Here’s a case study from a faithful reader who wishes to remain anonymous.
EMS is dispatched to a 47 year old female complaining of chest pain.
On arrival paramedics find the patient seated on the floor. She appears acutely ill. Her skin is cool, pale, and diaphoretic.
The patient confirms that she is experiencing severe, sub-sternal chest discomfort.
Onset: 15 minutes prior to EMS arrival
Provoke: Nothing makes the pain better or worse
Quality: “Very bad” (language barrier)
Radiate: The pain does not radiate
Severity: 8/10
Time: No previous episodes
She is also complaining of palpitations.
First responders initially suspect symptoms of anxiety based on her young age.
The patient’s son relates that the patient is a diabetic and hands paramedics a bottle of lisinopril and glipizide.
Paramedics ask the patient if she has a history of heart problems. She says “yes” but can not give specifics other than “blood pressure.”
Due to the patient’s poor appearance the EMS crew immediately loads her for transport.
In the back of the ambulance vital signs are assessed.
RR: 18
HR: 80
NIBP: 240/120 (confirmed with manual BP)
SpO2: 97 with NRB @ 15 LPM
Breath sounds are clear bilaterally.
The cardiac monitor is attached and a 12-lead ECG is captured.
What is your impression and what should the EMS crew do next?
02 via nrb 15lpm. asa 324mg; nitro; transport head elevated; obtain IV access. reassess periodically. repeat nitro as needed. have morphine on hand if available.
Poor quality ECG , but i can see STE in V1 to V4 could be due to early repolarization or ST mimic MI ( early repolarization as i read in smith’s blog always has prominant R wave in V2-V4 which i can see in this ECG ) BUT in the other hand i can see also mild ST depression in the lateral leads I and aVL !!..
Anyway in all cases i would transfer the patient to ER for better quality ECG and further manegment according to this.
I agree with the above, although I would suggest that there is nothing inherent about the ER that will allow them to get a better quality ECG. We should be able to get just as high quality of a tracing as they do if we take the time to prep the patient properly.
What’s the blood glucose level?
ASA and nitro and redo the 12 Lead. Due to the fact she looks sick and her BP is very high I’m going to go with acute STEMI and have someone else prove me wrong !
Stop the ambulance!! Get a better tracing. I am not a big fan of “lets get this pt going”. If you can get a good quality 12 lead on scene it will benefit the pt in the end. ST elevation in V-1 to V-4. Also in AVF but none in the other inferior leads. As stated above ASA NTG Fentanyl and fax a better 12-lead. Looks like and anterior wall MI.
While I agree that there is little reason that you cannot obtain a 12 lead in the field that is of high a quality as one that can be obtained in the ED, this is not the time to delay patient care in order to hook her back up.
The patient is profoundly hypertensive and is complaining of severe chest pain. Is there anything that repeat 12 lead is going to show you that will change your course of treatment?
The differential for this patient is narrowing and pointing to some frightening diagnoses; this woman quite likely requires the intervention of a cardiologist or a surgeon, and time really is a key factor here.
ASA, NTG, MS, high flow 02, and pedal to the metal.
Geoffrey,
In my region the outcome of a high quality 12-lead will determine me either going to the local hospital or diverting to the tertiary care centre approx 50 mins away with a cath lab. So taking a minute to get a high quality tracing IS critical in patient outcome.
Wow, thats rough. I guess I am a bit pampered being in a major metropolitan area.
I’m also pampered and my usual hospital is PCI capable, but I would probably attempt a second 12Lead. Regardless my DDx includes Anterior MI and Acute Pericarditis.
I’ve got elevation V1-V4 w/ recip changes I/aVL. I also think I see PR elevation aVR and PR depression almost in all other leads. Baseline is messy which may change my PR view.
Case – chest pain + 240/120 = hypertensive crisis. The nitrates will help in reducing the BP a bit. For the sake of ecg discussion, there is evidence of LVH in the precordial leads (S v1/2 + R V5/6), LAA -prominent second component of the P wave in V1 and wide P waves. This could suggest effects of HTN. ST elevations (V1-3) could be ischemia vs hyperkalemia.There is prolongation of PR interval which can be seen in hyperkalemia. The expected loss in the R wave progession is not seen (which could be seen in anterior wall MI) and the QT/c prolongation is also not seen. Changes (ST-T)in I,AVL and V5/6 could be ischemia superimposed on LVH. Q wave on III (nonspecific change?). A repeat could be nice. It was a wise decision for the paramedics.
Wow, thats rough. I guess I am a bit pampered being in a major metropolitan area.
Even in a metro area, not all of your possible destinations are going to be PCI capable. So yeah, it could even change YOUR treatment.
I have 8 possible destinations- only three of them are PCI capable. Am I spoiled with such available resources? Sure. But if the patient wants to go to one of the other 5, and I played it old-school, we could be 15 minutes in the wrong direction before the reality becomes known.
Sure, my scene time was great, and I got back in the recliner a few minutes sooner- and the patient will suffer because of it.
Do the job right or let someone else.
FIRST AND FOREMOST I WOULD GET A BETTER TRACING!!!!
*Looks* like MI in the anterior and septal leads. Lead III shows ST-elevation in the first complex but the tracing is so awful it’s hard to determine the baseline. En route to the hospital, I really want to call a cardiac alert, which is a step below a stemi alert.
In the best interest of the patient however, I would call a stemi, have serial ECG’s and have the doc still meet met at the door to determine if this is a stemi or not.
My plan:
Repeat 12 lead
O2 nrb
250 of fluids of a 1000cc bag and no more than 250 at a time pending the BP.
Repeat 12 lead
Transport
ASA 325
Nitro SL for relief
Repeat 12 lead
If relief with SL NTG, then a Nitro drip, for the chest pain and not necessarily the BP.
Repeat 12 lead
Morphine 4mg.
Repeat 12 lead.
If we have time, I will do a right sided ECG due to the inferior leads looking fishy
Addendum:
I almost want to say this looks like J point elevation…but am not going to call it early repol, still going with the stemi alert in the best interest of the patient and let the doc call the alert off, not me.
A 250 cc bolus? Why? Increase the volume equals increase on work load (think Frank Starlings principal). Maybe if R side 12 lead shows R side involvement and pressure drops. But good clinical judgment should help avoid that. Is that your regions protocol?
Yes our cardiac protocol is 250cc-500cc fluids at a time if patient is without signs of fluid overload, no matter the BP, repeated as needed up to 2L. In this case, I would give 250 due to HTN and fluids not necessarily indicated at this time.
Why that is? Not sure, but it’s protocol and our protocols suck.
Also, looking at this again, disregard my J point statement.
“Yes our cardiac protocol is 250cc-500cc fluids at a time if patient is without signs of fluid overload, no matter the BP, repeated as needed up to 2L.”
Wouldn’t the “as needed” part be referring to hypotension/hypoperfusion situations? Which wouldn’t be the case here, therefore doesn’t fall into the “as needed” category?
nitro is my friend on this one. The hypertension is likely the cause of our new friend’s troubles, that and her nervous system over-reacting to some kind of trigger.
No small talk from me on this one, breathing exercises and nitro will replace my usual witty banter.
The quality of the trace is enough to gauge destination and treatment for me. Optimal, no, but shows me what I need to know to get the system moving in the right direction.
IV, O2 on a cannula if it calms her and sirens only if we need them at commute time.
Code 2 1/2 we call it.
Appears to be an Acute Anterior MI. However the poor tracing is cause for concern. I dont believe the Septal wall to be involved even though there is elevation in the leads. Anterior MI’s have a habit of causing inflamation in the heart causing septal ekg changes. Anyway typical treatment and get rolling considering most anterior MI’s have a 70% death rate.
First and foremost, obtain a better tracing. Definitely looks to be emergent cardiac.
Here’s what I would do based on everything I’ve read:
1. Oxygen is good, although of she’s maintaining the bag @ 10L decrease it to that; or leave it @ 15L if she obviously needs it.
1a. Obtain a BGL
2. Start a line
2a. ASA 324mg while starting the line. (Don’t give NTG w/o control measures in place – you’re just setting yourself up for trouble if their BP takes a crap.
3. Obtain 12L; AND a Right-sided. Even w/ her HTN, the NTG w/o r/o right-sided MI could prove detrimental.
3a. Based on this, she meets STEMI criteria for STE in 2 or more contiguous leads.
4. I’d give a small fluid bolus (50 – 100cc) while myself or someone I trust check lung sounds.
5. I’d attach EtCO2 since I have this available.
6. .4mg NTG SL
6a. Reassess V/S, another 12, 12-R.
7. If BP is still very high I would start considering MS in 2mg increments for pain and cardiac effects.
8. Depending on transport time, location, time of day (0300 vs 5p rush hour) I may consider Tridil (NTG drip).
Trend V/S and EKGs en route to a cardiac facility. Id also opt for rapid transport.