63 year old male: chest pain

David here, posting my first case on the blog… hope you enjoy, and Happy Father's Day! Here's an interesting case submitted by "Mike from Mass".  Some minor details have been changed to preserve patient confidentiality.

EMS is dispatched to a residence for a 63 year old male with chest pain. Dispatch advises that a different crew had responded about 30 minutes earlier, but the patient refused transport against medical advice.

Upon arrival, the crew finds a 63 year old male walking towards them, in no apparent distress. There is a moderate language barrier, but the the crew is able to understand that the patient began experiencing right back pain while taking a shower about an hour ago. He may also have experienced shortness of breath and chest discomfort, but the crew is less certain of this due to the language barrier.  Patient is alert and oriented X 4, with clear lung sounds.  The crew obtains the following vital signs:

  • BP: 142/70
  • HR: 52 bpm, regular
  • RR: 14
  • SpO2: 98%
  • BGL: 137

While trying to obtain the patient's medical history, the crew learns that the patient has not received regular medical care until one year ago. The patient is able to deny any allergies, but regular medications and any past medical history are unclear. The patient is given 324 mg baby ASA, but nitrates are withheld due to unclear PDE5 inhibitor (ED drugs) status. Prior to transport to a PCI capable hospital, IV access is established and  the following 12 lead is acquired:

Enroute, another 12 lead is acquired:

Upon arriving at the hospital, the patient becomes acutely anxious and tremulous.  The crew observes that the patient now appears to be in moderate discomfort, with a rising heart rate. A third 12 lead is acquired by the crew:

What do you think is going on?

What do you think about the change in the patient's presentation?

How would you treat this patient?

 

11 Comments

  • Brandon O says:

    Early recordings could be Wellens. Seems to deteriorate to a full STEMI eventually; quality on the last is poor but there appears to be substantial anterior elevation with reciprocal changes.

  • Medic537 says:

    This comment was removed due to incivility. Thanks, Tom B.

  • Troy says:

    Initial shows Wellens Syndrome. ASA, nitro, morphine (but I prefer fentanyl), and serial 12’s. Wellens turned into a full anterior STEMI which I guess was do to withholding nitro and early treatment for what might be done in the tertiary care. Personally, I never base my treatment in the field off of what the hospital might do, except withholding Plavix in aVR elevation. That’s just poor paramedicine if you ask me :/ Don’t wait till your behind the 8-ball to take your shot.

  • Troy says:

    Lol! I thought when he said ED he meant the hospital, not erectile disfunction. What ever happened to just asking the patient? He could probably tell you if he was popping some Viagra 😛

  • bill says:

    Since you are now at the hospital, give him the nitro, start a second line and watch as he goes to cath lab

  • Todd says:

    Since he didn't outright say he was on any sexual performance enhancing drugs, with a SBP of 140+ I would have given him nitro any way….as well as ASA, Morphine, and maybe titrate oxygen to his sats if need be. Also I did notice a BBB even in the first 12 lead that got progressively bigger as time went on…

  • Chris T says:

    I learned a little about wellens syndrom. And it was cool to see that much elevation appear while with the patient. Neat case. Thank you for your time in posting. I learn from every 12 lead I look at.

  • bruce says:

    Sounds like pt. Maybe having as indicated on 12 lead

  • Carius says:

    I notice a wandering baseline (not sure if thats the correct term for it) on the third ECG. Anyone know what the source for this artefact / disturbance?

  • Brandon O says:

    Probably movement from the "acutely anxious and tremulous" patient, Carius.

  • FLMedic311 says:

    @Todd..  BBB? Could you be more specific, as I don't see anything that would indicate a IV conduction delay.  Also not sure that this would qualify as a Wellen's case, although the Biphasic T wave in V3 is concerning typical Wellens include changes in V2.  Not sure if anyone has anymore infor regarding this as a variant or not, would like to know.  I would however like to point out the hyperacute T wave in V1 and loss of precordial balance is very concerning for acute cardiac ischemia.  

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