43 year old female CC: Chest pain

Don’t worry, I haven’t forgotten about the 73 year old female CC: Chest pain.

The conclusion will be posted as soon as it’s available. In the meantime, here’s another case for you to ponder.

EMS is called to the residence of a 43 year old female with a chief complaint of chest pain.

On arrival, the patient is found supine in bed.

She is alert and oriented to person, place, and time.

She is anxious and diaphoretic.

Past medical history: Hypertension
Surgical history: One kidney removed (unknown reason)
Medications: Azor

She denies shortness of breath and breath sounds are clear bilaterally.

Onset: 1 hour prior to EMS arrival
Provoke: Nothing makes the pain better or worse
Quality: Severe “pressure”
Radiate: The pain radiates down the left arm
Severity: 10/10
Time: No previous episodes of similar pain or pressure

Vital signs:

RR: 18
Pulse: 76
NIBP: 114/71
SpO2: 98 on RA

The cardiac monitor is attached.

A 12-lead ECG is captured.

How would you treat this patient and why?

See also:

Conclusion to 43 year old female CC: Chest pain – Angiograms

40 Comments

  • Connie says:

    Suspecting an acute inferior MI with lateral ischemia. I’d treat with IV access, ASA, oxygen, do another 12-lead with V4R to check for right ventricular involvement, which you see quite often in inferior MI’s. If pressure falls and pt. becomes bradycardic, give fluid bolus as long as lungs remain clear. Be extremely careful with nitro and morphine in inferior MI’s, can cause hypotension and bradycardia.

    The company I work for has the ability to give TNK in the field, so I’d get the OK through medical control to give it, along with IV & SQ Lovenox, PO Plavix. Watch vitals closely, get ready with pacing and/or dopamine drip if hypotension & bradycardia develop, and boot like hell for the hospital!

  • Mark says:

    High flow oxygen, 324 mg ASA, IV, right sided 12 lead, withhold nitro and give morphine instead. Transport priority 1 and monitor vitals.

  • Patrick says:

    I wonder if the ST depression in the lateral leads is the strain pattern from the left ventricular hypertrophy. I still think she’s having an inferior wall MI.

    I would give oxygen, start an IV, look at V4R, and give ASA, morphine, and maybe nitrates depending on what V4R looks like.

  • Brandon Oto says:

    Inferior STEMI in setting of LVH.

    You’re too good Tom, I was just looking for a clean example of this.

  • Christopher says:

    While I have voltage criteria for LVH, I have STE in inferior leads consistent with AMI (with recip changes). Certain IWMI. I also have STE-III > STE-II with 1AVB, which makes me suspicious for potential RCA involvement.

    Right side 12L for certain, posterior given the time. Early STEMI notification, ASA, IVx2, fluid bolus per Right sided and lung sounds. NTG if no RVI or after 250-500mL bolus. Safe and expeditious transport to the cath lab.

  • Tom B says:

    Just remember, guys… A strain pattern with LVH is an anterior STEMI mimic.

  • khurram says:

    stemi inferior wall
    iv line oxygen aspirin300mg state colpidogrel 75mg4tblets state lmw heparin injection streptokinase in 30minutes betabloker if rate is gud ramipril and nitrates omeprazole

  • khurram says:

    and morphine first of all

  • Terry says:

    Looks like an MI that is high up in the RCA involving the inferior posterior wall. Look at the 1mm st elevation in V-1. A look at V4R would be very helpful. Also V-2 3 and 4 looks like a posterior MI flip the EKG over. The other V leads look like a strain pattern. Given the pts blood pressure I would be very cautious with NTG and MS. Would probably give Fentanyl and a fluid bolus. Another concern is the 1AVB. Could this turn into a 2AVB? Serial EKGS, transmit EKG to the ER and rapid tx to a cath lab. Pts with LVH can still have MIs.

  • Looks like indigestion to me…

    Just kidding.

    1st degree AVB. LVH with strain. Biatrial enlargement. Inferior wall MI. Pathological biphasic T-waves in V2/V3.

  • Terry says:

    One more thing–look at the qwaves developing in the inferior leads.

  • Aharon says:

    I think that we have to see the ECG with V7-V9 and V3R – V5R to be shore that we haven’t acute inferior poserior and right MI or to say shortly acstensive MI

  • sue says:

    I think this is an inferior and posterior mi,with first degree AV Block, looks like pathalogical Q waves are developing in v1 v2 and v3.I’m not too good at this but hope i have got it a little correct:). Would treat as per local protocols. 🙂

  • sue says:

    I would want to do a reverse 12 lead on patients back also 🙂

  • Isaiah says:

    I will transport on high flow oxygen via non rebreather consider two baby aspiran for pain and possibly acute MI . moniter vital signs every 5 mins while on the way too the hospital and just too be SAFE activate the cath lab.

  • Dave B says:

    ste inferior leads, iwmi, which would not be affected by strain pattern… also, ste in III > II, slight ste in V1 and std in V2 very suspicious for RVI… also, depressions in V2, V3 suspicious for posterior involvement… would want 15 lead..
    company it keeps: for a pt with hypertension, systolic bp seems relatively low… with clear lungs, also suspicious for RVI, and with the relative hypotension i would hold off on NTG… Strain pattern in lateral leads may confuse the issue of reciprocal changes in 1 and aVL… however, anteriorly, i would expect appropriately discordant ste and t waves in right precordial leads, and they are depressed instead, indicating a serious problem here in the setting of LVH with strain.

  • Balazs says:

    Hi, I’m a hungarian paramedic. I’m working by the Hungarian Ambulace Service. This is an inferior STEMI. We treat in Hungary with oxygen , iv line, nitro /carefuly RVI/, 500 mg ASA, 300-600 mg Clopidogrel /depended PCI/, 5000 NE Na.heprin iv., morphine or fentanyle /carefuly RVI!/, and go to cath lab. Some areas of the country we give Glycoprotein IIB/IIIA inhibitor.

  • rick says:

    I agree with the Inferior AMI. I would start with O2, IVx2 (Larger the better), Right Side EKG, Fentanyl (NO Morphine), and Tridil to titrate (NO SL NTG) if vitals maintain, Fluid Bolus for BP (250-500cc), have Pacer ready, like the Lovenox SQ, Heparin Bolus/Drip if MD approved, LOTS of Diesel to Cath LAB

  • Joe P says:

    So, um, I’ll be the first to ask. Given that the problem isn’t one of inadequate oxygen exchange in the lungs AND the fact that the AHA has finally figured out that oxygen isn’t a wonder drug, why are we still administering free radicals (oxygen) to patients who do not need supplemental oxygen?

  • JAMedic3799 says:

    IV Access,Right sided EKG, Oxygen ASA, NTG (spray/sl/paste) provided no Right sided involvement, Fentanyl (not a big fan of Morphine use in MI’s) early notification to OPEN cath lab.

  • Ben says:

    @joe P in the uk we dont! Until we get to the A&E/ED and the first thing the nurse/dr does is put the O2 on….

  • Doug says:

    I would run a right sided 12 lead, and my treatment would be O2, ASA, Plavix PO, possible Nitrates with caution due to possible right sided involvement, and rapid diesel infusion to the hospital.

  • Ben says:

    ps. imp. inferior MI, titrate morphine too pain, nitrates too BP/pain relief/side effects transport to PCI with alert

  • Geoff says:

    I too am going with IWMI w/ possible RV involvement. STE II, III, aVF, depression in I & avL. I would like to do a right sided ECG as well. I’m thinking RVI because of STE III > II along with a little elevation in V1. V2 & V3 depressed indicating posterior involvement. If there wasn’t RVI, I would think V1 would be depressed along w/ V2 & V3 instead of elevated (am I right here?). I assume the right sided ECG wouldn’t changed because of the LVH with strain in the left precordials that are already depressed? Rapid transport to STEMI Center.

    Cool ECG, thanks.

  • Chris S says:

    I believe that the patient is showing signs of an inferior MI due to ST elevation in leads II, III, and aVF with the reciprecal changes in in the lateral leads showing ST depression in leads I & aVL. Typically LVH with a strain pattern shows ST evelation in the anterior leads but we are seeing ST depression in those leads. So i am woundering if no ST depression in V1 is due to the usual slight ST elevation from the LVH allowing the ST segment to return to the baseline only due to the ST depression caused by a posterior MI in leads V1, V2, & V3. V2, V3, V4 & V5 all show ST depression so this could be indicative of a posterior MI which is possible with a inferior MI. Treatment for me would be a right sided ekg and a posterior ekg if possible if RV involvement is confirmed then a 500cc NSS bolus prior to nitro would be preferred. otherwise O2 15 lpm nrb, 324 mg ASA, 2 IV’s, nitro sl, morphine if needed, and tx to a STEMI equiped facility.

    I’m still learning the LVH issues so i hope this isn’t to far off. Thanks Tom

  • Chris Tanerillo says:

    Joe, In my opinion it is to increase available oxygen to a muscle that is dieing for 02 .

    For this patient I learned and validated some of my treatment directions in a STEMI with Inferior wall and VERY suspicious 12 lead for right sided involvment Yeah I see the LVH but changes are not consistant with strain so I dont care.
    Good plan and I agree, 02- 4 lpm is sufficient with no SOB In my humble opinion. 2 large as you can IVs, unless the patient lungs are flooded im more worried about treating the MI than I am filling lungs with fluid, though still listen for changes, So 250-500cc NS bolus prior Nitro, 324mg baby ASA, Nitro drip preferred for this pt skipping SL dosing for easy on easy off, right sided ekg if time allows, for this pt MS would not be on my first line choices- fentanyl for agalgesia, BP and HR do not fit criteria for Beta Blocker- i would think this would knock out our sympathetic buddy for compensation and we could get to be in a world of trouble, Maintain systolc presures of around 120mmgH 130mmgH, if lucky fluids and nitro will balance and we wont have to dig out the dopamine. Early notification to ED of STEMI. For me in this area this would likely be a Lifeflight call for proper transport to a cath lab.
    Always Learning—

  • Chris Tanerillo says:

    OH yeah and watch that block!!! Pads out but ill spare the patient for now.

  • D.tuck says:

    In agreement with what everyone says should also look posterior and right side. With positive posterior and right side MI and the patients hx of hypertension could be an ascending aortic aneurysm.(86% probability with listed stats)

  • Lonnie says:

    IV of Normal Saline @ KVO, High flow O2 by NRB mask, 324mg ASA, 2 mg of Morphine IV, Serial 12 leads and emergent transport to a hospital with interventional Cath capabilities.

  • Aharon says:

    Loke befor we make anythink we have to know what we have with the patiant if he was “stable” after we know what exactly what he have ‘ off course we give Oxigen ,give nitro spry , I usual give 2.5 mg SL , give ASA , we give in Israel 300 mg , open IV line give Heparin 4000IU IV , trasport to ICCU ask to catheterization room to make primery PTCA . usually in my area we get it and the staff weit to us

  • Nathan says:

    Print the strip off and turn it around and upside down…your now looking at an anterior infarct but in reality its posterior.

  • Hillis says:

    Inferior STEMI STE III> STE II , the BP is quite in the lower side( even with no signs of shock )rise my suspicion of right ventricular involvement so perform V4R. Am pretty sure of posterior STEMI STD in the anterior leads plus the progression of R wave which is the mirror of Q wave in posterior leads so V6-9 to be more wise with the diagnosis .
    I do agree with the rest- 1st degree AV block and LVH.
    The culprit artery could be both left circumflex artery and RCA , but RCA occlusion could be the only culprit artery in this case thu it’s rare to affect the posterior wall of the LV but still can occur !!

  • Tom B says:

    Excellent comments by everyone! See? You guys don’t need me at all! 🙂

    One small consideration for the so-called “strain pattern” with LVH. The ST-depression in the lateral leads should be “downwardly concave” (like a frowny face or pouty lip). This terminology becomes difficult because some sources will refer this morphology “convex”. That’s because one man’s “downwardly concave” is another man’s “upwardly convex” but it seems more sensible to me to refer to ST-depression as “downward” and then indicate the morphology in the direction of the ST-segment shift.

    In this case, the morphology of the ST-segment is downward and straight! That’s bad, and not typical of a “strain pattern”. I’m not saying there wasn’t a strain pattern in the beginning (because we don’t know without a “old” ECG for comparison) but we can say that this ECG’s ST-depression in the left precordial leads (V4-V6) is pathological.

    The other clue, as others have mentioned, is that with a “strain pattern” we would not have concordant ST-depression in leads V2 and V3. Quite the reverse! So while this ECG meets the voltage criteria for LVH, it is not showing the typical secondary repolarization abnormality.

    Tom

  • Pravin says:

    I am working with GVK EMRI- 108 ems services in India. In prehospital care we would like to recommend as most of experts commented, Aspirin, oxygen, IV access and fluids if required. As we dont have facilites of prehospital thrombolysis, we would be rapidly shifting the patient to the hospital with available facilites. The ECG is suggestive of inferior wall infarction. Remeber to provide rest and comfort without allowing the patient to walk or exert.

  • Chris S says:

    Tom i was wondering if the fact that V1 is elevated < or = 1mm if this would suggest that there is RT Ventricular involvment. I think the elevation would be a little high in V1 but maybe cancelled out some by the posterior st depression. Also would the fact that the ST depression in V2-V5 would mean a larger area of injury other than just a posterior involvoment as well. The lateral ST Depression itself would just be reciprecal from the inferior elevation.

    ??????

  • arnel says:

    SR, STE III>II, STD aVL>I, STDV3:STEIII about 0.5, STEI (?), STD V2-V6. These are suggestive of IWMI with RCA as the culprit artery. STD in V5-v6 in the setting of IWMI signifies concomitant disease in the LAD. Also pts with max STD in V4-6 is bad. They have higher mortality and morbidity and more often have multipe PCI and CABG.

  • marc says:

    right sided 12-lead,O2,ASA,Nitro but watch for pressure drop,MS again watch pressure, consider lopresser and head to cath-lab. prepare for fluid bolus, have pads ready, repeat 12-leads if time allows, im 45 min. to cath lab. treat S/S.

  • Jim says:

    15 lead, O2, ASA, IV acces, consider nitro, fentanyl  activate code STEMI

  • david bruce says:

    Agree with Stemi
    pain tele is differing from country to country
    Iv access left acf for ppci
    gtn
    Aspirin
    Iv paracetamol
    Iv morphine
    No oxygen as above 94% air
    Diesel

  • shaun says:

    http://www.scancrit.com/2014/11/26/avoid-oxygen/

    In relation to oxygen for myocardial infractions this is a great read. Suggests oxygen causes more harm. Only administer it if spo2 low

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