53 year old female CC: Chest discomfort and shortness of breath

Here’s an awesome case submitted by Nathan Stanaway of Grady EMS in Atlanta, GA.

The patient is a 53 year old female c/o chest discomfort and mild dyspnea.

The pain is described as “severe” and she gives the pain a 10/10.

Past medical history is significant for migraine headaches and anxiety.

Patient is a poor historian and does not know what meds she takes.

Drug allergy: ASA

The patient is found sitting in a car in the middle of the road.

Skin: pale and very diaphoretic.

Vital signs:

  • RR: 24 shallow
  • HR: 84 R
  • NIBP: 113/76
  • SpO2: 98 on RA

Breath sounds: clear bilaterally.

The cardiac monitor is attached.

A 12-lead ECG is captured.

What should the paramedic do next?


  • Josh says:

    call in a STEMI altert. inferolateral STEMI w/ reciporical changes. do a 15 lead to check possible posterior and right ventricular involvement

    — @medicjosh

  • Tom B says:

    Josh –

    Why not just assume both and treat accordingly?


  • Nick M says:

    MONA ( w/o Asa for allergy) with cath lab activation. The ol standard cardiac MI treatment. And just because it’s fun, have your partner go lights and sireeeennnnn a blarin( it make the young one happy)

  • Tom B says:

    Nick –

    Does he hold his head out the window? Hahaha! 🙂

    I would add that it’s a good idea to ask a patient exactly what happens to them when they take aspirin. Often it turns out they’ve been advised against aspirin due to a GI problem.

    I phrase it like this. “Have you ever had an allergic reaction to aspirin?”


  • Geoff says:

    I’m going with inferior-lateral wall MI as well, possible right sided involvement. O2, I would go with an IV first before NTG, MS. Specific ECG findings STE Lead III > Lead II, V1 not elevated, but it appears baseline with depression in V2 & V3. V4 appears normal, but V5 & V6 elevated, could V4 be “normal” because of a reciprocal depression as well as STE in the lateral leads (V5 & V6). STEMI Center.

  • Tom B says:

    Geoff –

    Great analysis!

    I don’t think V4 is reciprocal to the low lateral leads (a stronger argument could be made that it’s anatomically contiguous) but I like the idea of a preemptive fluid bolus for this patient!


  • Josh says:


    I would call it in the STEMI alert ASAP and update hospital if 15 lead was remarkable. It doesn’t really take very long. I wouldn’t start a fluid bolus unless the patient developed the clinical signs of RVI or there was evidence on EKG. I would definetely still be slightly more cautious with my nitro admin and have an IV in place in case there is RVI w/o STE in right sided leads and the pt is pre-clinical.

  • Tom B says:

    Josh –

    I’m more of the mind set to presume RVI in the presence of acute inferior STEMI, especially when STE in lead III is > STE in lead II.

    In those cases I won’t hesitate to perform a preemptive fluid bolus. At the very least I’d obtain IV access first as you recommend.

    Having said that, I certainly don’t have a problem with checking the right-sided chest leads!

    Posterior leads? I usually reserve that for those occasions where the only abnormality on the standard 12-lead ECG is ST-depression in the right precordials (V1-V3). I’d hate to see a delay in the emergency department because the ECG doesn’t show ST-elevation!


  • Scott says:

    So it’s sinus mechanism @ ~ 75 no ectopy (yet) no blocks. STE in II, III, AvF, V5, and V6, with reciprocal changes in I, AvL, V2, and ? V3. Tom made a good point about the ASA allergy, can’t hurt to ask. 2 IV’s b/c of presumed RV involvement and a VERY cautious trial of nitrates being ready for their pressure to plummet. A consideration of fentanyl, and serial 12 leads w/ a look at the R side thrown into the mix enroute to the closest cath lab.

  • Tom B says:

    The pretty much says it all, Scott! Now all we have to do is make this happen for every STEMI patient in every EMS system in the country!


  • akroeze says:

    Just out of curiosity with all the talk of fluid bolus, do you guys have that as a standing directive for RVI where you are? I know here we don’t, we only can give fluid by standing order if the systolic is < 100.

  • Christopher says:


    At least where we are there is latitude written into the IV Access / Fluid Administration procedure to allow for these clinical judgment calls. Certainly it would be the “standard of care” to provide a fluid bolus in an RVI even though it may not be in the protocols.

    I don’t have much to add in terms of the ECG besides I showed my basic partner and she asked if she should start driving 🙂

  • Tom B says:

    Alex –

    What if the pressure was 102/55, the pulse rate was 118, the skin was cool and clammy, and the history of present illness was that the patient had been experiencing vomiting and diarrhea?

    I don’t remember whether or not our chest pain protocol recommends a fluid bolus for acute inferior STEMI but I have never been questioned about a fluid bolus when it made sense clinically.

    I always spike a 1000 ml bag of 0.9% NS for chest pain patients.


  • Tom B says:

    Christopher –

    Did you say, “Yes!”?


  • Mike Sherriff says:

    Tom wrote: “Posterior leads? I usually reserve that for those occasions where the only abnormality on the standard 12-lead ECG is ST-depression in the right precordials (V1-V3).”

    I completely agree. V4R results can be a treatment changer. Knowing that you have a posterior extension of a known inferior infarct is not. If you think you are dealing with an isolated posterior MI, then have at the posterior leads.


  • Tom B says:

    Mike –

    Exactly right. An acute inferior STEMI needs a cath lab whether there’s posterior extension or not, whereas confirmed RVI could make you withhold NTG or morphine.


  • Scott says:

    Akroeze, I didn’t mean to infer that I’d be running my lines wide open of even give a fluid bolus. My meaning was having them in place for when the patient decompensates. Anticipating and being prepared for the worst case scenario.

  • DaveO says:

    I wish all my CP run EKG’s were as obvious as this one !

  • Tom B says:

    DaveO –

    Isn’t that the truth? That’s an excellent comment, because in reality they aren’t all this easy! If they were, there would certainly be no need for ECG transmission.


  • Chris T says:

    Nice. STEMI much. Inferior STE MI with + recip changes. Looks like some lateral extension and more than likely posterior. I too assume RVI. Sooo um here is where im trying to learn. very big RCA block.
    Large bore IV, x2 if enough help. ASA depending on why he has an “ASA” allergy. I have Nitro drip as option. I would contact med control to bypass SL nitro and go right to drip easy to titrate and quick off if BP drops. 02 sat 98% 2lpm NC. 250-500 cc fluid bolus caution lung sounds. Early notification of receiving ED. Fentanyl with caution. I will advocate for a helicopter since nearest cath is over 1hr away ground 20min air. Unfortunatly im sure the local ED will want the pt transported there and this causes huge delays in patient care to a proper facility.IMHO Only advantage to the patient is maybe getting thromb meds, a bigger bill, and likely more dead tissue.

  • Becky says:

    Plain as day-Infero-lateral MI with reciprocal changes. Admin O2 and ASA prior to movement of pt (and as soon as SAMPLE is gained w/no detrimental allergic reaction to ASA is determined). 12 lead is definitive-should glance for physical presentation of this particular 'breed' of MI while moving pt. Perform V7-V9 for possible posterior or V4R to confirm possible right-sided involvement. Activate cath lab and initiate dual IV ports for med/fluid administration. Nitro may be administered after thorough assessment of specific areas of involvement. Re-assess lung sounds while fluid is administered to decrease the possibility of placing this pt in distress. She already has a big enough problem.  Consider alternative meds for pain management if right-sided involvement is confirmed-Dilaudid is excellent in this case, as Morphine Sulfate shares properties w/Nitro. Rapid transport to PCI while maintaining stability of pt. Pain management as needed-She's already behind the 8ball.

  • James Oz says:

    What Tom said about the Aspirin. Unless she almost died of super-anaphylaxis last time she had aspirin, then she is getting one. 

    No GTN. I think thats a no brainer. 
    No Oxygen.

    Fentanyl instead of morphine. 25mcg increments initially. 

    Second line on the way to a cath lab. 

    Stretch arms and back in preparation for CPR.

  • Matthew R says:

    I think everyone has the same ideas as to what we have – that is a patient that needs a cath lab quick fast and in a hurry. So consider these items:
    2 iv’s, 18 or better if possible, with Saline Locks, and hang a bag on one.

    Get patient naked (within reason) I go down to underwear, and remove bra if possible

    Draw lab tubes with the kit of tubes that your ED will gladly give you (probably)

    Take patient in on the Monitor, with Defib pads laying on chest (negotiate this in advance with your ed – most have policies that require pads on a patient to go to the cath lab.

    Perhaps you can take the patient directly to the cath lab table and save 10-15 minutes…

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