A 59 year old male presents to the fire station during a 12-lead ECG class (you can’t make this stuff up) and complains of chest discomfort.
He is anxious, appears acutely ill, and is rubbing his chest. He senses that “something is wrong.”
- Onset: 30 minutes ago while patient was walking on the beach
- Provoke: Nothing makes the discomfort better or worse
- Quality: A “sort of pressure or ache”
- Radiation: The pain does not radiate
- Severity: 7/10.
- Time: A similar episode occurred yesterday but resolved
The patient is placed in the back of the ambulance and undressed from the waist up. Lead placement is supervised by yours truly and is perfect.
Skin is flushed, warm, and diaphoretic.
Vital signs are assessed.
- RR: 20
- HR: 60
- NIBP: 104/44
- SpO2: 98% on room air
A 12 lead ECG is obtained.
Sinus bradycardiaÂ with a rate of 54. There is subtle downsloping of the ST-segment in lead aVL. There is a straightening of the ST-segments in leads III and aVF with slight terminal T-wave inversion in lead III. The R/S ratio in lead V2 is < 1 butÂ it doesn’t feel quite right. There is a slight flattening of the ST-segment in lead V2.
As we have described on many occasions, a downsloping ST-segment in lead aVL is often an early sign of acute inferior STEMI! Although this ECG is suspicious it does not meet our prehospital Code STEMI criteria.
The patient was given aspirin. An IV was started, the patient received a 250 ml infusion of 0.9% normal saline, and a single sublingual nitroglycerin spray was administered.
On arrival in the Emergency Department the following 12-lead ECG was obtained.
Sinus rhythm with a rate of 66. Now there is ST-segment elevation in leads II, III, and aVF. Although the ST-segment elevation is minimal the QRS complexes are small (rule of proportionality). There is new ST-segment depression in leads V1 and V2. This ECG is diagnostic for acute inferior-posterior STEMI.
The patient was taken to the cardiac cath lab and was found to have 100% occlusion of the right coronary artery (RCA).