Elderly Female: Chest Pain

As usual, some minor details were changed to protect the patient as well as the providers.

You are called to the residence of an 82 year old female, chief complaint: chest pain.

As you arrive, you and your partner find the woman sitting just inside the front door of her house.  She looks pale and uncomfortable. She had been doing some "yard work", and developed sudden onset of chest pain.  She denies SOB, but states she is a bit nauseous, and you note she is very diaphoretic.

  • Onset: Began while she was raking some leaves on the lawn.
  • Provocation:  Nothing makes the pain better or worse.
  • Quality: She states is feels like someone is "squeezing her chest" and she makes a squeezing gesture with her hands.
  • Radiation:  Pain radiates to her back.
  • Severity:  She rates the pain 10/10.
  • Time:  Discomfort has been going on for about 40 minutes prior to your arrival.

You inquire about any cardiac history, and she tells you her only history is for a-fib, stroke and hypertension, although she admits her blood pressure has been "very high lately".  She tells you she is fairly active, and has never had this kind of pain before.  She takes aspirin since she had her stroke, and has taken more before your arrival.  she also is prescribed Lopressor for her hypertension, She states she's "not sure" what she takes for the a-fib, and she doesn't have her meds handy.  Her only allergies are to "some antibiotics".

Vitals are as follows:

  • HR: 92 and irregular
  • BP: 210/120
  • RR: 20 regular
  • CTC: pale, cool and very moist
  • Lungs: clear bilaterally
  • SpO2: 97% on O2

You put her on the monitor, and although the patient is unable to stay still due to her discomfort, you do your best to acquire the following rhythm strip and 12 lead ECG:

You are 20 minutes from the local non-pci hospital, and the PCI Center serving your rural area is a 20 minute flight by helicopter.

 

What are your impressions of the ECG's?

How do you treat this patient?

What is your destination facility?

 

*****   UPDATE   *****

  • Patient had taken ASA prior to your arrival
  • After 12 lead transmission and consultation with Medical Control, it was decided not to activate the Cath Lab, but to transport to community hospital…
  • Patient was given 1 SL NTG, after which her pain did not diminish
  • A couple of minutes out from the community hosptial, the patient stated her chest pain was worsening, and the following 12 lead was then acquired:

What are your thoughts now?

53 Comments

  • UK Medic says:

    From the UK here!

    Anteriorseptal MI
    GTN, Asprin, Morphine, And carry on 02 therapy if SATS are < 95% on Air
    Destination is: PCI Cath Lab

  • Newer EMT-I says:

    Have to call a STEMI on this one.  O2, ASA (depending on how much she already took), Nitro, Fent, Air to Cath Lab.

  • Chance Gearheart says:

    UK Medic, forgive the American idiot here, but what's GTN? You guys speak a lil' differently across the pond.
    Can't you just give me a pericarditis? One of the problems with working strictly with NICU babies and pediatric asthmatics is that adult cardiology tends to get rusty! 🙂
    Does not appear to have a LBBB/RBBB by diagnostic criteria.
    3-lead shows inverted T-Waves in II and III with ST Depression, rhythm is an atrial fibrillation as evidenced by irregularly-irregular QRS complexes and wavy, poorly defined P-waves. There does not appear to be any "missed beats" or PVCs noted. No R-On-T events.
    12-lead reveals ST Elevation in V1-V4, with questionable ST-Depression in other leads as well as T-Wave inversion in limb leads. Suspect Anterioseptal MI, with possible lateral involvement.
    O2 titrate to shortness of breath, let's start off with a BNC at 2 lpm. No evidence of help, some evidence of harm to blowing them up with a NRB. Let's do an ETCO2 cannula as well. Establish IV access, and let's bump her ASA total up to 324mg/day if she has taken some already. Nitrolingual tabs or spray to attempt to control BP and chest pain.  Forget aeromedical, you can be at the PCI center by the time they lift to be back en route. Let's go. Diesel bolus to engine, make lots of noise and light up the street. Establish second line en route. Pop a fibrinolytic checklist, and make sure to take a family member with due to hx of stroke. Morphine for both BP and Chest Pain, careful titration to pain. Consider zofran for Nausea. Blood glucose check, anyone? Let's also consider nitropaste if we have it available, 0.5 to 1in applied to chest wall. Consider Labetalol to bring down heart rate and myocardial oxygen demand, and control blood pressure.
    20 minutes by aeromedical away from PCI is a relative descriptor. Do you mean 20 minutes flight time? That can translate into up to an hour depending on how much time is spent on scene to stablize and assess prior to transport. (20 mins flight time, 20 mins scene time, 20 mins transport time) Rapid ground transport to PCI is 20% cooler in 10 seconds flat.

  • Ben says:

    @Chance Gearheart – What I believe you call Nitroglycerine(?NTG) we decided to call Glyceryl Tri Nitrate (GTN) 😛

  • Lindsey Parker says:

    Bilateral blood pressures… if difference greater than 20 systolic, suspect aortic aneurysm due to the radiation to the back.
    Has she taken her medication recently?  Is she compliant or has it been awhile?  Has she ever been cardioverted, electrically or chemically, and what did they put her on to maintain rhythm?  What blood thinners does she take besides the antiplatelet aspirin? 
    Based on EKG, anterior infarct… PCI facility.
    MONA and all that good stuff. 
    Note:  I'm a poor little nursing student!  I hope I'm not way off here.

  • Chance Gearheart says:

    @Lindsay – Not at all. One discounts the student at their own peril.

    @Ben – you chaps across the pond! First tea and crumpets for brunch, and now the odd, yet refined names for Nitro! 🙂

  • Ken says:

    Going for anterior MI, based on in the elevation in v2-4 & the depression in v5-6 (?). Plus the fact the lady is describing classic cardiac sounding chest pain. Cath lab job.

  • FB says:

    So, I don't think it shows STEMI. I think the elevations and depressions are secondary to LVH (some of the QRS in the precordial leads are cut off by the machine). I personally hate this type of EKG because it is the most common mimic for STEMI. The degree of ST depression though in the lateral leads is concerning. I also think there is a ratio rule of STE and R wave that I think this EKG would end up not being classified as a STEMI. I think NTG to bring the blood pressure down is a good start. I would also wait on giving ASA until I tried to r/o dissection via bilateral blood pressures (although how specific is diffential blood pressures to aortic dissection?). Due to her presentation I still think this will be ACS but I don't believe she needs to be sent via helicopter because of her EKG unless you are highly suspiscious of a dissection.

  • FB says:

    And fentanyl. 

  • FB says:

    And maybe be suspect of 1mm of elevation in aVR with all of the ST-Depression…but still I go with changes secondary to LVH.

  • Firemedic24 says:

    I would be willing to bet her unknown a fib med is digoxin

  • firemedic24 says:

     

    Impression of the pt is ACS
    Impression of the ECG is normal axis deviation, a fib, depression in the lateral leads + long qtc makes me think digoxin, also LVH or borderline LVH… hard to tell because the QRS runs off the paper.
    Although it is hard to tell with the wandering baseline and inverted t waves, I don't consider that reciprocal depression.  Plus the concavity of the anterioseptal t waves makes me think STEMI Mimic.
    Still treat it as ACS, but would not call a helicopter… I don't think it is a STEMI

    Aneurysm is a possibility… bilateral BPs would be pertinent before ACS meds.

  • Bevis says:

    From the looks of this 12 lead, I would go with a anteriorseptal wall MI, but I would not discount the pain radiating to the back, I would keep in mind that it might be a triple AAA.  Treatment at this time, 2-IV's, Morpine, 02, and reassess and reassess.  I would transport this patient to a facility that has a cath-lab and STEMI team.

  • Firemedic24 says:

    whoops, forget what I said about qtc It is supposed to be short qtc not long qtc…  does not change my answer though.

  • NREMT-P 858 says:

    I am thinking STEMI… I would not let the AAA slip my mind and would bet bi lat bp’s…. I think nitro drip, Asa, fentanyl would do this pt all the good!

  • FMF_DOC says:

    I hate a-fibb and moving patients when it comes to 12 leads. Not all of the QRS in v leads 1-4 have actual st elevation. I dont know if im barking up the wrong tree but what about PE. I think the v lead elevation comes from LVH.

  • Rich Y says:

    FB, I'm going have to tell you that giving nitrates to a patient you think is disecting is generally a bad (ie. fatal) idea.  

  • FMF_DOC says:

    If the 12 lead said MI then cath lab. If not let the doctor at the closest facility sort it out.

  • Tatonkadtd says:

    Global st segment changes with pain raidiating to the back and htn puts her at high risk for a dissection…this has to play into your differential diagnosis, as well…

  • the new guy says:

    So being a rather new medic I would have ask the reason behind vaso dialators when u are not going to give asa due to possible AAA. O2 for sure and probably ms due to the low vaso dilating effect. But personally I would base the stemi center and consult.

  • David Baumrind says:

    For those that mentioned aortic aneurism and bilateral BP's, i can tell you the BP's were virtually the same in both arms…

    For those that mentioned LVH with Strain pattern as a possibility, i agree that is definitely on the table as a DDX… 

    So, for those that say MI, why not LVH with Strain? For those that say LVH with Strain, what do you make of the ST depression in the inferior leads?

    Great comments so far… keep them coming!

  • MedicNC says:

    @fmf doc I know a lot more medics working on the street that can call a STEMI better or just as good as ER docs. With all the movement of the patient there is no telling what the machine will say. They do teach us to read a 12 lead and most take it beyond that. Have a nice day.

  • Cait says:

    What about a-fib with CHF? Chest and back pain with hx of hypertension, and cva. With cardiac involvement.

  • Vicki B says:

    My god, I hope they notice my severe allergy to aspirin if I ever have this happen to me. I wear the bracelet but it only says 'This patient has allergies.' Then they have to look in my purse for the card. They don't always remember and, unfortunately, I don't always wear the bracelet. But the card is always in my purse.
    I stopped breathing when I took aspirin. I got severely dizzy, felt like all the blood was rushing to the front of my head, became confused, broke into a rash that suddenly jumped out all over my body, and finally stopped breathing.
    I had pain in my throat for 18 hours after being ETI and then something with cricothyroid. I don't remember it anymore, b/c I haven't used the knowledge for a while.

  • FMF_DOC says:

    At medicnc. I know alot of medics who can also read 12 leads pretty good, me being one. I also know alot of the same medics who found out they werent as good as they thought. This is an unclear 12-lead that is best handled by the doctor. Its for the best of the patient. Not your ego. Have a wonderful day.

  • UK-SAP says:

    I would hazard along the lines saying the ST elevation is not at STEMI criteria (1mm V1, 1mm V2, hard to say in V3 but between 1 and 2mm).  I would query unstable angina due to the marked depression – treat with GTN and aspirin (assuming the patient hasn't just taken a full 300mg).  Probably fax the ECG on for a second opinion with clinical and repeat ECGs.  Asuming no changes pre alert and blue light to the nearst hospital. I would say the description of the pain and the patients condition sounds more ACS than it does aneurism – but it would certainly be worth checking bilat BPs.

  • brainscrewed says:

    I wouldn’t be concerned about aaa, and lvh doesn’t seem particularly concerning to me. I’d give asa, nitro, morphine. I would want some vasodilation due to the b/p, but would wonder about pericarditis

  • M7 says:

    Possible aortic dissection? A fib overall underlying rhythm. LVH strain pattern. Oxygen admin,fibrolynic checklist,establish IV access of at least one line, 12 lead left and right chest and possibly posterior if time allows-then make a field Dx and rx per protocol,contact med cobtrol,consider stemi center

  • MR says:

    Hey all.. I’m a newer medic so can someone school me on “LVH with strain” I get LVH=left ventricular hypertrophy. Whats the patho behind it. Pt has Hx of afib. I’m definitely concerned with a triple A. So bilat BP’s for sure. As far as pericarditis… Wouldn’t we see depression in other leads rather than just V5 & V6?? Lungs are clear so id like to take a look at the ankles if im thinking CHF. The rapid onset points me towards MI, but I would like to run another EKG and see what V4R and V7 V8 and V9 look like. I’d rather error on the side of the patient…. I’m gonna call a STEMI… She is on O2…ASA, IVx2, NTG and C3

  • Jim Hendey says:

    A good history seems to point to AMI. Lungs are clear,acute onset pain with exertion,HX of HTN,A-fib and stroke . EKG seems to reveal a-fib with possibly some s-t depression. Regardless; O2 high flow since this is proven to reduce damage d/t hypoxia and there is no hx of COPD, Nitro sublinqual,possibly 1/2 to 1 inch nitro paste and morphine to titrate to maintain a systolic B/P of 90 to 100 or pain relief.

  • woody says:

    afib with st depression in lateral precordial leads.  qrs does not appear wide enough to call LBBB.  st elevation of 1-2 mm in v1-v3.  differential includes acs/hypertensive emergency, aortic dissection, pe top 3.  textbook pericarditis is diffuse st elevation –> isoelectric –> diffuse st depression. 
    need more info…is she taking digoxin? the st depression could be dig effect, ischemia, or strain.  really need an old ekg for comparison, but in the context of 10/10 pain probably ischemia. 
    best approach imo would be nitro, narcotic, o2, asa and transport to pci facility.

  • VinceD says:

    ECG definitely shows LVH with strain and a bit of QRS widening which match her Hx of HTN, but she's got a good story and physical exam so we really have to scrutinize what we're seeing. She may also be on digitalis, accounting for the shape of the ST-segments in the inferior leads, but that's not something I'd want to call without the bottle in front of me.

    I'm not going to drag in the cath team for her right now, but she is definitely sick and it would sure be nice to transmit this to someone for a second opinion. Her secondary ST-changes are also borderline for what I might expect from just LVH (+ maybe dig), but:
    1. Most of her QRS complexes are clipped, and
    2. LVH can create some very impressive ST and T changes
    so maybe this is her norm.
    That being said, maybe it is NOT her norm so we'd have to watch her like a hawk and worry about worst first with this clinical picture. She doesn't qualify for urgent PCI (at the moment), but as for which hospital she should go to, it's not a call I think I can make here from my computer. It's a weak move, I know.

  • Danny Masarick says:

    J-M-J
    I am just an EMT, but I did stay at a Holiday Inn Express and have spent time as an aide on a medic unit.  
    ECG:  The 1st ECG: strain: ST Segment elevation with T wave inversion in Leads I & III (Please verify lead placement)
    The 2nd ECG: Bundle Branch Block (BBB) in Leads II, III and aVF (wandering p waves).  Pacer spike shown in trunk leads.  Is this ECG normal for her or a new finding?  Did I miss something there is no ST segment elevation in this ECG taken two minutes later.    Blame it on the aide placing the leads high up the trunk (ST segment elevation).   
    Voltage in Leads V5 is compatible with unresolved hypertension consider patient history of stroke.   If possible assess patient with Cincinnati Stoke Scale, call Code Stroke.  Note any peripheral edema.  Obtain list of medications (ie Digitalis Toxicity). 
    TREATMENT: Perform rapid head to toe medical assessment: Managing the patient pain will save her heart muscle.  Obtain blood glucose level.  Administer Cocktail: HI flow O2 mask w/humidifier, (3) 81 mg aspirin, IV KVO, (1) sublingual nitroglycerine up to total of 3 tablets every (5 or 15 minutes) been out of service for a few years.  If time permits and pain is still present then administer Morphine with Phenergan for nausea.   
    Secondary effect of nitro, and morphine will resolve Hypertensive Urgency 210/120mmHg (goal reduce mean arterial pressure up to 10%) else further exacerbate or cause MI.  Regarding suspicion of Aortic aneurism this is all we can do in the field to stabilize and prevent dissection.     
    FACILITY:  I choose to err on the side of caution and send her by flight to Cath Lab. 
    Just for my own edification:  what is the presentation of coronary artery tear with an occluded renal vein?

  • Lance says:

     
    Treat the patient not the machine, especially not with this 12 lead…  The only definitive thing I can tell you from this 12 lead is that there is inferior and lower lateral myocardial ischemia.  Her beta blocker doesn't fit with the heart rate (if she's compliant), her blood pressure doesn't fit with her presentation (or lung sounds), the radiation of the pain doesn't fit with the quality of the pain…  The only thing I know is I'd treat for ACS, consult a doc on NTG and transport.

  • FB says:

    Rich Y, can you point me to any guidelines or literature against the use of nitrates in dissection? I know it is not indicated with severe aortic stenosis but thought it was ok in dissection along with a beta blocker and more commonly nitroprusside?

  • David Baumrind says:

    Excellent comments guys… FYI patient update, as well as an additional 12 lead have been added to the case.

  • Firemedic24 says:

    Whoops, goes to show you the importance of serial ECGs.  

  • VinceD says:

    Really great case David, with the update, I'm calling it a STEMI now. Win one for serial ECGs, and thanks for posting this.

    oh and @FB: Actually there was an awesome study a few years ago where they gave nitroprusside to critically ill patients with aortic stenosis and LV dysfunction and quite surprisingly the patients actually did better, however I'm sure there's still controversy over whether that's actually the right move. As for nitro in dissection, I have no idea.

  • Danny Masarick says:

    Quick question.  In ECG #2 the AV lead show A-fib, Limb leads show BBB and you see pacer spikes in the trunk leads V1-6.  Is this a cut and paste job or I am missing something.  I am eager to hear the final outcome for this patient.  PS. thanks to all for the post this is a ggreat learning tool for me. 
     

  • UK-SAP says:

     
    Well thats now a STEMI! Serial ECGs prove their worth there!
    Danny, your quite right, in all the ECGs shown here there is atrial fibrilation (the irregularly irregular QRSs and the lack of P-waves indicate this), and this is visible in all leads of the ECG (as no lead has a p-wave).  A BBB either left or right would show with a QRS of >100ms (partial) or >120ms (full), this equates to 2 – 3 or more small squares on the ECG and again, would be visable in all leads of the 12 lead (though can sometimes be hard to spot if the begining or end of the QRS are indistinct).  In this case there is no significant widening (though it does appear to be borderline – it could potentially be right on the edge of a LBBB).  There arn't any pacing spikes that I can see, are you maybe looking at a fold in the paper? A pacing spike would appear as a very narrow vertical line just before the QRS which would usually appear quite wide like a LBBB. Hope that helps!

  • UK-SAP says:

    Acually, looking in more detail, I would say definately no LBBB here, the QRS appears to be 2 small squares (80ms) in duration.

  • Danny,

    I'm not so sure I see any pacer spikes in the second strip. It may be the "cutting off" the monitor does to the R/S waves when they exceed the 50mm combined height for the lead. Additionally, the complexes are narrow and irregularly irregular, all of which point away from a paced rhythm.

    I hope this helps!

  • David Baumrind says:

    @Firemedic @Vince and others: makes you wonder how many STEMI's are missed in the field by not doing serial 12 leads doesn't it?

  • David says:

    Great discussion…nice to flex some brain muscle rather than trying to explain to a 15 year old that there is a higher probability that her altered state is not due to her drink being "spiked" but maybe the half bottle of vodka she just downed…
    The first 12 lead…is it in "monitor" mode ie. 0.67 – 21Hz rather than "diagnostic" mode 0.5 – 150Hz? Worth checking as it can artificially exaggerate the ST segment.
    Have a safe shift.

  • VinceD says:

    @ David B – Not just in the field…

  • Danny Masarick says:

    I just had an epiphany.   
    Do  LEADS II and aVF show Crochetage sign?  Does this patient have a atrial septal defect(ASD)?      I would have to consult with med control for treatment.   Reasses lungs and heart sounds check for JVD and peripheral edema.  Note any murmur especially s2.  hmm Nitro already on board so dizzniess is a given.  Any shortness of breath at this point? 
    Obtained focused patient history: Expect patient to be easily excerted during activity leading up to this episode.    Expect patient would be barrel chested and depending on disease stage may see axcerssory muscle.   
    American Heart Association mention secondary pulmondary hypertention for folks with ASD.  One Medical Journal found supports giving  Nitro as it appears to improve associated pulmondary hypertention.   another artilce state high volume o2 improves PHP, but nitro does nothing. 
    If so is morphine contraindicated?  hmm times up press gas pedal to floor.  Follow up with Doc after shift. 

  • Danny,

    The notching is certainly noticeable, however, I believe without RBBB the Crochetage Sign is less specific. ASD often has other right sided heart strain changes.

    As for morphine vs others, there is some literature against morphine so if you have fentanyl available it may be a good option!

  • ToddB says:

    A dominant LCA might also explain the depression/reciprocals in the inferior and low lateral leads.

  • David Baumrind says:

    Just to elaborate on what Christopher said, morhphine has it's association with hypotensive effects due to histamine release…fentanyl doesn't have that issue, which is why it is preferred, along with it's shorter half life… although, i have heard anecdotally of agencies using benadryl along with morphine to deal with the issue… anyone doing that?

     

  • Danny Masarick says:

    MR,
    This is how my doctor explained it to me.  Heart strain: when the heart is overtaxed for many reasons leading to weakening of the muscle resulting in ECG changes.  The t waves become inverted.    
    Unresolved strain can progress to Ischemia (muscle damage) with or without infarct due to poor perfusion (oxygenation).  This is shown by t wave inversion with ST segment depression.    
    Treat the patient, and be aware of lead placement.  Look out for the Grandpas that wears his pants up to his chest when placing limb leads on the trunk.  Some medic do this to reduce noise in the limb leads.  When place too high it can result in the a strain or even ST segment changes.   
    There is a decent chart showing this progression in ECG NOTES by E A Davis Company

  • ilovewaffles says:

    @ Jim Hendry

    Regardless; O2 high flow since this is proven to reduce damage d/t hypoxia

    Not too sure about this anymore.  Check out this Cochrane Review RE: Oxygen therapy for AMI
    http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007160.pub2/abstract

  • Mel says:

    Initial limb leads show A-fib with RVR, ST seg depression.
    12 Lead shows A-fib as well with ST seg depression in the inferior leads, elevation in the anterior V3, and peaked T waves in V4.  Lateral leads V5 * V6 show ST seg depression as well. 
    Second 12 lead shows continuing progression of ST elevation in the Spetal and Anterior Leads, with continues A-fib.  My diagnosis would be A-fib with Anterior MI.  I would recall the hospital and activate cath lab for the Anterior.  O2, Iv, another admin of Nitro, Morphine and continued eval until turning patient over to hospital.

  • Mel says:

    Sorry… Septal/Anterior MI.  Ya, serial ECGs really helped in this case!  Thanks for posting that!  Great crew to obtain a serial.  I dont see it done enough in the field, but I myself try to push for it.  This far from the hospital, if air transport is not utilized, there is no reason why a serial shouldnt be done.  This goes to show the importance of them!  Keep em coming guys!  This is a great case!

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