77 year old female CC: Chest pain

EMS is called to a residence on a horse farm for a 77 year old female with chest pain.

On arrival, the patient is found sitting on a wooden bench. She appears anxious and acutely ill.

Skin is warm, flushed and diaphoretic. She is rubbing her chest.

Onset: 20 minutes prior to 9-1-1 call
Provoke: Slightly worse with deep inspiration
Quality: Unable to describe but when pressed “more sharp than dull”
Radiate: The pain does not radiate
Severity: 5/10
Time: She’s had chest pains before but not recently and “nothing this bad”

Past medical history: Hypothyroidism, dyslipidemia

Medications: Synthroid, Lipitor

Vital signs are assessed.

RR: 24
Pulse: 104
NIBP: 201/118
SpO2: 97 on RA

She admits to feeling short of breath.

Breath sounds are clear bilaterally.

The cardiac monitor is attached.

A 12-lead ECG is captured.

What would you do next?

*** UPDATE ***

By request here is another 12-lead ECG taken approximately 15 minutes later.

See also:

77 year old female CC: Chest pain – Conclusion

16 Comments

  • Wes says:

    Diffuse concave st segment elevation throughout; leads II, III, avF v2-v6. If measured against the tp segment then there does not seem to be much elevation at all. j point notching in v2 and looks like pr segment depression in II and avF. Associated with sharp chest pain on inspiration sounds like pericarditis. Get serial ekg’s and look for acute changes before alerting the cath lab imo.

  • Wes says:

    Awesome blog by the way, I’m learning a lot. Thank you.

  • just another medic says:

    What I see:

    Minor ST-segment elevation in most leads
    Significant PR-depression in 1, 2, aVF, a little in V3, V5, V6
    (I think) Pathological Q-waves in III, aVF, maybe II
    Sinus rhythm
    Large T-Waves in II – do they look symmetrical to anyone else?
    Low voltage QRS complexes in precordial and maybe inferior leads

    I would want the following questions answered before treatment:
    Temperature (thinking pericarditis)
    Any recent episodes of chest pain, similar or otherwise?
    Heart tones muffled or normal? (That’s about as advanced as I can adequately evaluate them at this point)

    Maybe I’m overthinking this one before my first cup of coffee. Interested to see what others say about it.

  • just another medic says:

    Also, I’d want to see if chest pain changes when leaning forward. Forgot to mention my money is on pericarditis. I would give ASA, transmit to hospital, transport non emergency with O2, serial 12 leads, IV KVO, monitor blood pressure manually and keep the possibility of pericardial tamponade in the back of my head.

  • The patient’s temperature is normal and the pain does not get better leaning forward.

  • NJ Newbie says:

    With the second ECG looks like the MI is evolving right in front of us. 02, ASA, nitro, morphine and cath alert

  • DaveO says:

    The Q waves in the inferior leads and the STE in lead II could be due to an old MI (?) however I’d be more concerned about the anterio-lateral leads due to the large size of the t-waves compared to the QRS complexes.
    R. side EKG because of the possible inferior involvement, O2, ASA,IV, NTG (with a systolic of 201 I’m not too worried about giving NTG) and a ride to the cath lab.

  • Neil Holtz says:

    Looks like an inferior/lateral wall MI to me. I am not thinking pericarditis. Definate Q’s in the inferior leads.

  • Patrick F. says:

    IV O2 fentanyl asa nitro cath lab activation. STEMI !!!!! I would like to say that sometimes I think that prehospital providers try to over analyze the ECGs. I think for some patients you are better off with activating the cath lab. where i am from they sometime have to be called in at night or have to call in a second team and that can take time. I would also like to see how the treatment works with the meds to see if you get any changes in the ECG but i would call this a STEMI.

  • Lance says:

    The T waves are predominately convex, where as if it were pericarditis they would present concave.

    I vote for MI, O2, NTG and diesel to cath lab.

    I’d like to rule out PE as well.

  • Troy says:

    I would go with a global infarct. Although the patient has PRI depression the J point isn’t notched, the Q-waves in the inferior leads are pathological, and the T-waves are not concave. Also the serial EKG shows septal elevation evolving.

    I would be surprised if this was pericarditis

  • Aharon says:

    In this case I have a big dilemma , I son’t shore 100% that it’s STEMI , and I have a chance that it pericaditis , so the dilemma in teatment is if to give Heparin yes or not?

  • Chee Yong Chuan says:

     
    It is indeed a tough one, diffuse concave ST elevation with a few leads manifesting PR depression points to acute stage 1 pericarditis. Good to also know that the T waves are indeed disproportionately large as compared to the QRS voltage. A few pitfalls here:
     
    1) Absence of reciprocal changes in lead aVL to suggest inferior STEMI. ST elevation in lead III and aVF in the presence of pathological Q waves could suggest persistent ST elevation after MI a.k.a the ventricular aneurysm morphology. 
     
    2) PR depression seen especially in lead I and II might sway us towards the diagnosis of pericarditis in the absence of reciprocal changes as mentioned above.Not sure whether my eyes are fooling me but I can actually appreciate ST depression and PR elevation in lead aVR which is deemed classic for pericarditis
     
    Is RBBB present in this tracing? Considering the rSR morphology in lead V2 and slurred wide S wave in I and aVL? QRS complex is at about 120ms
     
    Retrospectively I thought the CONCORDANT ST elevation in lead V2 kinda gives the diagnosis away considering that in RBBB, you should have discordant ST-T changes in V1 to V3
     
    Please enlighten

  • Troy Hart says:

    I would agree with many comments above as a paramedic my belief is transmit for referral but I am suspicious of pericarditis. Having said this a stemi will kill this pt before a chronic pericarditis. 

  • Greg from Greece says:

    I agree totaly with “just another medic ” it must be a pericarditis because it does not have a miiror image in the ECG , you can’t take that chance , you should do a coronary

  • darren says:

    Low voltage could be hypothyroidism or is she obese? QRS axis shifts but T wave axis stays same.
    ST elevation in II and aVF with Q wave in aVF. ST elevation v4-6.
    Evolving Inferolateral MI
    rsR v1 and widened QRS suggest RBBB.
    Alert cath lab and if pericarditis let Cardiologist make that call.

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