An 81 year male reports to the fire station to have his blood pressure checked.
He tells the paramedics he had just finished a round of golf and was sitting in the clubhouse when he felt, “cold and shaky.”
He relocated to his car with the windows rolled up and the A/C turned off. The ambient temperature was very warm but he still felt cold.
That’s when he decided to drive to the fire station.
At the time of evaluation his BP was 120/70 and his pulse was 76 and regular, which was consistent with the other vital signs recorded on his BP card over the past 2 weeks.
When he left the fire station he did not appear acutely ill.
Two hours later an ambulance was dispatched for a male patient with shortness of breath.
The paramedics recognized the man standing on the side of the road wearing a jogging suit as the same man who was at the fire station earlier for a BP check.
He states that he called his doctor who was out of town, and the on-call physician advised him to call 9-1-1.
The man was helped into the back of the ambulance and undressed from the waist-up. A surgical scar is noted down the center of his chest.
Past medical history: MI and CABG x3 in 1985
Meds: Unknown
His vital signs were assessed.
Resp: 18
Pulse: 80
BP: 114/76
SpO2: 96 on RA
He states that “nothing has really changed” since he was at the fire station.
When asked about shortness of breath, he denies it.
The cardiac monitor is attached.
When specifically asked about chest discomfort he states, “Well, I do a little bit of chest pressure, but it’s nothing like when I had my heart attack.”
A 12-lead ECG is captured.
What is your impression?
See also:
this is an inferior wall MI,extending to posterior wall-st depressions and deep inversions in V1V2 with reciprocal changes,
this is an inferior wall MI,extending to posterior wall-st depressions and deep inversions in V1V2 with reciprocal changes,
this is an inferior wall MI, extending to the posterior wall- ST depressions and deep inversions in V1 and V2plus reciprocal changes for inferior wall MIthis pt should have V4R V5R V6R V7R and V8R also to see the RV and the posterior wall…
i concur with inferior Mi with reciprocal changes. Treatment of 02 and ASA at this point. Need to do a right sided before we can decide whether or not to give NTG. Earlier commented deleted for clarity.
Most everything said already sums it up pretty well. Everyone is getting too good at this stuff lately, and I blame it all on the quality of the teaching information on this site.Anyway, for the sake of my own mental exercise: ST-elevation in II, III, aVF, with reciprocal ST-depression in I, aVL indicative of acute inferior infarct. Marked ST-depression in V1, V2, V3, most likely associated with an acute posterior infarct. I also note ST-elevation in V6, possibly associated with the assumed-STE in the posterior views (Tom, does that make sense?). ASA, o2, and timely transport to a cath-capable facility with early notification. Also capture V4R to rule out right ventricular infarction prior to administering nitro, and V7, V8, V9 to confirm posterior STEMI. Serial ECG's in route to monitor for changes. Tell the guy to get married if he isn't, cause a woman definitely wouldn't let him walk around for several hours with those symptoms.
Did they perform a 12 lead ECG at the fire station?
angor animi – No they did not, and this is exactly why the ED doesn't do "BP checks". Performing these checks at the fire station presents a significant liability, but we choose to do them as a public service.We encourage citizens to seek medical care when they have a chief complaint that would normally warrant such care, or when they have grossly abnormal vital signs, but it's not always obvious when a bystander should become a "patient" with full documentation requirements.Most of the citizens who come in for BP checks are elderly and have complex medical histories. We could find something wrong with just about any of them.Tom
Something's up here.We're out with him due to a 3rd party caller that saw a gentleman with "Shortness of breath" on the side of the road… in a jogging suit.CABG X3, and previous MI. Well that would certainly explain the suggestive Q's on II, III, and AVF. Further, given the apparent severity of his previous MI, and lack of Q's anywhere else, I'm going to suggest that perhaps these EKG changes that we're looking at are normal to the patient, and not indicative of an acute MI today.My feeling is that the answer is on the rhythm strip. He certainly has what looks like a wandering atrial pacemaker.Which would to my mind explain the majority of his exertion based complains.
I'd have to agree with Max on this one. Knowing previous MI that warranted a 3x cabg, not having any reference 12-leads, and the patients presentation with current "SOB" or "feeling different" on activity should still warrant further investigation. V4R+, eliciting current meds and recent med changes, and whether the pt normally experiences this on activity should be some initial questions. (Maybe he just likes the jogging suit for comfort, doesn't jog, and was golfing for the first time in many many years today.)They may also have a differing presentation due to previous MI and CABG. Depending on what if anything was damaged on previous MI, this could very well change the underlying rhythm presentation, and if the abnormality shown on the 3 lead (either 3rd deg, or second type II – looking at small screen at the moment) is "new", it wouldn't be able to compensate as a healthy heart might, and could present with the same S/S and ischemic T-wave deflections. ??
Apologies that I can't figure out how to edit my previous.I misinterpreted the dispatch information, and see now that it wasn't a 3rd party caller but the patient that called. Which really, just further cements my suspicion of a more "on exertion" based pathology.
Max -We're not really sure how dispatch came up with "shortness of breath" although the questions they ask the callers can be quite leading.Tom
3L shows NSR @ 70bpm. 12L shows STE inferior, recip changes high lateral, STD V1-V3.IWMI, considering posterior involvement as well!
I'm assuming no questions were asked about his history at the station.If he'd come walking into mine with those complaints and that history, I think I would try to talk him into a 12-lead right then. I think this crew (and the department, and the city) got lucky.
I should have added: I realize it's easy to judge after the fact, but I think we have a responsibility to have the highest degree of suspicion possible.
CBEMT – It is easy to judge after the fact.To maintain "the highest degree of suspicion possible" would require vital signs, a physical exam, and a 12-lead ECG on every citizen that walks into the fire station.We have a protocol called "12-lead ECG indications" which is very comprehensive and "cold and shaky" isn't on the list.It will be a sad day when we stop providing free BP checks out of fear that we'll get sued for missing something.Tom
We do BP checks on the industrial fire brigade I work for, but to alleviate the concerns we standardized our refusals to include a section for "BP Check Only" with number ranges to guide the pt. AKA when do you need to go to our clinic, when should you see your doctor, and when everything is 10-4.
Christopher -That's a good idea, but it wouldn't have helped in this case, as the patient's BP was within normal ranges and consistent with the other BPs recorded on his BP card.Tom
I see i've misssed alot, but inspite of that i won't miss my opportiunity to share my comments. Firstly thanks alot for sharing the interesting case .. So the ECG here shows ST elevation in the inferior leads II,III ,aVF ( with STE more in the III lead so exclude right ventricualar involvement by V4R )lateral leads V5 and V6..Deep STD in the anterior leads ( do the posterior leads V7-9 ). I think the patient is having combined MI inferolateral and posterior STEMI.. Is the culprit artery in this case is LCX ?
It will be a sad day when we stop providing free BP checks out of fear that we'll get sued for missing something.I'm surprised more places haven't already.
Clearly an inferior wall MI. I can understand doing a quick V4R to rule out right ventricular involvement. But this pt needs to be tx rapidly to a cath lab. Doing all the other right side v leads will not help in the treatment of the pt. We already know by just looking at the 12-lead and his B/P around 114 systolic that his right ventricle may be involved. But how do we treat this pt in the field. If we just give him fentanyl we have helped with his pain and anxiety but have done nothing for his MI. If we give him ntg we vasodilate not only the coronary vessels but his other vessels as well and could drop his B/P to such a low level that we make things worse. Our protocols are to with hold ntg if B/P is 100 systolic or less. I would like to see it changed to "and no STE in V4R." Again thanks for the case presentation.
If this patient has a right coronary dominant posterior system this makes perfect sense. The SVG to the PDA/RCA/LV branch has a stenosis. Therefore this patient has an inferior/lateral STEMI with posterior involvement. The anterior precordial leads show ST depression as a reciprical change for the posterior STEMI. To see it well, turn the ECG upside down and backwards.
MI inferior wall. Do 15 lead and rt. side. transport, alert cath lab.