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63 year old male CC: Chest pain – Conclusion

10 comments

Here is the conclusion to 63 year old male CC: Chest pain.

Let’s take another look at the patient’s heart rhythm.

I can see why some of you thought this was Torsades de Pointes but the cycle rate is over 300 and the underlying rhythm showed a normal QTc. In my experience it’s not unusual for the onset of VF to be relatively slow and then accelerate (sometimes with a cyclic rate over 700).

I feel confident this is course VF. Either way, it was pulseless.

The paramedic in charge of the call shocked the patient at 200 J.

Here is a 12-lead ECG of the post-shock rhythm.

I find it interesting that the limb leads become non-diagnostic during accelerated idioventricular rhythm (AIVR).

Several minutes and later the rhythm had stabilized.

The patient was delivered to a PCI-hospital where the interventional cardiologist was waiting.

Here is the 12-lead ECG captured prior to the procedure.

Here is the post-cath 12-lead ECG taken after successful stenting of the LCX.

These are the days that make it all worth while! Thanks for sharing the case, Phil!

Posted by on January 1, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , , , , ,

10 Comments

  1. Ben says

    good case and looks like a good conclusion!

    Now one question I have is – on the pre-PCI 12 lead it shows ST depression V1-3 (?posterior) and some elevation in the inferior leads with reciprocal changes, if I remember my cardiac physiology right, aren’t these areas fed by the R coronary artery?

    Obviously I defer to the cardiologist and the vastly improved ECG!

    on January 1, 2011 @ 7:59 pm.
  2. Christopher says

    Ben, I too was thinking RCA given STE III>II w/ posterior involvement (yet we have V5-V6 STE). Most folks are right dominant (PDA supplied by RCA). Tom has a great post which covers the algorithm for culprit artery in inferior MI’s.

    Perhaps this is a big LCX?

    on January 2, 2011 @ 12:03 pm.
  3. Phil says

    Hey Ben, if the patient had a left dominent system, the LCX will supply the Posterior and approx 40% of the inferior L Ventricle. A left dominent system is found in roughly 10% of cases. The other 90% will indeed have these systems supplied by the RCA.

    on January 2, 2011 @ 3:17 pm.
  4. Ben says

    Thanks Phil that clears it up :)

    on January 3, 2011 @ 7:03 am.
  5. Brandon O says

    Hey Tom, do you have any numbers on M&M for LCX occlusions?

    on January 5, 2011 @ 12:43 pm.
  6. Tom B says

    Brandon O -

    No I don’t, but I’d be skeptical of any numbers, because STEMI in the distribution of the circumflex artery is under-reported. It seems likely that many are misclassified as NSTEMI.

    Tom

    on January 5, 2011 @ 11:20 pm.
  7. Tom B says

    Remember this thread at the EKG Club?

    http://health.dir.groups.yahoo.com/group/ekg_club/message/13018

    Tom

    on January 5, 2011 @ 11:27 pm.
  8. Brandon O says

    Yep. I’ll keep my ears peeled for any more numbers, it’s an interesting dark area.

    on January 6, 2011 @ 12:14 am.
  9. burnedoutmedic says

    i wish we had the 4th line on the tracing, the monitor lead. it certainly is useful.

    on April 1, 2011 @ 8:34 pm.

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    on January 2, 2011 @ 7:59 am.