This is the discussion for 46 year old female: injuries from a fall. You may wish to go back and review the case.
To begin with, lets review the patient presentation. Is there anything based on presentation that raises red flags for Acute Coronary Syndrome (ACS)?
She is pale and diaphoretic, with nausea and vomiting. She also complains of feeling "weak". Diaphoresis alone is one of the most concerning signs of ACS; and of course, there is the bilateral shoulder and arm pain. Considering the diabetic history, I think we all would be suspicious of ACS in this patient.
However, there is the matter of the fall the night before. The shoulder and arm pain, and other symptoms, could be attributed to the fall.
One of the biggest challenges we face is assessing for ACS in the presence of other injury of disease, which can distract us from serious signs and symptoms. Can we imagine a scenario where medics attribute the patients complaints to the fall, and don't even run a 12-lead? I think we all could see how that could happen.
Another confounding factor is the high blood glucose. In this case however, the paramedic, who by his own admission was not initially thinking ACS, registered enough red flags that he rightly investigated ACS.
Now, let's look at one of the 12-leads:
The rhythm is sinus bradycardia, with a first degree AV block. That happens often with an inferior wall MI, and I'm sure many of you were looking to the inferior leads. As most commenters pointed out as well, we see ST elevation inferiorly, with reciprocal depression in leads I and aVL.
What about concurrent Right Ventricular Infarction (RVI)?
What ECG signs do we look for to determine if an RVI is present? Let's review:
- ST elevation in III > II
- ST elevation in V1
We have IWMI… if we compare leads II and III, we see that indeed the ST elevation in III > II:
If we look at V1, we see there is about 1 mm of ST elevation there as well:
It is also reasonable to get a right sided V4R, to look for ST elevation. The paramedic did that in this case, and this is what it showed:
In the presence of IWMI, any ST elevation > 0.5mm in V4R should be interpreted as RV MI.
Regarding the patient presentation, the hallmarks of RVI are:
- Clear lung sounds
Now, how about treatment for suspected RVI? In this case, the crew could not gain IV access. ASA was given, but NTG was held off due to the low BP and no IV access. Fluids would have been indicated.
NTG and Inferior Wall MI's seems to be a frequent topic of debate. Can we give NTG in the presence of RVI? We are all familiar with the anecdotal bottoming of pressure due to giving NTG, but while it may happen, it is not the rule. If the patient's BP is normotensive, can we give it?
Do we give it "cautiously", whatever that means (I always picture taking great care while squeezing the nozzle on the NTG spray)? While i think we all would agree that it is contraindicated in the presence of hypotension, there is not uniform agreement if the pressure is normotensive, of hypertensive.
What do you think?
The crew took this patient to the nearest PCI center, where she was rushed to cath and found to have a 99% blockage. While the culprit artery was unknown to the crew, however, it would be fair to speculate that the RCA was occluded. She received stents, and was discharged several days later and was expected to make a full recovery.