved. If so, would hold the NTG and use LOTS of fluids. I had one similar patient once, had to push as much as 2000mls of fluids, including kolloids to keep the BP up. And no, no SOB/pulmonary oedema.
    Rush to cath lab or instant thrombolytic therapy.

  • Melissa Parker says:

    Inferior MI…. def get him on some oxygen first and foremost. Two large bore I’ve and fluid bolus to raise bp. Aspirin. Hold nitro and morphine. Consider fentanyl admin for pain. Morphine may help if his bp was greater and increase oxygenation to the heart, but considering its anatomical location, profound hotn with morphine is a given. His bp is hypotensive enough. I would def stay away from the morphine on this one. Also I will not waist time with lead adjustment. Get him loaded and gone. Treat in route and call cath lab. No point in using up time beyond this is tx when definitive care is the true tx.

  • Danny says:

    I had a Patient presenting with some of the same Symptoms a while back. Obviously Junctional. He ended up with elivated levels of Potassium actually off the chart levels. He actually coded while placing the Pacemaker in the ED. No MI,He did well after a few days in the CCU,and getting his Potassium Level back to normal.
    However while in the ED his Heart Rate dropped to 16 BPM,just before he coded. He is doing very well follow his discharge.

  • Jared says:

    Unstable bradycardia?? TCP. Oxygen, IV’s, sedation (if his LOC supports that), Dopamine (if pacing and fluid doesn’t bring that pressure up), and diesel bolus. Atropine is NOT an option.

  • Aharon says:

    what I do give O2 and guve micropirine , after that chek BP again , make a right and posterior leads , that on the way to hospital that can make ctheterization monitoring BP after I give bolos of fluid 100-200cc.

    I glad to see the ACG with the right and the posterior leads

  • 12leadekg says:

    Junctional rhythm, with inferior posterior lateral MI. Brady and hypotension in present of Inferior MI indicates RVI. Patient needs 02, ASA, Fluid bolus and NTG. Transport to Cath Lab.

    • Medicboss says:

      NTG is contraindicated due to his blood pressure.
      Dopamine and Fentanyl would be more appropriate in addition to the O2, ASA and fluid bolus.

  • ARSHAD HASAN says:

    HR–50
    ST ELEVATION—Lead 2,3,aVF& V5,6
    ST DEPRESSON—V1,2,3
    Abscent——–‘P’
    Dx
    INFERO LATERAL MI(POSTERIOR STATUS NOT GIVEN)
    JUNCTIONAL RHYTHEM
    Rx
    diethyle morphine
    O2
    ASA–325mg
    Atorvastatin—80mg
    Enoxaparin–40u/sc
    Strepto/Urokinase
    …………
    If not responding….
    PCI
    Temporary Pacing

  • chris T says:

    ever hear the nickname tombstone T’s, widow makers…. Es no good. I agree with most above.

  • Medic-Minx says:

    Why are some giving NTG in dangerous hypotensive state? He needs fluids (pacing and/or dopamine if that’s not working) and rapid transport to a cardiac facility. I cringe about giving NTG with a SBP around 110; I’d NEVER give it or even recommend it with a SBP of 80’s – and if you don’t do a right-sided 12L and then you give the NTG you’re going to dilate everything and drop his pressure even more. You’ll then be walking in with a cardiac arrest.

    Morphine and Fentanyl still drop pressures (decrease preload and vasodilate) so I’d use extreme caution with that as well – (+) CNS depressant so you’re also going to slow their breathing down as well. Fentanyl doesn’t cause the histamine release as much as Morphine but I’d stick with a fluid bolus (absence pulm edema) first then re-evaluate.

  • Southern Medic says:

    Ok where I am from we would give up to 2 liters of fluid dependent on lung sounds also Fentanyl is a definite however no MSO4, no NTG, Dopamine up to 20mcg if no response to intial fluid bolus of 500 cc, be ready to pace and be careful pacing this due to the fact we don’t know how long he has had the bradycardia and if we pace to a rate that gets his pressure up over 100 systolic we might also cause a clot to move and cause bigger problems. This person needs a cath lab.

  • Chief Harris says:

    There is no argument that this individual is having a multi wall MI, the problem is its more than one vessel that’s occluded. The inferior wall and SA node are the RCA, the lateral wall is the circumflex. The only thing keeping his BP up at all is preload which is why we avoid NTG and morphine at all costs. I would also discourage the use of dopamine and this would drive your MvO2 through the roof, worsening the infarct. He needs high flow O2, fluids to support a pressure of about 90 systolic, TCP if bradycardia worsens, fentanyl prn for the pain, and rapid transport for PCI.

  • Alan Spirdione says:

    I’ve been out of EMS for 10 years and haven’t followed protocols, so I’m surprised there were those responses that omitted pacing, 51 isn’t the bradiest of bradycardias 🙂 but with fluid and increased rate, wouldn’t that be a good way to start? Thanks for any responses.

  • medic77p says:

    Amen Chief Harris I thought for a minute I had missed something.

  • VT EMT-intermediate says:

    High flow O2 and rapid transport in position of comfort, ASA 324mg if no allergies, ulcers, or prior ASA use that day. STEMI alert at receiving facility. Large bore IV and fluids to treat hypotension. Call for a medic intercept if you’re not one…

  • wayne says:

    Every thing I have been taught to do and if that doesn’t work out then I know that he was J.T.J. (Jerked To Jesus)…some times it happens and their isn’t anything you can do.

  • Renee says:

    We are not a medic service but we can transmit 12 leads to our medical control. Obviously due to low bp, no nitro for us (SBP must be 100 or higher), ASA maybe if not already on board, IV, O2, Intercept. Transmit and prolly get rerouted to cath lab and drive it like u stole it.

  • Mark says:

    Heavy on the LSPOR!–long skinny pedal on right.

  • jeff munoz says:

    Load and go not stay and play call a STEMI and Treat the patient. 2 large bore IV’s,O2,Monitor,Capnography, Puls Ox, and Diesel Bolus to the ED,

  • David says:

    Oxygen Agressive treatment with IV fluids ASA 325 mg transmit EKG to cath lab rapid transport(helocopter transport possibly) Place pacer pads in case they are needed right sided EKG enroute monitor vitals treat as needed and to protocol.

  • Chris Bishop says:

    JR c inferior/lateral STEMI. High flow O2, position of comfort, large bore IV and a bolus of 500 cc. Good SAMPLE Hx, ASA, Atropine, Pace if atropine is ineffective. STEMI Alert to a cath. Lab.

  • Nick Adams says:

    Dx: Junctional rhythm @ 50 bpm is shown with retrograde PW’s
    seen in leads II, III, aVR, aVF, V5 & V6.
    Inferolateral AMI with probable RV and definite posterior
    involvement…II, III, AVF, V5 & V6 elevation with
    reciprocal ST depression in V1-V3 (posterior elevation). The patient is right-sided dominant (RCA feeds the PDA). Also, there is ST depression in aVR which indicates significant posterolateral involvement, so posterior leads are not necessary. You can do a quick V4R, but we know what the results of that test is going to be…(elevation). Based on the patients presentation, RV involement is strongly suspected.
    The patient has a proximal RCA occlusion.

    TX: ASA, O2 @ 4 lpm, ECG(3), ECG(12) TRANSMIT TO PCI CNTR, Paced pads on to be ready to pace, 2 very large bore IV’s with NS boluses to increase B/P & preload (Freq Lung sounds), 25 – 100 mcg of fentanyl for pain (decreases O2 consumption and demand), SpO2, ALL with rapid diesel bolus to a cath lab while that is the only definitive treatment (time is muscle).

  • MRMEDIC says:

    hIGH fLOW O2,asa 325MG,250CC BOLUS OF NORMAL SALINE,TRELENBURG TO RAISE B/P IF THAT DIDN;T WORK WITH THE FLUID THEN FLUID BOULS AGAIN MAKE SURE LUNGS ARE CLEAR PT CAOX4 I SET PACER PADS UP INCASE IF PT HAS DECREASED LOC GO WITH DOPAMINE AND THEN PACE HOPE TO GET A PRESSURE ABOVE 9O, SO PT COULD HAVE PAIN CONTROL CODE PT TO CATH LAB

  • Nick Adams says:

    Medic-Minx…..I get what you are saying, but if I may, I’d like to point out a few things in this situation.

    1. While I totally agree with you about not giving NTG to this patient at this time, RVMI’s may need 2-3 liters of fluid to increase preload. Once you have increased the preload, a trial dose of NTG can be given. NTG dilates the coronary arteries and therefore, may increase O2 delivery to the infarcted tissue. I would be very hesitant about giving dopamine in this situation while it increases myocardial oxygen demand. If I were the patient, I would hope you would be so kind as to give me some fentanyl prior to pacing me. fentanyl does not cause histamine release and therefore no vasodilation or drop in B/P. As for CNS depression, 50 – 100 mcg of Fentanyl will not cause significant respiratory depression……besides, I have O2.

    How about 2 lg IV’s with rapid fluid boluses, Fentanyl, then pacing while CO = HR x SV

    Please do not be offended by my comments, I mean no disrespect, I just have a different view.

    Respectfully,

    Nick Adams

  • Hillbilly Medic says:

    NTG will probably kill this pt, TCP and fluid, then Dopamine if those don’t do it. High flow diesel and O2 are very called for in this case. ASA is also called for but secondary to the other tx’s, hopefully transport to a cardiac capable facility. In rural TN though sometimes that’s not an option. We can’t transmit 12 leads but are taught to read them and this guys is def having a bad day.

  • fcreager says:

    This is obviously an acute MI which I can’t fix on a park bench or in the ambulance (no matter how many stickers I put on him). I would have had the high flow O2 on long before messing with the 12 lead. Diesel bolus and a early alert for the cath lab are my highest priorities. I would have had him chewing on the ASA while I set up the 12-lead. Once we are under way I can work on the rate and pressure with fluid bolus, atropine, and probably pacing. Hopefully I won’t need to start into pressors (dopamine or Epi drips). If and only if I can get a reasonable pressure I may start reducing the pain and opening up the pipes with NTG and morphine.

    Last but not least I would do my best to calm the patient and explain that this is really a problem that can be fixed with the early intervention that he is experiencing.

    Thank you so much for putting up this scenario. I appreciate the opportunity to put myself through the paces and see other perspectives.

  • Chuck says:

    Too hypotensive for NTG and morphine. High flow 02, lot of fluid trendelenburg and blankets, treat s/s en route. High priority due to absence of signicant medical hx. I’m a basic so in this case I’m calling you guys and praying that we get an intercept.

  • Chuck says:

    I wouldn’t tell the patient it’s a problem that can be fixed bc then they’re gonna think that they’ll be fixed when they may not be. We tell him we’re gonna do everything in our power and that’s it.

  • Chief Harris says:

    Hillbilly, I disagree that ASA is secondary to all other treatments, it should be one of your first and primary interventions. The administration of ASA in ACS reduces the chances of mortality by up to 30%! Fcreager avoid any and all pressors, all they are going to do is increase the damage the infarct is causing. A pressure of 80 is more than adequate for this patient. Nitro and/or morphine would probably kill this patient as it would decrease his preload. His blood pressure is ENTIRELY preload dependent at this time due to the RVI and junctional rhythm.

  • Joel says:

    The Patient is hypotensive and has RVI and lateral STEMI involvement. You could place the patient on 02 and conduct a 15 lead to see if their is any posterior MI involvment. Nitrates and analgesics should’nt be used or should be limited due to being preload dependent, until you are able to get their systolic BP up. Give ASA and use aggressive fluid replacement with 1500cc fluid bolus, and consider dopamine if the PT remains hypotensive.

  • Alycia says:

    With the elevation in several leads (confirming a STEMI) I wouldn’t do right-sided leads. Due to the hypotension I wouldn’t be giving NTG or morphine anyways. I’d rather prioritize and get in two large bore IVs and bolus to increase BP. The pt is only complaining of mild discomfort so I’d hold any analgesics. I would’ve attached high flow 02 on scene prior to transport as well. ASA would be the only med I’d administer.

  • medic10 says:

    HARRIS IS THE SHIT!!!!! Listen to him

  • Brian C. says:

    The only thing that would make that 12-lead look any worse is if u wrote “R.I.P.” on the st segments, what he needs more than anything is diesel medicine, aka drive fast, he could also use ASA, fluids, and TCP, I doubt atropine would work very well for the bradycardia because its a junctional rhythm

  • eff dog says:

    in addition to what has been said. I'd like to point out that the initial rhythm strip isn't to scale and shows barely a mm of elevation even in the same lead II. Lead II in the 12 lead is to scale!
     

  • Mohamed Wafiq says:

    Infer-Lat STEMI, check Rt & post chest leads (Marked ST depression of the Precordial leads).
    Analgesics (Diluted Morphia), IV fluids, Temprary Pacing (Bradycardia & Junctional Rhythem),if not available be ready with Atropine if indicated or deteriorated Bradycardia. 325mg ASA , Faxing the EKG to nearest Hospital facilitated by Cath lab, loading dose of Clopidogrel or Ticagrelor, then rush him to nearest cath lab.

  • Stabby McIV says:

    Looks like and inferior lateral STEMI…. Take a right sided lead.. 160 mg Asa… No right sided involvement?? nitrospray 0.4 mg SL, morphine to max 20 mg, IV OLMC, patch… And s whole lot of diesel….

    • Gio says:

      Why Morphine if he only feeling chest discomfort in inspiration?, is not like he is having chest pain. I would think in the BP is low so I would not give Morphine.

  • ali says:

    monitoring ..   cardiac enzymes
    1-rest
    2-o2 therapy
    3-fluids to increase blood pressure
    4-morphine
    5-300mg aspirin-clopidogril
    6-pci(( thrombolytics if difficulty is found))

  • Gio says:

    The blip looks like an Osborn wave. think in Sepsis .

  • Shawn says:

    Paramedic in MA, I personally with what I have in my box would treat this: Obvious STEMI alert to facility and early, 2 lines, o2 nasal at 2-4 LPM, a fluid challenge of 250 ML, weight based fentanyl for slight discomfort, 4 MG Zofran, and 324 MG ASA, right sided 12 if time allowed, however I feel most important thing here is early notification to cath team.

  • Marc Berenson says:

    Gut says RCA – I think LCx dom to SA/AV and Posterior is only about 10% of pop but know that can’t exclude this individual case. Will say that the STE in V5/V6 morphology is not what I’ve seen commonly with RCA occlusion. Maybe it’s cognitive dissonance, but I still lean RCA. Would love some more PE findings. Rhythm = Junctional v 1AVB… but the size of the “blips” seems out of proportion with the size of the QRS (esp V4) so I wonder if those are just the ischemic “last chances” of starved myocytes rather than meaningful indicators of atrial conduction.

    Remember, this is all IMHO from an amateur who really should be studying Immunology right this second 🙂

  • Drew Boeckx says:

    I read a comment about trying to pace this patient if he becomes too hypertensive, but in reality would you really? The nodal arteries are already starved of oxygen and nutrients from the location of the presenting MI and trying to pace and already injured heart you’re just going to kill it. Making the heart work harder than it already is with injury is a for sure no for me. I’d try a dope drip for the alpha effects to vasoconstrict and increase the preload before I’d pace. Also reading more comments of similarly presenting patients there was another fellow that said the ER tried pacing him in hospital and he coded. Just justification of proving my point. Try not to pace inferior/right sided MI’s!

  • West Virginia medic says:

    In reading the responses above I agree with the chief
    I can live with the pressure of 80 . ASA fluids are the way to go. I wouldn’t wast time with right sided Ekg with this patient pain management is not because of preload and wouldn’t help anyway. The pain won’t go away until the prefusion is restored. If I needed to treat the rate I would do TCP because you can’t control the rate with atropine. Never give these patients NTG you will kill them. This patient needs a Cath Lab ASAP. I’ve seen different amounts of fluid bolus from 250 ml to 2 litters the correct amount would be 20 ml/kg

  • Nick Adams says:

    You have to do the right sided leads. If it’s a RVMI, that would explain the hypotension and bradycardia. It’s either a multivessle occlusion RCA and LCX, or the pt is left dominant and just the LCX is occluded. If the pt is that hypotensive with an LCX occlusion, this pt has severe left ventricular disfunction and loading them up with fluids will not help except to put them in PE. If it’s a RVMI, then you can more cautiously give them fluid boluses to raise the BP. Not all RVMI’s are preload dependant, so a trial dose of SL NTG can be given after getting the pressure up after a fluid challange. As long as you have 2 larger IV’s with 2 L bags hooked up. If the hypotension is due to only LV dysfuction, fluids would be ecentually contraindicated because of PE. Tough patient. Reguardless, a right sided ekg must be performed and only takes a second.

  • Jack Cook says:

    Good patient presented! I agree with everyones assessment of a STEMI. V4R lead would have been nice with the inferior involvement indicated on 12 lead. Based on how this patient presented, I believe this patient would benefit from prehospital thrombolytics. Oxygen via n/c to keep oxygen sats up, ASA and start fluid infusion wide open while patching for thrombolytics. He stated his pain was minimal so I would be conservative on pain meds; fentanyl if necessary but no Morphine. And no nitro until after thrombolytics given and pt reassessed for response to thrombolytics and BP raised.

  • justin w says:

    Personally i wouldn’t be too worried about his pain level. It is minimal. I would like to think that I would give 4 aspirin, 2 good sized Iv lv’s and call the cath lab. I’d lay him flat, or semi fowlerr depending on his blood pressure and level of consciousness. Getting him out of the seated position and reclining him in the stretcher might show significant improvement.

    I had a symptomatic v-tach pt one time and after I laid her flat her radial pulses returned, her blood pressure increased to 110 systolic and I treated with amiodarone instead of sedation and cardioversion. Not only did her blood pressure improve but she had almost complete relief of symptoms other than palpitations. I always tell newer medics “just because we can, doesn’t mean we have to.”

    This is a clear cut cath lab patient. Stay one step ahead, get the pads out and ready, you don’t necessarily have to put them on. Be ready for them to decompensate, give the hospital early notification. I have a 45 mile transport to the nearest hospital at one of my jobs, sometimes less can be more. This pt needs reperfusion therapy, not over aggressive paramedics in my opinion

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