79 year old female CC: Chest pain

Here’s a cool case from a faithful reader named Mike M.

EMS is called to evaluate a 79 year old female with a chief complaint of chest pain.

  • Onset: Sudden while watching TV
  • Provoke: Nothing makes the pain better or worse
  • Quality: “Heavy”
  • Radiate: The pain does not radiate
  • Severity: 7/10
  • Time: About 30 minutes prior to 9-1-1 call

On EMS arrival the patient is alert and oriented to person, place and time, speaking in full sentences.

Skin is cool, pale and diaphoretic.

  • Past medical history: Breast CA, Parkinsons
  • Medications: Unknown
  • No known drug or environmental allergies.

Vital signs are assessed.

  • RR: 20
  • Pulse: 72
  • BP: 152/84
  • SpO2: 98 on RA

Breath sounds are clear bilaterally.

No JVD or pitting edema.

The cardiac monitor is attached.

A 12-lead ECG is captured.

What do you think is going on?

How would you treat the patient and why?

See also:

79 year old female CC: Chest pain – Conclusion

28 Comments

  • eff dog says:

    asa, o2. inferior wall mi. (II,III). fluid bolus right off the bat prior to ntg due to likely rv involvement and suspected pwmi. (v1, v2 depression). 15 lead ekg to eval for extention. would have expected some jvd though… notied 1st deg avblock and maybe anterior hemi block so may need to avoid av blocking drugs if it came down to that.

  • Chris T says:

    STEMI. Sinus rhythm, Inferiolateral MI with poss posterior involvment. This would be a large RCA block i think. Also treat as R sided invol. Watch borderline 1st degree AV
    ASA, 02 2lpm NC, Large bore IV x2 if time, NS 250-500cc bolus caution LS, trial SL nitro x1. Early notification of closest ED. If pressure holds nitro every 5 min x3 then drip. Or contact med control to bypass SL nitro and go right to drip, easy to titrate, fast off. Fentanyl 25-50mcg then 25 mcg prn for additional pain control to nitro, caution if pressure goes below 100 sys. When speaking with Med control i am going to advocate for helicopter either in route, or meet at hospital. Some local docs want to play around and see the patient, some want them on the bird. BTW nearest PCI 1hr 20min by ground. about 20 min by air.

  • Chris T says:

    oops, add seriel EKG. V4r and posterior EKG if time or have partner.

  • Christopher says:

    Inferior-posterior MI. V4R/V7-V9 if time permits. Early STEMI notification. Emergent transport to PCI center. Tough to say about the culprit artery II/III look about the same elevation. IV, O2, NTG, fentanyl for the pain.

  • Harrison says:

    Sinus @ 80, Normal axis and intervals, granted the dropped p.

    ST elevation inferior and lateral leads with ST depression anterior leads and T wave inversion in septal leads.

    STEMI alert, treat and transport per protocol.

    Right sided ECG and serial ECG’s post treatment.

  • Harrison says:

    Ignore the “dropped P” part of my above post 🙁

  • Matthew says:

    STEMI….looks like inferiolateral to me, O2 3lpm, ASA, Nitro x3, transmission of 12-lead, IV access and ALS for morphine prn since I’m a primary care paramedic in Nova Scotia (our version of BLS except we have 7 drugs, 12-lead interpretation, some have IV endorsement with D50, it’s a 10 month college program). If in metro activate cath lab and go direct to PCI if in rural and have an advanced care paramedic around have them administer prehospital thrombolytics of course if all of the many criteria are met, if not transport to nearest regional ER.

  • Paramedic1052 says:

    Patient is experiencing an inferolateral myocardial infarction, most likely an RCA occlusion.

    My treatment would consist of…
    – 324mg Aspirin per orem
    – Supplemental oxygen at 4lpm via nasal cannula
    – 15-lead to rule out right ventricular or posterior involvement
    – IV access, 18g or larger preferably in the left AC, normal saline KVO
    – If no right ventricular involvement, 0.4mg Nitroglycerin via sublingual spray every 5 minutes. If there is right ventricular involvement, I would deliver a fluid bolus prior to Nitroglycerin.
    – Rapid transport to the closest PCI-capable facility
    – 2mg Morphine if pressure holds and time allows
    – Early medical command contact

  • mary shane says:

    inferial/lateral stemi, asa, morphine, oxygen,large bore iv in event of hypotention, transport to the closest stemi/ cath center

  • Josh says:

    Inferolateral MI with high chance of posterior involvement. This is probably a A LEFT circumflex artery block in a person who’s LCA feeds the posterior descending artery and the posterior side down to the apex instead of the RCA. Run both 15 lead and leads V3R,-V6R. Give ASA, nitro, fluid, consult receiving facility for 5-10mg retevase, and give some metoprolol. Serial vitals and ekgs en route to er.

  • Jeremy says:

    Inferior MI, with reciprocal changes, notify receiving facility of STEMI alert, transmit 12 lead to receiving facility, O2, defib pads applied, ASA 324mg, 2 IVs with fluid bolus 250-500ml, posterior 12 lead ECG, consider SL nitro watching B/P closely. Probably would not consider IV nitro given the right sided involvement. Keep pt calm possibly Ativan SL if pt is anxious. We don’t want to increase mycocardial O2 demand any further.

  • Billy says:

    High flow o2, fluids, ASA, nitro, high flow diesel.

  • Dave B says:

    1st degree block…IWMI…inferior elevations with reciprocal changes in aVL..probable posterior involvement…Christopher, i agree hard to judge culprit artery… but, i will say that i agree STE in III does not seem greater than II or aVF… in addition, with no STD in I, and the STE i see in V5 and V6, the circumflex becomes much more likely in this case… but who knows… Cath lab either way.

  • STE in Leads II, III, aVF – IWMI & STE in V5 & V6 = Inferolateral MI
    Lead III STE > Lead II STE = probable RVMI
    aVL shows typical down-sloping ST-depression associated with IWMI
    V1 & V2 show PWMI changes – ST-depression, inverted T-waves, & R:S >1

    This is probably all due to a proximal occlusion of a very dominant RCA.

    ASA, activate cath lab, NTG (sparingly, and with fluids attached)

    *Extra leads would be a bonus if time permits, but not exactly needed.

  • Caleb EMT-P says:

    STEMI, Inferior, high probability of right sided/posterior involvement, as well as first degree AV block. 15-lead EKG to confirm/deny. Aspirin, Oxygen, IV, Monitor, serial EKG’s, nitro drip, start at 10, titrate to pain/BP, Fentanyl for pain management, consult medical control for Heparin orders, and possible Heparin drip. If out-lying county, consult med control for Retavase. Haul butt to the closest appropriate facility, early notification of the Cath Lab, and they better be in the cath lab waiting on me, cause I’m probably skipping the ER all together.

  • frenchy says:

    She looks sick. oxygen 15L via NRB, Aspirin 300mg PO, Nitro 0.4mg SL, IV access, Morphine sulphate 2mg aliquots IV consider up to 10mg if required.
    Question: At what stage is the Cancer???
    If I am conviced this is am MI Clopidogrel 600mg PO, second large IV access, if rural, consider Tenectaplase and Enoxaparin 30mg IV. Pre-alert hospital for PCI.

  • Aussie_medic says:

    Inferior-posterior MI. Obtain V4R. Treatment as follows: supplemental oxygen, Aspirin 300mg, withhold GTN until RVMI is ruled out. IV access (large bore), 2.5mg morphine as required, NS primed and ready to go if cardiogenic shock develops. ICP back up for Reperfusion: Clopidogrel 600mg, Heparin 5000 units IV, Enoxaparin and Tenecteplase. Transport to hospital with cath-lab facilities.

  • tex-med88 says:

    O2, Large Bore IV access, ASA 324 mg, R-side EKG, NTG sub-lingual while monitoring BP response, Fluid bolus if needed for BP, Plavix 600mg, 70 u/kg IV Heparin, Rapid transport to cath-lab.

  • tex-med88 says:

    Fentanyl for management of pain!!!

  • Let us remember, the patient is NOT hypoxic.

    The AHA has finally got on board, and recommends that supplemental O2 is not a priority with the non-hypoxic patient.

    O2 can be harmful. Basically, when unneeded, oxygen becomes a free radical that can induce oxidative stress. You would think that patients with ischemic tissue need O2. On the contrary, they have plenty of O2, its just being blocked. The old “hypersaturation” technique doesn’t work.

    Of course, we never withhold O2 when it is needed.

    Just some food for thought.

  • Troy says:

    I agree with adam. Oxygen has a vasoconstrictive property to it and has been known to cause coronary vasospasms with hyperoxemia. Also, with the possible posterior involvement, I would definitely worry that this is a proximal RCA occlusion which would lead me to believe RVI. Do V4R-V6R and if positive hold off on NTG and fentanyl for pain

  • Troy says:

    Correction…..and give fentanyl for pain.

  • M4ttjabz says:

    I agree with Josh. Probably a left dominant circulation (PDA coming off LCA) with a circumflex lesion.

  • KW says:

    Are you all doing 15 lead prehospital ? Does it impact your D2B time?

  • Pete says:

    inferior and low lateral involvement the depression in v1,v2 is big so ? posterior I would expect her to be more sick 15 lead and posterior if available time permitting ,serial ecg we discuss with pci they make final call on lab or not treat symptoms we dont give 02 unless hypoxic.
     

  • William says:

    Inferior Lateral MI with with marked ST depression in V! and V2 so probably at least  posterior ischemia if also not involvment.  O2 IV NG and TX

  • Jen H says:

    It frightens me that some of you are considering NTG drips and Morphine. Regardless of her current pressure these are contraindicated in this MI. Always do manual pressures in PWMI’s. She needs fluids WO and ASA and O2 at 2L/NC. For sure obtain a 15 lead and contact closest Cath lab stat.

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