88 year old male CC: Chest pain

EMS is called to the residence of a 88 year old male patient with a chief complaint of chest pain.

On arrival the patient is found standing at the front door. He appears anxious and acutely ill.

Skin is pink and warm but diaphoretic.

The patient is led to a kitchen chair and the assessment begins.

Past medical history: Hypothyroidism, Dyslipidemia

Medications: Synthroid, Lipitor

History of present illness:

The patient states that he was cleaning the house when symptoms began.

  • Onset: Sudden and getting worse over time
  • Provoke: Nothing make the pain better or worse
  • Quality: Sharp
  • Radiate: Pain radiates to the left arm
  • Severity: 10/10
  • Time: No previous episodes

Breath sounds are clear bilaterally.

No JVD or pitting edema noted.

Vital signs are assessed.

  • RR: 20
  • Pulse: 68
  • NIBP: 145/85
  • SpO2: 96 on RA

The patient admits to nausea but has not vomited. He denies palpitations.

The cardiac monitor is attached and a 12-lead ECG is obtained.

Computerized measurements:

  • HR: 66
  • PR: 292
  • QRS: 146
  • QT/QTc: 414/434
  • P-QRS-T: 21, -50, -19

What is your interpretation of this 12-lead ECG?

What do you think is going on with this patient?


  • Shawn says:

    Firts impression would be a Type 1 second degree AV block, acute MI .

  • AJOkey says:

    1 degree, RBB, elivation in 1, AVL. R wave progresion looks off, and AVR looks wide but I'm thinking thats from the RBB? I would get 7,8,9 and RV4 to see if that gives any more info. O2, IV, Morphine, NGT, ASA ,searial 12 leads. Watch for changes in V5,V6 , that would lead me to think Lateral MI.

  • Nick Adams says:

    First of all, I don't agree with walkiing the patient back into the kitchen. He looks sick, so why walk him.  The patient has classic signs of AMI (except for the pain being described as "sharp"), but that is this patient's interpretation. Q-waves in V1, mild ST elevation in V2, reciprocal ST inversion in III, aVL.  The electrical conduction systems runs down the septum, so BBB's and fascicular blocks are common.  The next step is a CHB.
    SR with a 1st degree AVB, RBBB, LAFB……… Hey, that's 3 HB's… PUT THE PADS ON NOW!
    ASA @ 324mg PO, O2 @ 2-4 lpm to maximize SaO2, IV (1-2), ECG (3), Serial 12 leads, NTG @ 0.4mg SL x3 with a NTG gtt starting @ 10 mcg/min & titrating up to pain level and B/P, Zofran @ 4mg IVP for nausea, transport to PCI center.

  • Rob says:

    @Shawn, no lengthening of the P-R Interval, no dropped QRS complexes = no 2nd degree type I.
    NSR w/ a 1st degree AVB, some STE in V2, TWI in several leads, suspicious Q-wave in aVL, & bifasicular block w/ acute onset.  I probably would've moved him out to the unit rather than into the kitchen (provided I'm not in a chase car or a paramedic engine company).  Treatment, O2, IV w/ labs, ASA, NTG, Transmit the strip & consult, & serial 12's en route.  Destination is not a big issue as only one hospital in the county is not a PCI facility.

  • Im going to just say it and be wrong.
    Looks like a brugada syndrom pattern with 1st degree AV block. Im also suspicious of hypothermia as I may see a developing osborn wave.

  • John D says:

    Why do we continue to walk cardiac patients  Sit them down preferably on your stretcher or the stair chair and assess. I agree with Nick as to his interpretation but let's make sure there are no phosphorodiasterenase inhibitors on board before we hit him with nitrates. Should be a standard question in your litany by now. While we are enroute let's also consider a right sided 12 . Early notification gets the team mobilized and if you have that second line in place your receiving facility will be appreciative. 

  • saraswathi thangavel says:

    I degree HB , aute antero septal mi, RBBB with reciprocal changes in the inferior leads..pt not in cardiogenic shock  may be because of small territory infarct.. bed side echo to confirm the diagnosis.. pt need to be taken up for primary pci ..

  • NewMedic says:

    Wow, I feel stupid compared to all these other posts.

  • Follow this site New Medic. You will be teaching paramedics around you at work things they didnt know existed ! Always follow Toms review to his posts for further links and material. I owe a lot of knowledge to this site!

  • Rob says:

    NewMedic, I’m relatively new as well. Follow this blog, take a systemic approach to each strip in order to interpret it, & always remember the big picture & how this piece of that puzzle fits the picture. This takes some time to learn, but it’ll eventually click & you’ll look like a rockstar.

  • I agree with hemiblock and RBBB forgot to add oops. Reguardless this is not good. High priority. Basically what Nick said

  • marionurse44 says:

    1 Degree, RBBB. Long Q-T, Inf changes,  Avr-V2 some elevation. 

  • VinceD says:

    Acute lateral STEMI w. ST-elevation in I and aVL with ST-depression in III and aVF. V2 also has inappropriate concordent ST-elevation, but I'm not sure what to do with that as the whole ECG is fairly atypical in how the findings fit together. Anyway, it's a STEMI.
    Of note, as others have stated, first degree AV block, RBBB, and LAFB means at least bi- (or arguably tri-) fascicular block, which portends a poor prognosis in the setting of AMI.

    IV x 2, O2, monitor, defib pads at least out (if not in place), ASA, nitro, miorphine, serial ECG's and transport to a cath capable facility w. early notification.

  • Terry says:

    Trifasicular block. 1st degree hear block, RBBB, LAFB.

  • FDWhiety says:

    I agree with most of the assessments of this patient, but one thing I noticed was everyone is placing the patient on O2. According to the 2010 AHA guidelines for the treatment of ACS:
    "EMS providers administer oxygen during the initial assessment of patients with suspected ACS. However, there is insufficient evidence to support its routine use in uncomplicated ACS. If the patient is dyspneic, hypoxemic, or has obvious signs of heart failure, providers should titrate therapy, based on monitoring of oxyhemoglobin saturation, to ≥94%"
    With this in mind, are your systems still administering O2 prophylacticly?

  • Juan Pablo Peña Diaz, MD says:

    I see a 1st degree AV  block, Complete RBB and ischemic changes in inferior leads. This patient is probably having a heat attack, an NSTE-ACS, the management should follow the guidelines of AHA/ACC or EHA (recently published).

  • Medicbksc says:

    Would love to see a rhythm strip. PR appears to vary, but not enough strip to properly measure. Very possibly 3rd degree heart block. ST elevation in I, aVL indicates possible lateral STEMI.

  • Mel says:

    Im saying possible 3rd degree AVB… I think the PR interval is slightly longer than a typical 1st degree, but then again, I could be wrong.  Possible high lateral.  Def RBBB from V1.

  • Saad says:

    1st degree av block, rbbb, lafb, plus concordant t wave in avl, 1, v2 with st elevation! so im suspecting an anterolateral stemi with trifascicular block! this pt is critical

  • gaga says:

    AV block with MI

  • RBBB with acute anterolateral STEMI: STE and hyperacute T-wave in aVL.  Slight STE in V2 (where there should be ST depression), with upright T-wave.

  • james ebstein says:

    Hi there, I decided to write down my observations before reading others options (sorry for my english I’m from italy)
    the main problems seems to be:

    -AV: I degree AV block 280ms
    there are: S wave in I
    T wave in III
    but no Q in III
    rSR in V1 + T inversion
    all of those are wave that look at right ventricle (eg: pulmonary embolism, and classical RBBB, and also other causes)
    -repolarization: seems to be normal
    -ST segment elevation in I aVL

    a question can be:
    why there is not Q wave in III?
    what are those little J wave and the precordial lead qrs notch?
    what about that q wave in aVL?

    can those things be linked together? how?

    An infarction occurring in Cx artery in a patient with left coronary dominance, if I’m not wrong, can produce signs of:
    -I degree AV block
    in this case q and little J wave can be signs of death tissue

    maybe too sci-fi

    let me know

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