90 Year Old Male CC: Chest Discomfort


Here's an interesting case submitted by a faithful reader who wishes to remain anonymous.  As usual, some details may have been changed to protect patient confidentiality.

You are called to the residence of a 90 year old male.  Prior to your arrival, he was met by a BLS crew, walking around his apartment in no obvious distress.  Upon questioning, he admits to some sub-sternal "chest discomfort" starting four hour prior to calling EMS.  As your partner starts to get vitals, you continue your history and learn that the discomfort started while "sitting in a cab on the way home".  The discomfort is non-radiating, and not reproducable.

Your partner obtained the following vitals:

  • BP:          130/90
  • Pulse:     100+, very weak
  • RR:          18 regular
  • Skin:          "unremarkable"
  • Lungs:     clear bilaterally
  • SpO2:      99% on high flow O2

The patient receives 162 mg of ASA (per regional protocol), and as you get additional history your partner starts to put the leads on:

  • Discomfort began while at rest in the cab
  • Nothing makes the discomfort better or worse
  • Pt can only describe an uncomfortable feeling in his chest
  • Discomfort does not travel anywhere
  • Pt rates it as 7/10
  • Discomfort began four hours prior to calling EMS

The only medication he admits to taking is Plavix. His history is significant for DVT (for which he says he takes the Plavix) and Previous MI with CABG (time unknown).

You acquire the following rhythm strip and 12 lead ECG and begin your transport:


While the "data quality prohibits interpretation message" is given, you attempt to get a better tracing but this is the best you can get.  In addition, you are unable to get IV access.

The nearest hospital is a community non-PCI center about 10 minutes away, and the closest PCI center is 20 minutes away.








  • Marlene says:

    Give 1 sl nitro, 2 additional asa (162 mg) and do a right-side ecg.

  • Gary says:

    RBBB, LPFB which is common in RBBB.  LVH and RBBB causing the wide and bizarre QRS complex,  I would not call a STEMI alert, there are no reciprocal changes.  The fact that I can not get a line would probably lead me to going to the closest facility and I would not give nitro.  Definatly at least V4r is always idea.  Never give nitro before you have a line and rule out posterior.

  • Kevin says:

    Looks like A-Fib RVR with abarent conduction. IV, O2, monitor, with serial 12 leads q 10 min. Nitro ASA, and MS/Fentenyl BP permitting. Consider Cardazem 0.25 mg/kg if rate is sustained or increases and symptoms don’t resolve with “MONA”. Transport to a cardiac facility. EKG is non diagnostic for STEMI.

  • matt says:

    Did the machine give an axis measurement?  Looks way off to me…

  • Robert says:

    A Negative tracing in lead V6?  Everything I've been taught tells me a Negative Tracing in V6 is ventricular in origin…  I'd call this V Tach.  I would cardiovert, and transport to the PCI center, 

  • David says:

    Continue with chest pain protocol, SL NTG until pain reduced, Fentanyl PRN and NTG paste.  Transport to PCI facility as a precaution.

  • David says:

    Possible Septal ischemia possibly a posterior MI.  Due to quality cannot R/O MI.  Rate is too regular for a-fib.

  • BH says:

    Cardiovert a stable blood pressure in a fully alert patient without a line? 

  • Larry says:

    Its definitely v tach. He is stable at this time. Go to the pci center. Continue attempting I’ve access. Consider the high probability that the patient has an embolus causing cardiac irritability.

  • Sam says:

    V1 up V6 down its vtach [edited for civility TB]. Immediate cardiovert.

  • Matt says:

    Interp. Wide complex v-tach.  Treatment: 02, 2-IV's. Apply defib pads, Pain Mang. Have Amio ready, Transport to the closet facility, conduct reassessments, and repeat 12-leads.

  • JM says:

    Looks like VT, deisel therapy.

  • Newer EMT-I says:

    I think this is VTac.  Have the Pads on and ready.  His is stable for now however could go down hill.  No line = No Chemical Cardioversion.  Keep Pt calm and relaxed.  O2, Vitals q/10.  Vagal Manuevers to try to convert.

  • JM says:

    Diesel therapy

  • Jeff says:

    Stable tachycardia doesn't need cardioversion.  Maybe amiodarone or lidocaine if we could get that line.  I would probably just transport.

  • just another medic says:

    Pads, oxygen, watch v/s closely.  Initial R in aVR I think is pretty specific for v-tach, and I think that we have that here.  Closest facility, I would notify them of what we have and spend time trying to get a line and monitoring his condition closely.

  • bm says:

    Conscious VT, give full dose of 324mg ASA, apply pads and attempt to establish IV access, have amio ready, but I would consider lidocaine also. If IV is established attempt chemical cardioversion, reaccess vitals Q 5mins, transport to nearest facility for stablization. If IV cannot be established enroute and pt remains stable I would hold off on cardioversion until arrival at the hospital.

  • Mat says:

    Right-superior axis deviation,initial R wave in aVR, and AV dissociation visible in  V1 would favour VT. Does no one else feel anterolateral leads may be excessively discordant? The concordant ST depression in V2 is also concerning.

  • Tac Med says:

    V1-6 down shows me VT. Pt stable at this time. Throw the pads on and work on conventional access. Should he deteriorate can always consider an EJ or IO. Have amio bolus ready and contact the pci facility. Sounds like our pt through another clot and will need angiography to get it out.

  • Brian says:

    I am interning and we had a pt that fits this perfectly just last week. We picked him up at a clinic and he met the above (stable, chest "discomfort," adequate BP, etc.), and we called it SVT w/aberrancy. We pushed Adenocard 6mg, and it was subsequently converted with the additional 12mg. The lateral leads do look a bit hypertrophic, but you're Tx the SVT, here. I'd in turn, probably withhold the NTG until I ruled out the rate as the cause. I'd still go to the closest Cardiac Care facility though.

  • Rhonda...from Iowa says:

    I’m just a Paramedic (in training/class) could you tell me what your saying about Diesel Therapy. What is it? I’m hoping its NOT SOMETHING REALLY OBVIOUS AND I LOOK STUPID FOR ASKING)!! Thank you, and LOVE YOUR SITE!!!! Merry Christmas EVERYONE and VERY SAFE AND HEALTHY NEW YEAR!!!!

  • Andrea says:

    Sedate and cardiovert immediately

  • Scott says:

    Good call on the Axis: Negative in I, Negative in aVF is somewhere between 90 and 180, which is consistant with a rythum ventricular in oragin (since the electrical flow is going back towar the atria, and not down toward the ventricules) and I beleive falls under the technical name of FUBAR.

    As for treatment, I like Lido, but I can't give it without a line, so MONA.  If his LOC changes I'm thinking pads and IO, Lido (maybe Amio) and a PCI center.

  • Will says:

    Diesel Therapy = Drive Fast

  • Philip says:

    I would have to agree with VTACH, V1 is positive and V6 is negitive, aVR is upright and it appears to be a mostly right axis devation coupled with wide complexes. I would tirate the oxygen down as needed, hold off on the NTG and continue to work on getting vascular access and be prepaired with the IO (if the service has it) or to check for an EJ if his condition declines at all. Transport destination is a tough call in this patient… He is sick now but he has also been complaining of symptoms going on 4 hours, I personally would choose the PCI facility without cath lab activation since its only 10 minutes further, being at the right facility if he needs the cath could save him hours of transfer arrangements. 

  • Scott says:

    Diesel Therapy is drive fast to the hosptial.  It's ok to be new, we were all at one point, just stay curious.

  • David Baumrind says:

    @Rhonda: Good luck in your training! Diesel Therapy refers to stepping on the gas and getting to the hospital ASAP!

  • medicdad29 says:

    Medical control anybody ? this guy is holdong up ok for the time being. pumping a 91 yo man full of meds could have negative outcome. 10 minutes from the hospital isn't that bad. be carefull of med addministraion without IV access. I'm not 100% convinced of  Vtach. possibly sinus with a block pattern, but without iv access I'd keep trying vagal maneuvers, no ntg and no amidorone. If we did get access lets try a fluid bolus and if we're still not at the facility then start the 10 minute amio. DO NOT SIT AROUUND on scene. do not delay transport.

  • Will says:

    I’m getting rate = 150 per tracing provided, pt stable: BP 130/90 A&O, HR 150. Pt hx of CABG and MI could explain a horrible 12 lead. Amio drip with consult is a good option, or else chest pain protocol with transport to PCI is appropriate. as far a axis deviation etc see pt hx.

  • Christopher says:

    Extreme Right Axis Deviation (ERAD) and an initial positive deflection in aVR with a regular monomorphic wide complex tachycardia @ 160 bpm: likely VT. Certainly a bizzare morphology though.

    Work on better 12-Leads and a line. If he has an obvious EJ, give it a go (while stopped).

    If no line, consider IM ativan, IN versed, or IM/IN fentanyl for sedation with elective cardioversion. Otherwise, if the gentleman decides to remain stable, we can just hang out until we arrive at the receiving facility.

    Best to go to the closer non-PCI center, but of course, we should give them the appropriate heads up:

    "Enroute, 10 minute ETA, with a 90 year old male complaining of chest pain. Upon our arrival, V-tach on the monitor at 160, vitals stable, working on a line however access is difficult. Will continue monitoring enroute and notify of any changes. Do you require any further?"

  • Jason says:

    Monomorphic wide complex in lead 2 with Brugatta's/Josephson sign present, although non-concordinate and narrow complex in V2.  Id say that it's probably V-tach, but could be an abarrent SVT.  Pressure is stable so I'd try 6mg Adenosine and if that doesn't convert it, 150 mg Amiodarone or 1.5 mg/kg Lidocaine.  If antiarrythmics are unsucessful I'd consider cardioversion.  Transport to nearest ER, can't determine STEMI from a wide complex rhythm.

  • doobis says:

    I would also jump on the V-Tach bandwagon given the axis deviation from I and aVF along with the wide QRS.  Regardless, even if it was an abbarent conducted rhythem, I would treat the same.
    Impression is the PT is boarderline unstable.  Given he has had these symptoms for hours which have not gotten worse, I would likely elect for medication control vs joules if they could be started quickly.  I would absolutely go to a cardiac center.  20 minutes is not that much longer than 10 and they would have the ability to treat his condition promptly.
    If his radial pulse was that weak I would be suspect of his B/P being accurate so I'd take more B/P readings and verify them to be accurate.
    I would be less inclined to go through the full MONA tx as more likely the reason for the PN and any possilbe ischemia is more due to the sustained rate for a 90 yr old than some sort of blockage of the coronary arteries.
    EJ or IO followed by Ami @150mg over 10+ minutes.  Place the defib pads on him as well.   If the B/P lowers or he becomes more unstable go for the synch cardioversion.  If it is v tach or A fib RVR, either tx would, hopefully, work.

  • Tyler says:

    I am going to have to disagree with what seems to be the majority consensus of a wide complex rhythm. Lead V2 looks to me to have a narrow complex QRS with P and T waves present. I think this is a sinus tach. I'm interpreting ST elevations in V3-V6. I wouldn't disagree with an indeterminate axxis deviation, but it's hard for me to say with Lead I being hard to read.

  • Gary says:

    Still not getting on the Vtach wagon.. No precordial concordance, no R in V6 and yes the axis is right, however it is not in no mans land.  I think this either what I said before, RBBB w/LPHB which is common in RBBB.   Or this is ventricular rythm with abbarence. 

  • Jeff Spangler says:

    Looking at the 12 lead, it looks to me like a paced rhythm, although the man didnt say he has a pacer, he is 90 years old and it may have slipped his mind. If there was no pacemaker however, the course of treatment would change obviously.  Remember he had a CABG, so it is a good possibility that he does in fact have a pace maker/defibrillator.  That being said, the rate stilll indicates v-tach seeind as how the inherant ventricular rate is 20-40 BPM.  ASA and NTG would be acceptable pre-IV because his pressure is stable.  IO would be an option for venous access if it is the newer style gun as it is relatively painless for the patient and not contraindicated for a concious pt.  I would not call in for a STEMI, because the 12 lead is inconclusive.  Aside from the nasty EKG, this pt is relitively stable.  As stated before, depending on whether or not he has a pacemaker would dictate where to transport him.  With a pacemaker I would transport to the non PCI, without pacemaker and the fact that he is stable at tthis point I would hage amioderone 150mg/10 min and transport to the PCI center after calling Med Control for permission to do so.

  • arnel says:

    I am not from the fast lane community but I love this waves. Anyway here is my take:
    1. Chest dicomfort r/o ACS on the list, PE(?). A little cardiac PE would also help like crackes, little murmur findings, JVD. 
    2. ECG – Wide complex tachycardia. Atrial flutter vs Atrial tacycardia with RBBB. I go for atrial flutter considering I can see the waves in V2. I can safely say this is not VT because there is no AV dissociation. The wide complex could be the baseline of the patient because of the background cardiac problem or an electrolyte problem like K or could be ongoing demand due to the tachyarrhytmia. There could be a prior MI the inferior wall (Q waves) or there may be an ongoing MI in the anterior wall. There is also extreme axis deviation. Most likely the lab would reveal troponin leak and high pro-BNP. 
    3. Tx in the field – (NA for me). If I can pitch, I will try to control the heart rate with an AV nodal blocking agent – diltiazem vs aniodarone . Digoxin can be secod line. If I can decide I will go for amiodarone. Good for patients on a background of heart failure and controlling tachyarrhyhtmia.
    4. PCI center – difference of 10 minutes.
    Will wait for results…

  • Shawn says:

    first 10 thing that cause a wide complex tach are V-tach. combine that with the extreme left axis makes me pretty confident.
    treatment: high flow O2, defib pads 2 LB IVs, 150 mg amio drip over ~ 10 min, 324 ASA. watch BP and monitor and have versed ready if cardioversion is needed. high flow diesel to the PCI center 

  • Hugh says:

    Never posted on here before so I'll take a crack at it I guess.
    Wide complex at a rate of 150 give or take deffinately points me towards V-Tach as my most pressing concern. Just for grins I'd like to confirm the limb leads are on right cause of that positive deflection in aVR but I'll assume they're on properly. Right axis deviation supports electrical current moving north rather than the other way around, although Tyler is right the tight complex in V2 points me away from V-Tach, maybe a low junctional rhythm judging from the PR Interval in V2 could cause the wide complexes? Either that or the pacemaker could by high in one the bundles, right probably, and accessing the conduction system for the right but not the left? Just a thought.
    Also, does our patient happen to be a dialysis player? this is the kind of FUBAR rhythm I would expect comming out of a dialysis center.
    Tx: O2 and ASA. I'd hold off on the NTG, if he's in V-Tach the last thing I want to do is tempt fate by knocking out compensatory mechnisms that seem to be doing just fine on their own. In any event he's tachin' away pretty nicely so I'm gonna get ready with the pads, maybe call for some IM sedation, 10 mg of Versed on stand by, if he starts to deteriorate we can light him up like a christmas tree – regardless of whether he's in V-tach or SVT the rate needs to be fixed, otherwise keep looking for that line. I'd probably lead off with the 6, 12 and 12 of adenosine and maybe a 250 cc fluid challenge to see if that brings the rate down before I call for the amio drip if I'm not already at the hospital (yeah I know ::groan:: I have to call for the amio drip). 

  • ChrisR says:

    The patient is stable so relax. Get an iv acces. No need to defib now. The rhytmn is 150 bpm; problably an atrial flutter with bbb, or an V.tach because of the p-waves you can see in pre cordial leads. The discomfort can be caused by the arrytmia. No nitro s.l. , first discover the rhytmn

  • G Howard says:

    I have been a certified Paramedic since 1978, so I have a much less agressive approach than some since I have to remember the days with not much to work with just an old 3 lead. However as the times have changed, Diesel thep however If line was established I would give MS/Fent and cardiovert Vtech wagon I gues i'm on no line well heck MS alot tube them and shoot the med down the tube( I was kidding) Diesel, cardiovert if line access and nearest, no time for Advanced cardiac facility. I would like to wish all a great holidays and remember thank you for being there for all that need field medicine. G Howard,EMT P (ret.)

  • Baker says:

    Im not certain what we have here,  but I am nearly positive it is not V-tach nor SVT,  look closely at V2  on the 12-lead it is not wide complex,  every V-tach i have seen is wide complex in every lead,  not the case on this one and on the other hand svt is narrow complex rhythm,  i think that for the most part all of the wide complex business is closely related to the severity of the anterio-lateral MI this man is having, confirmed by the reciprocal changes in V1,V2 R- wave progression is not looking to good either.

  • Jim Hendey says:

    not sure but unless he becomes more unstable I would agree that you should continue with the chest pain protocol and transport to the hospital that can handle whatever it maybe. its only 20 mins and with his history I would get him there asap! if he becomes unstable you could cardiovert.

  • Chris says:

    Not that experienced at 12-Leads here, but am I the only one that sees "Q" waves in Lead III?  I'm saying some sort of Anterior MI, since they have the ability to generate tachydysrhythmias anyway with a stable BP….Some of this could be explained by his prev. Hx, but since we don't have a comparison….I definitely wouldn't cardiovert this guy if I thought it was VT, he's too stable.  I could see the Amiodarone gtt/10 min. also.  Can't sell 100% on the VT thing either with the "normal" QRS widths in some of the leads.  I'd probably go ahead with the ASA, O2, NTG and MSO4 IM as long as no disqualifiers, Tx the 12-Lead and get on the phone with the MD since I'm not sure, otherwise.  I'd be comfortable heading to the PCI Capable center with no IV access, but i'd be hunting for something on the way, hurts my image, otherwise.  🙂

  • Baker says:

    Good catch Chris i wasnt even looking for the Q-waves,  just leads me further into believeing this is a massive MI in the making, widespread ischemia for sure.

  • Dev Krev says:

    Just a P student here as well, so here’s my stab…

    If we ignore all the machines just for a minute and look at the patient. He doesn’t appear to be showing any signs of cardiac insufficiency. He was walking around his apartment in no obvious distress. His skin is “unremarkable” and his BP ain’t bad considering his preload is probably shot. He is mentating properly (I’m assuming), and his lungs are clear. I’m definitely concerned about his rate, but right now he appears to be compensating adequately.

    I agree with Kevin that the EKG is A.fib with RVR and aberrant conduction. It is tough to check the R to R, but it looks irregularly irregular (if only by a little). This patient is on a blood thinner, he might be in A.fib at a baseline, and his rate decided to get a little rowdy today. It could be V.tach, but the patient is stable either way, and without access there isn’t much ALS Kung-Fu to be done. I think the funkyness of this EKG is all the more reason to get him to a facility that has a previous EKG on file to which to compare.

    I would ask this patient “Does the discomfort feel like your previous MI?” Since this fella has had an MI in the past, we are in luck because he knows exactly what one feels like(hopefully). I’m not saying he isn’t having ANOTHER one, but we gotta go with what we know.  I would ask what his sp02 was prior to O2 administration, because I’m certain the BLS crew checked that before slapping a non-rebreather on him.

    Considering his extensive cardiac history, and his current (relatively stable) status, he is definitely going to the PCI center. Its probably the hospital he got his work done at(hopefully), and most likely the one to have an adequate medical history(hopefully), and possibly a previous EKG done(hopefully). Even if these circumstances aren’t the case, I would still go the extra 10 minutes.

    I wouldn’t give him any more aspirin unless he said that it helped his symptoms. Plavix + ASA could be a bad combo. I would give him 0.4 mg SL NTG, if it helped, great, if it didn’t no more.

    I would get at least 2 more EKGs en route, probably q 10 minutes, and I would get one just before we unloaded him from the truck at the hospital. I would get v4-6R, and v7-9, I wouldn’t delay transport, and if resources were limited, I would rather attempt IV access, than get the other EKGs,

    I would have the IO ready if things went south, probaby have a site palpated and ready as well.

    In summary, my treatment would be prepare for the best, hope for the worst….no wait…thats not right 😛

  • Hereandthere says:

    I'm a new medic (An EMT-I…in my system I's and P's occupy the same "medic" position on an ambulance) so I'll give it a try.
    V-Tach is very questionable here. Yes the axis deviation and wide complexes suggest V-Tach but there are a few leads (V2 in particular that say other wise). I'd definitely say a RBBB is present. The tachycardia could be from the thrombus. Right now he's stable. Have the pt perform vagal maneuvers (I like having someone either blow hard on their thumb or cough a few times) while you get them packaged. Since I don't have vascular access I'd be going to the closest ER. I don't see any sign of a STEMI. In our system our EMT-Bs can give ASA so hopefully that already happened. My protocols say w/o an IV x1 nitro as long as the SBP is above 100. I'd have the combi pads out in case I was wrong. If the vagal maneuvers don't work I'd be looking to control the pt's rate. At this point I'd be calling our med control and transmitting the EKG along with giving them a thorough pt hx. The entire time I'd be trying my damndest to get an IV. Arm, Hand, Foot, EJ. I'd even be thinking about the drill. If I had to choose I'd be thinking about Amiodarone once I got an IV. Hopefully most of this would be going on WHILE I'M GOING DOWN THE ROAD!

  • Baker says:

    I must be going crazy because im one of the few that see a major MI going on here.

  • Jarrod Flynn says:

    I agree with Baker. I see a Big fat posterior wall MI.

  • Jarrod F. says:

    may also be an electrolyte issue, hyperkalemia? if so, lidocaine will kill this patient being a sodium chanel blocker. Those t waves if severe enough with a tachy rate can look just like vtac. Take away the the  the depol ability with the lido while the pt is also having repol issues, thats not a pretty picture IF THIS IS ACTUALY GOING ON. I have been wrong before. Just a thought.

  • medicdad says:

    Also poor R wave progression. Significant finding.

  • David Baumrind says:

    Lots of great comments people! The spectrum of interpretation of this ECG is across the board…

    Can we narrow it down? Is there a good reason to assume it's VT? or is there a good reason to assume it is something else? 

    When we interpret an ECG like this, how will our assumptions affect patient care, and what can we do to protect our patient from a dangerous treatment?

    Keep them coming folks!

  • arnel says:

    Let me spill again what i think. Based on the algorithm developed by Brugada's differentiating VT vs SVT. #1 . Absence of an RS in all precoridal lead? If yes VT if no proceed differentiatiing SVT. Ansewer is no. You can see RS in V1,2 and 3. # 2 – R to S interval in one precordial lead > 100 ms? If yes VT and if no proceed.Answer is no. The maximum RS I can see in V3 is 80 ms. # 3 Is there AV dissociattion?If yes then VT and if not proceed. Answer is No. I can see p waves in V2. # 4 – morphology criteria for VT present in V1,2 and V6?. This is an RBBB like wide QRDS tachycardia. In V1 it had a monophasic R and in V6 there is QR. These 2 findings are suggestive of VT based on their algorithm developed. So if this is stable QRS tachycardia vs SVT (e.g. AFl)wtih aberrancy then a good drug would be amiodarone. It will both solve both. Amio is for VT and it can control heart rates. But you know it hard to run this in your mind in the field. It is nice for an arrhtymia club discussion and not used in the bedside. But if you  have the EP eyes then you are a gifted person. This is a very good tracing!

  • Rose says:

    I agree with most of the comments that the strip is showing VT.  Going with the previous comments of this blog's commentator- "if it is wide and fast, we have to go with VT until proven otherwise."  Several markers are present to show that this is VT.  I, II, III are all negative, AVR is positive. V1 is positive.  The patient complains of 7/10 chest discomfort.

  • johan theunis says:

    Atriumflutter with aberrant conduction

  • Anono1 says:

    I would probably consider this VT. I do have a question, that if it is VT why is ther still narrow complex QRS (<.12) in V2 and V3?? Consider vagal maneuver in case SVT then amiodarone because it is effective in SVT and VT and stable.

  • Tidal Medic says:

    Look at it again. I'd lean more to an abberrant LBBB, simply looking at V1 and V2. Find out if the patient has history leaning toward a history of BBB. Treat with chest pain protocol, V4R EKG. Be careful with the Nitro, but don't withhold. We're lucky enough to at least have PCI facility in every direction, some more capable than others.

  • Sarah W says:

    With the history of MI/CABG, as well as Hx DVT—I'm personally not going to rule out a cardiac event, however this screams possible PE to me….even though oxygen saturations are maintained at 99% on high flow oxygen, and it doesn't say he has shortness of breath.  I had a patient with a similar EKG, but there were obvious P waves present (the final diagnosis was a PE).

    IV, O2, Moniotor, Deisel Therapy…that's about all I got. If he becomes unstable/unresponsive, cardioversion (if pulse)/defib (no pulse), and start the drugs. Nearest facility. Stabilize, transport to advanced hospital if higher level of care is necessary.


    I am stumped…

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