Found on the LIFENET – January 2011

I was checking out the old LIFENET Receiving Station and this case caught my eye.

What do you think?

See also:

Found on the LIFENET – October 2008

Found on the LIFENET – September 2009

Found on the LIFENET – November 2009

12 Comments

  • Chris T says:

    I dont feel great about this one but how else am I going to learn.
    IRREG
    QRS .108 borderline LBBB
    Normal QRS complexes has flipped P waves clear in V1- Junctional Rhythm
    Run of V tach
    This heart looks very unhappy. Ischema suspected Check lead placement. If I am reading the proper complexes on the 12 lead then I would think there is excessive discordance ST Elevation In Anterior leads with excessive discordance ST Depression in inferior leads. I am not confidant on the lateral extention but I see the Huge depressions in inferior leads, seems likely reciprocal to the anterior.
    TX: 02,IV,Nitro(bp> drip if needed, ASA. Reassess, second 12 lead. If no changes.
    Med control consult
    Amioderone 150mg/50D5W over 10 min for excessive PVCs and run of V tach.
    Reassess. Pain eval. morphine or fentanyl depending on BP

  • Chris T says:

    I meant to add the underlying rhythm appears to be regular

  • Chris T says:

    one other concern. T waves. Look like “tombstone” Ts to me but im sure there is a more medical way to assess those

  • Dave B says:

    IMHO, it looks like inverted P waves in lead II on the strip, also P wave evident in V1 and V2… possibly ectopic atrial (also P waves positive in aVR), but PRI looks to long for it to be junctional.
    early complexes seem like PAC’S.. P wave precedes in lead I, plus QRS morphology does not seem to change in the early beats. ST elevation V2-V5 diagnostic of anterior MI…ST depressions in inferior leads seem reciprocal to ST elevations in leads I and aVL. seems like large anterolateral MI…also, ST depression in V1 is suspicious for posterior involvement… i am wondering if posterior surface is fed from one of the OM’s off of the occluded circumflex, and the would be depressions in V2-V3 are obliterated by the large anterior elevations. Cath lab.

  • Dave B says:

    Just to add, in my interp, it would be proximal LAD occlusion (proximal to Cx).

  • Chris T says:

    Guess I better get the Pads on and Call a LifeFlight

  • Christopher says:

    Ugly! Looks like a huge anterior MI, I’m with Dave on the LAD occlusion and ectopic atrial rhythm.

  • Dr Dave Albert says:

    Acute antero- lateral MI. Might be left main occlusion. Pt. Needs to be in cath lab stat.

    DrDaveAlbert

  • VinceD says:

    Agreed it’s an ugly one, I’m not entirely confident either.
    Rhythm Strip – Ectopic atrial rhythm (borderline junctional, I’m seeing a PR of about 120ms on the dot, comp says 130something). Non-sustained runs of V-tach.
    12L – Same rhythm w. PVC’s. Large amount of STE V2-V5, I, aVL and STD II, III, aVF, V1. Very likely acute antero-lateral MI (posterior leads could confirm involvement there from the LCX as well), but depending on the patient presentation, hyperK+ isn’t out of my differential with such large amounts of depression/elevation.

  • Mike C. says:

    Nasty Tom. Just nasty. In the initial 3lead the complexes are exhibiting invert P’s leading me to think they are retrograde thereby possible junctional complexes. The rhythm begins with an irregularity followed by 5 regular complexes followed by…(mumbles)…I’d hate to call them PVCs because they don’t quite look wide enough, but I’m not sure how else to explain the irregularity.

    The 12lead shows what I’d interpret as a fairly massive anteroseptal c lateral extension MI. (ST Elevation V2-5, tombstone T’s, reciprocal inferior depression) with a PVC at the beginning and the end.

    ASA, IV Access, O2 IF the pt. is hypoxic (I’m on the hyperoxia bandwagon at the moment), NTG as long as the pressure holds out, early notification of STEMI for the cath lab, nice quick trip up! Probably throw the pads on too just in case.

  • Terry says:

    Looks like an unhappy heart. R on T–> V-tach. Antereo lateral wall MI.

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