65 year old female CC: Chest pain

EMS is called to a hotel for a 65 year old female complaining of chest pain.

On arrival, the patient is found sitting on the edge of the bed in her hotel room. She is alert and oriented to person, place, and time.

Her skin is pink, warm, and dry.

Onset: 30 minutes ago while getting ready for bed.
Provoke: Nothing makes the pain better or worse.
Quality: Patient states the pain is “like a vice”.
Radiate: Pain radiates to the neck and left arm.
Severity: Patient gives the pain a 9/10.
Time: No previous similar episodes.

Past medical history: Thyroid disease and thyroid removal. Recent checkup at the doctor’s office was unremarkable.

Medications: Unknown

The patient states that she thinks today’s problem might be related to her thyroid.

Resp: 18
Pulse: 76
BP: 130/78
SpO2: 99 on RA

The cardiac monitor is attached.


A 12-lead ECG is captured.


A “clean” rhythm strip is captured.


An additional 12-lead ECG is captured in the ambulance.


This arrhythmia is documented en route to the hospital.


Your thoughts on the case?

28 Comments

  • SoCal Medic says:

    Great cases Tom, this was not after a 12 lead class was it?Inferior Wall MI as noted by the elevation in II, III, aF with reciprocal changes noted in I, aVL.Slight Depression in V2 with Inverted T Waves in V1&V2; couple with the poor R Wave Progression leads me to believe Posterior Wall is also Infarcting.Noted First Degree Heart Block is also concerning. Willing to bet it was induced by the MI. In the last strip it is hard to tell if the PR changes (my eyes hate counting boxes on screen this early). If so, she could be transitioning into a Second Degree Type 1 (where the PVC fires rather than the dropped beat.) If not, she is around the corner from transitioning into something very bad (i.e. third degree heart block or V Fib judging by how close those PVC's are getting), either way, a long strip would help identify that.ASA, Oxygen by NRB. She has a good blood pressure so I might be inclined to try the Nitro despite the Inferior/Posterior Wall MI, only after a line is established and fluid has been started, assuming Edema has not developed. Morphine for pain, cautiously, she is 65.Transport to a Cath Lab with a STEMI Activation per our protocol since the machine reads ACUTE MI Suspected and my interpretation of the MI.

  • Tony D says:

    Great case, I don't know why machine interprets as anterior MI when its clearly an inferior MI. I would be careful with nitro and have a bag of fluids very close by, if not running yet.Did they give nitro ? and how was the BP afterwards if they did? Also was the first degree block new or had history?

  • Billy says:

    Other than the obvious STEMI, I see poor R wave progression in V1-V3 and the QRS complexes change amplitude instantly in V4-V6 which is not what we would normally expect. I assume this is common in an MI?I also see that ST elevation is greater in lead III than lead II, so there may be RVI. I also see ST depression in the anterior leads. I would have run a 15 lead on this patient.

  • Christopher says:

    Obvious elevation II, III, aVF w/ recip changes as everyone has noted. Definitely calling a STEMI on this puppy. I'm with SoCal, it almost looks like 2nd Deg Type I in that last rhythm strip.Rx: O2, 324mg ASA, IV KVO, V4R/V5R, NTG w/ caution, early STEMI notification.

  • Tom B says:

    @SoCal Medic – Very well thought-out interpretation, Christopher! @Tony D – My guess is that the interpretive statement says "Anterior infarct – age undetermined" because of the QS complexes in V1-V3 (actually there's a tiny nub of an R-wave in V2-V3 but it's essentially a QS complex). It's the "Inferior injury pattern" message that corresponds to the ***ACUTE MI SUSPECTED*** message. Your point is well taken with regard to the fluids. My understanding is that the pressure came down with the NTG (but not dangerously low) although the patient c/o a headache almost immediately following the first dose.@Billy – I agree with the poor R-wave progression, although I'm always suspicious of precordial lead placement when I see a sudden transition like that. I wouldn't make too much of it! I agree with you that RV infarct is a strong possibility! @C.Watford – There is some variability in the PR interval for sure, but that's not what I find most interesting about the last rhythm strip! :)Tom

  • Christopher says:

    Tom,I used my diff tool and it looks like the first PVC on the strip narrowly missed the relative refractory period. Also the diff confirms the compensatory pause (the PRi's are a bit different, but you can march out the R-Rs).The second PVC looks to be followed by a different ectopic foci if you look at the initial rhythm.My other observation is what could be a delta waves in the FLB's! WPW?

  • Tom B says:

    C. Watford – Remember, the relative refractory period starts at the apex of the T-wave! I like where your brain is. These are R-on-T PVCs, and they almost trigger a run of VT on the second half of the strip!Tom

  • Downunder Paramedic says:

    Great ECG mate. I did not see any vitals on the patient. Even if I had them I would do right sided chest leads to check for RV infarction. If here SPO2 was low she would get high flow O2 but if it was above 94% I would only give her low flow as the research shows O2 causes vasoconstriction (which we dont want in the coronarys). 250ml bolus of fluids to see if the heart could increase coronary perfusion and take care of the chest pain. Once RV MI has been ruled out or discovered I would then decided about my GTN. Depending on where her blood pressure was would depend on if I gave it or not at all. Low doses of MS. If there was RV involvment and depending on the BP I might use Methoyflurane for the pain (if she had any). If there were no contraindications to our reperfusion program and the cath lab was closed I would then give her Heparin, Tenectaplase, and Clopidogrel. Hopefully then I would see the ST elevation going away in minutes. That or treating the rhythms I have just caused from the reperfusion. Mate, love you web site!! Awesome job. I follow it a lot and have not commented before. I have a bit more time today!

  • Tom B says:

    Downunder Paramedic – Thank you for the positive feedback! I really appreciate it. It's very cool that you have a reperfusion program! I suppose you need it "Down Under"! Just out of curiosity, how large is your district? Tom

  • Downunder Paramedic says:

    Mate, I work in Queensland Australia and our area is the entire state of Queensland. Very large! It's like the state of Texas. The reperfusion program began in 2007 and has had great success. (more than happy to send you a PDF of the guidelines, I don't think that it guide). Basically the state is broken into six areas. Each area has a different timeline for reperfusion in regards to how many PCI hospitals are around them. For my area, if it is more than 20 minutes from time of discovery of the STEMI to PCI we thrombolys. If not and within the hours of operation we take them to PCI. Very amazing results and amazing that the ICP's do this own their own judgement. We don't send the ECG to the hospital and then get permission. The ICP's make this decision. (ICP: Intensive Care Paramedic). Again, keep up the good work mate. Your teaching a lot of people, including me!!

  • SoCal Medic says:

    Downunder ParamedicI work in Southern California and am curious as to the breakdown of EMS is there where you work. You mentioned the Intensive Care Paramedic, what other levels of pre-hospital medicine do you have?Christopher

  • Billy says:

    With this being an inferior STEMI would thrombolytics work well here? I seem to remember a post on this site describing how thrombolytics won't work well in certain types of STEMI's and an inferior STEMI seems the most logical since cardiac output is reduced the most, although I wouldn't think too much output would be needed to achieve coronary circulation, which occurs during diastole at the base of the aorta if memory serves. I have searched for the post and can't find anything on the topic. Any thoughts?

  • Tom B says:

    Downunder Paramedic – I'd love to see a PDF of the guidelines! Please email to ems12lead.blogspot.com.Thanks!Tom

  • Tom B says:

    Billy -I think the post in question was located at Dr.S.Venkatesan MD's blog. He discussed risk stratifying STEMI patients, if I remember correctly.Tom

  • Downunder Paramedic says:

    Billy: I had a lady a couple of months back with a inferior STEMI. Brady, almost hypotensive, and every sweaty. I elected not to give her GTN and only small amounts of MS. The MS began to drop her BP significantly. I didn't do right sided chest leads as I had a high suspicion of RVI because of the signs and symptoms. She was given Tenecteplase and Heparin, no more STEMI. It was beautiful! About an hour later she re-occluded at the ED and was rushed to the cath lab where she had a full occlusion of the right coronary artery. Throughout the state we have completed many many reperfusions with not many problems being seen with any certain type of STEMI.

  • Downunder Paramedic says:

    SOCAL Medic: Here in OZ, or Queensland there are three student paramedic levels, Advanced Care Paramedic, and the Intensive Care Paramedic. It takes about 2 1/2 years to become a Advanced Care Paramedic. This can be completed through on the job training through the service or you can go through the college for a bachelors degree. Then you have to work as a ACP for two years before you can apply for the ICP program. This is a graduate program at UNI. It is a year and three month program. At the end you sit a two day panel. 10 stations with either just ICP's or a ICP and Doctor. Very stressful. The knowledge of just a student paramedic is amazing. I was not trained here in Queensland so I'm not biased either way. Although they are a bit behind on EMS they are now using reperfusion and Ketamine.

  • SoCal Medic says:

    Downunder ParamedicI am curious as to how the treatment modalities and scope of practice differ between your different Paramedic Levels as it relates to STEMI care, and also, what would be the time commitment from start to finish to complete the ICP requirements?I don't want to jack Toms blog (sorry Tom), but I am curious how the different levels in your system handle STEMI Patients, and how that care relates to the pre-hospital certifications that you have. If you like, email me at CLinke8314@aol.com.Christopher

  • Tom B says:

    Christopher – That's what the "comment" section is for! Communicating with me and with each other. Don't worry about me! Tom

  • Downunder Paramedic says:

    Chris, (sorry Tom, I tried to send this through email but it wouldn't go for some reason).From start to finish it would take 7 to eight years if not longer. The initial training is almost 3 years to become a Advanced Care Paramedic. Then you have to stay a ACP for two years before you can apply for the program and hopefully be excepted. 20-25 people each year are excepted. There are only about 250 ICPs in Queensland and about 70 on the road actually working. Once you get excepted into the program it is a year and 3 months total if you pass the first time.The knowledge base of the medics here are amazing. I was not trained here in AUS. Amazingly different here.Talk soon

  • Downunder Paramedic says:

    Tom,mate did you get the email with our reperfusion guidelines?

  • Tom B says:

    Downunder Paramedic – Yes! I did. Thank you very much! I've been extremely busy between the launch of a new ePCR program, the STEMI program, the CARES program (cardiac arrest registry), and studying for the Captain's exam.I appreciate it very much! I'll read it as soon as possible and I may have some questions.Thanks again!Tom

  • brendan says:

    From start to finish it would take 7 to eight years if not longer. The initial training is almost 3 years to become a Advanced Care Paramedic. Then you have to stay a ACP for two years before you can apply for the program and hopefully be excepted. 20-25 people each year are excepted. There are only about 250 ICPs in Queensland and about 70 on the road actually working. Once you get excepted into the program it is a year and 3 months total if you pass the first time.And in America you can be a paramedic in 6 months, if not less.I guess American patients just aren't as sick as Australians, so it's ok. *snort*

  • Downunder Paramedic says:

    BRENDAN, (SORRY FOR THE CAPITAL LETTERS, NOT YELLING, JUST A BROKEN COMPUTER), MATE I WAS ACTUALLY TRAINED IN CALIFORNIA PRIOR TO MOVING TO AUS. I WORKED FOR THREE DIFFERENT AMBULANCE COMPANIES PRIOR TO BEING HIRED BY QUEENSLAND AMBULANCE SERVICE. I BELIEVE EACH PLACE HAS ITS PROS AND CONS JUST LIKE ANYWHERE. AUSTRALIANS ARE NOT SICKER BUT HERE IN QLD THEY PAY FOR THE AMUBULANCE ON THEIR ELECTRICITY BILL. SO YOU GET MANY CALLS FOR TOOTH ACHES, STUBBED TOES, ETC. ALSO REMEMBER, THERE ARE ONLY ABOUT 30 MILLION PEOPLE IN THE ENTIRE COUNTRY THAT IS ALMOST THE SIZE OF THE US. YOU REALLY DON'T NEED THAT MANY INTENSIVE CARE PARAMEDICS SINCE THERE ARE NOT A LOT OF CRITICAL CASES HAPPENING.

  • Royce Worrell says:

    When the R-on-T appeared was Lidocaine or Cordarone given…or did the STEMI/block keep them from it…???   Thanks, Royce.

  • The New Guy says:

    @ Downunder Paramedic – I am a new Paramedic actually taking my National Registry Test tomorrow and one area I am very interested in working is in Australia. I was wondering if you would be willing to share any information, tips, or suggestions with me on how I go about searching for employment in Australia and the process of transferring into their system. Any info you can supply is greatly appreciated.

  • Chris T says:

    LOVE this post!! all smiles. @ Brandon *sigh* 🙁 @ downunder an ICP sounds like a lot of schooling-AWESOME. Are these medics also a level of physician or nurse practitioner? and do they work out of a hospital base? And if the incidents are low, how on earth do they maintain high level skills? Sorry to shoot so many questions im facinated ! I had no idea @ SoCal, Christopher, Tom B awesome helpful discussion. Neat case!

  • WVHillbilly says:

    Inferior ST elevation w/ reciprocal changes in I and AVL.  PR interval = ~.4.
    Inferior MI w/ 1st degree block.

  • a reader says:

    According to the charts, this woman is only 55, not 65.  that's a big age difference.

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