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:
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.
Awesome blog by the way, I’m learning a lot. Thank you.
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.
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.
With the second ECG looks like the MI is evolving right in front of us. 02, ASA, nitro, morphine and cath alert
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.
Looks like an inferior/lateral wall MI to me. I am not thinking pericarditis. Definate Q’s in the inferior leads.
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.
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.
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
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?