Respiratory distress, chest pain, right bundle branch block, and posterior STEMI

EMS is dispatched to a 50 year old male in respiratory distress. En route, dispatch advises that the chief complaint is actually chest pain.

On arrival, the patient is found lying supine on the floor just inside the front door to his house. He is cold to the touch and pale but his skin is not diaphoretic. He denies falling and the head is atraumatic.

He appears to be mildly short of breath and admits that he is having chest pain.

  • Onset: 3-4 hours ago while walking
  • Provoke: Nothing makes the pain better or worse
  • Quality: He is unable to describe the pain (some language barrier)
  • Radiate: The pain radiates down both arms
  • Severity: The patient gives the pain a 10/10
  • Time: No prior episodes although he does state the he was recently diagnosed with anxiety and is scheduled for a “cardiac exam”

He denies nausea or vomiting.

Vital signs are assessed.

  • RR: 24
  • HR: 70
  • NIBP: 80/60
  • SpO2: 92% on room air

Auscultation of the chest reveals bilateral crackles.

A 12-lead ECG is obtained.

2010_01_08_A_wmSinus rhythm with a rate of 70. There is right bundle branch block (QRS duration > 120 ms, rSR’ in lead V1, slurred S in lead I). There is an inverted T-wave in lead aVL which is nonspecific. However, the deep “down-up” ST-segment depression in leads V3 and V4 is suggestive of acute posterior STEMI.

The patient and his family request to be transported to the local (non-PCI) community hospital.

Although the 12-lead ECG does not meet the treating paramedic’s criteria for a Code STEMI he persuades the patient to be transported to the PCI-hospital which is located across town.

He intends to obtain a 12-lead ECG with posterior leads V7-V9 once the patient is loaded in back of the ambulance. He doesn’t get the opportunity because the patient goes into ventricular fibrillation. A precordial thump is not successful.

Chest compressions are initiated while defibrillation pads are placed and the monitor is charged. A shock is delivered at 150 J. After 1 minute of post-shock compressions the patient regains consciousness. He remains in sinus rhythm for the remainder of the transport.

An additional 12-lead ECG is obtained post-arrest.

2010_01_08_B_wmThere is new ST-segment elevation in lead III and reciprocal ST-segment depression in leads I and aVL. There is new “down-up” ST-segment depression in lead V2.


The patient is taken directly to the cardiac cath lab on arrival at the receiving PCI-hospital

The angiogram reveals a near-total occlusion of the left main coronary artery limiting flow to both the left anterior descending (LAD) and circumflex (LCX) arteries.

They are unable to stent the lesion. A balloon pump is placed and the patient is referred to cardiothoracic surgery.

Updated 03/09/2016


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