Here are the serial prehospital 12-lead ECGs for 74 year old male CC: Chest pain
Angiograms and cath report to follow.
Pay close attention to the right precordial leads (V1-V3).
Consider the following graphic.
The most important changes occur between 16:41:26 and 16:50:30.
Just for fun, here it is “flipped”.
See also:
Cath report for 74 year old male CC: Chest pain (with angiograms)
[...] The first update to the case is here: Update to 74 year old male CC: Chest pain [...]
[...] Update to 74 year old male CC: Chest pain [...]
[...] 74 year old male CC: Chest pain – Update [...]
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Appears to be worsening STD in V1-V3, I/aVL/V5/V6. Looking back at the rhythm, I guess I'm seeing an RP interval of ~0.12, so a junctional RBBB @60.Perhaps left dominance and PDA occlusion could give:- V1-V3 depression and tall R waves- I/aVL/V5/V6 if there is some LCX involvementNot sure how to factor in the possible junctional rhythm, at any rate I'm looking at something ugly and my H's/T's put MI way up at the top.
That's the key finding, Christopher. A worsening of ST-depression and T-wave inversion in the right precordial leads (V1-V3).I will post a graphic to help illustrate your point.Tom
Nice, thanks! Annnd it looks like I shouldn't have included V5/V6. If anything it should be evolving STE, but I think I am seeing something that may not be there (baseline?).
Flip it over and it would look just like an MI–st elevation. Posterior infarct is my dx.
Anonymous -Thanks, that's one of my favorite tricks!
See my previous post at Paramedicine 101:Anterior ischemia or Posterior STEMI?Tom
The STD does get worse and the shape changes a little bit. A very important point to prove we need to use the power of observation to find these progressions. Another interesting thing I saw was the ectopic beats that in Lead I & 3 look totally different from the underlying rhythm as compared to lead 2 which one might not notice at a quick glance.Cool EKGs, thanks again, can't wait to see the rest of the case.
Still like the Carousel Ponies concept (gimmick
) from Garcia for posterior infarcts:
Slide 67-68 of
http://www.authorstream.com/Presentation/rsprue1-368631-Chapter15-Education-ppt-powerpoint/