Here’s a case submitted by Captain Jack Sparrow from the UK Ambulance Forum.
I’m presenting it here with minor modifications.
Turns out Mark Glencorse isn’t the only clever Brit! We Yankees can learn a lot from the way they do things across the pond.
EMS is called to the residence of a 69 year old male with a chief complaint of chest pain.
Onset: Gradual while driving
Provoke: Nothing makes the pain better or worse
Quality: Describes pain as pressure
Radiate: The pain does not radiate
Severity: 3/10
Time: Similar episode over the weekend while gardening
Past medical history: CVA x 13 years ago, AF
Past surgical history: None
Allergies: No know drug or environmental allergies
Medications: Warfarin, digoxin, others
On arrival the patient is found sitting in a chair.
Skin is pink, warm, and moist.
He appears ill.
Vital signs
RR: 16 regular
Pulse: 130 irregular
NIBP: 137/102
GCS: 15
BGL (BM): 146 (8.1)
SpO2: 99 on RA
Breath sounds: clear bilaterally with normal air entry
No obvious trauma or anything else out of the norm.
The cardiac monitor is attached.
A 12-lead ECG is captured.
What’s wrong with this patient?
See also:
Appears to me that it is atrial fibrillation, rapid ventricular response, with WPW. There are prominent delta waves (very prominent in the precordials) with the Q-waves and flattened T-waves in the inferior leads that can accompany WPW.
Treatment would include:
1. ASA depending on medical director’s preference given coumadin Rx.
2. Consider procainamide or amiodarone to control the rate.
3. Pain management with fentanyl 0.5-1 mcg/kg.
4. Cardioversion for any signs of decompensation
5. Transport to a hospital with PCI and an EP lab for ablation.
Bill –
Are you saying this isn’t a RBBB but rather WPW Type A? Does your Medical Director not feel comfortable with giving aspirin to chest pain patients who already take warfarin? That’s the first time I’ve heard that.
Tom
Yes, my impression is WPW Type A (upright V1 & V2 vs. B that has a negative V1 & V2 if I remember correctly). I’ll defer to you, but I’ve heard of a Type C and have no idea what that one is.
Our medical director advocates ASA for all CP and most ACS/arrhythmia unless there is a true anaphylactic reaction. We work in a mother-may-I system and if we forget to administer it prior to call in we have some old school physicians that believe ASA is not necessary if the patient is on coumadin…One of our adjacent systems does not give ASA if coumadin is prescribed. Wacky but true, anecdotal practices.
Presuming ASA is Aspirin and Coumadin is warfrin(?); just to add that giving any pt Aspirin who is currently on warfrin is contra-indicated in the UK ambulance service. I believe that is to do with CVA risk.
arguably meets criteria for LAFB. the delta-like wave is probably just the delayed intrinsicoid deflection that comes with LAFB.
Giving aspirin to someone on warfrin is no longer a contra indication in the UK, as it works on different clotting cascades to warfrin.
Aspirin is contraindicated in the UK if the patient is on warfarin. Aspirin and warfarin are transported on the same protein in the blood plasma, but aspirin binds preferentially. So aspirin administration increases the amount of free (hence active) warfarin in the bloodstream, which is not usually desirable.
Whether this is a problem (or indeed helpful in the context of MI) is no doubt debatable!
AF w/ RVR, RBBB. Inferior STD, STE in aVR, V4 doesn’t look right but its a transition lead. If this were WPW Type A you would not have the Q wave (or at least that is my understanding). I’d like to control the rhythm on this one…I’ll get back to this post (receiving call).
Afib with a RBBB, rate is a little high which could be contributing to the chest discomfort but I’m also seeing significant depression in II and AVF.
ASA, IV, NTG, O2 if he starts getting dyspneic. We’ve got no issue giving ASA to warfarin users. Serial 12leads, keep an eye on vitals and run ‘em on in.
Hmm so im guessing he is on those meds for AF. My needle in the hay stack is digitalis toxicity resulting in rate induced chest pain. Due to shortened QT, inverted Ts and possibly rate.
Would have to see the pt to rule in or out ischaemic chest pain.
Out protocols in my state in Australia is Aspirin as a precaution with PTs on warfarin- if they have thorough understandings and knowledge of current INR you can justify not administering it…. But clinicians should remember the efficacy in AMI. So it’s upto us and 99/100 we give it…. If it’s say straight forward rapid AF you could justify not giving it if for example they have problems maintaining therapeutic INR.
Anyway my 2 cents and plenty of discussion for this case- thx
Nickinbrisbane -
Did you mean to say shortened QT? QTc is 479 ms.
Tom
looks like AF with RVR, and RBBB + LAFB… I agree with Christopher about STD in inferior leads and STE in aVR… also, i believe the Q wave in V1 is abnormal, as is the ST elevation in see in V1-V4.. unlike LBBB, RBBB should not distort the ST segment, so i believe this ECG is very suspicious for STEMI.
Concordant STE Septal and Anterior leads, with subtle but present inferior reciprocal depression. This combined with what looks like STE in aVR makes me think proximal LAD, or left main occlusion. STEMI in the presence of tachycardia looks odd, but those rules don’t apply to Afib. I agree with the bifasicular block, and wonder if the LAFB aspect isn’t new onset secondary to anterior ischemia. Treat per chest pain protocol and activate the cath lab.
Tom, yeah sorry shortened.
On a glance of ECG today does anyone else see elevation in avR?? If so LCA occlusion… Our service is trying to get this sign approved for cath lab activation
Nickinbrisbane -
I actually think that’s a terminal R-wave in lead aVR!
Tom
It certainly is an interesting RBBB with the narrower limb leads and wider precordials. Could the narrowing be secondary to the ST changes due to the AMI?