EMS is dispatched to a 72 year old male patient. Third party call. History of Parkinson's Disease. Patient is conscious. No further information.
On arrival, EMS finds a 72 year old Spanish-speaking male. Through an interpreter the lead paramedic determines that the patient became dizzy, fell down, and hit his head. A small hematoma is visible above the patient's right eye.
The patient is awake but somnolent. He is oriented to person, place, time, and event. The remainder of the neurological exam was normal.
Since the patient is not alert the crew applies manual C-spine stabilization and continues the exam.
The patient denies chest pain or shortness of breath.
Breath sounds are clear bilaterally.
The patient denies any significant medical history and states that he takes no medications.
Vital signs are assessed.
- Resp: 18
- Pulse: 80
- BP: 104/70
- SpO2: 98 on RA
The cardiac monitor is attached.
*** UPDATE ***
The first complex in lead III helps foster the perception, probably due to wandering baseline.
Compounding the illusion is the ST-depression in lead aVL! This is one of the first things I look for when considering the ECG diagnosis of acute inferior STEMI.
It's helped me pick up on dozens of subtle presentations!
This is important for two reasons. First, it fools your eye into the thinking that ST-segment elevation is present. Secondly, it fools the GE-Marquette 12SL interpretive algorithm!
Having said that, I have respect for the GE-Marquette 12SL interpretive algorithm, and I'm certain it also picked up on the ST-depression in lead aVL.
Keep in mind that the ACC/AHA STEMI criteria is far from perfect. I've called STEMIs before with less than 1 mm of ST-segment elevation, specifically when ST-depression was present in lead aVL.
This case demonstrate that sometimes, the emergency department is exactly where a suspected acute STEMI patient (with a marginal ECG) belongs until the diagnosis can be confirmed through other means.
I'll be posting the conclusion to the case in the next couple of days.