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?
@ Jim Hendry
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
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.
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!