63 Year Old Male: "Dental Pain"

Here is an interesting case submitted by Adam Frederick, NREMT-Intermediate.  As usual, some details have been changed to protect patient confidentiality.

EMS is called to the local Urgent Care for a 63 year old male complaining of upper jaw pain related to "dental work". He had made two trips to the dentist this past week for pain related to "work done on a crown". Both times the dental work was in order, and the dentist could not find a reason for the  jaw pain. Today, while walking on the treadmill at the local fitness center, the jaw pain returned. He drove to urgent care because the dental office was closed. 

While at urgent care, he reported to the nurse that the pain began about 45 minutes ago, and seemed to worsen when he did strenuous activity. He thought it odd that today he had some chest discomfort as well, but felt it was probably due to his anxiety.

EMS arrives to find the patient in exam room 2. He looks pale, and his skin is cool and moist. He reports jaw pain of 8/10, and substernal chest pain of 4/10. History is significant for hypertension and anxiety. He takes Lipitor, ASA, and Metoprolol daily. He has no known allergies. His vitals are as follows:

  • HR: 90 and regular
  • BP: 180/114
  • RR: 16
  • Skin: cool/moist/pale
  • Lungs: clear bilaterally
  • Spo2: 98% on supplemental oxygen

You apply your cardiac monitor and acquire the following rhythm strip and 12 lead ECG:

 

Prior to EMS arrival, the patient was given 4 baby aspirin, but now refuses nitro and the IV. He states he "doesn't know what all the fuss is about", and that he "just wants to go home", and you get the feeling that he just might refuse transport.

  • What do you tell your patient?
  • Are you concerned about the ECG? If so, why?
  • How would you treat this patient, and where would you like to take him?

33 Comments

  • mohammed says:

    cardiac problem 
     

  • Rose says:

    I would advised the patient that abnormalities in the EKG would warrent an evaluation by the ER. 
    I am concerned about the EKG in that it does show cardiac injury (RBBB and inverted T waves) and the patient needs evaluation to tx the continuing problem.  I would recommend an IV at least to allow for access.  If the patient continues to refuse NTG, I would still transport to ER. 
     

  • Erin says:

    Left main vessel disease – referral to cath lab. Great ECG!

  • Dave Jones says:

    I would tell the patient that he needs further investigation. The symptoms accompanied by an abnormal ECG mean he could be in danger of a life threatening event.
    I'm not necessarily concerned with the ECG in that judging ishaemic changes is difficult at best in someone with a conduction abnormality (right bundle branch block), especially when there is no 'baseline' ECG to compare. But we don't treat ECG's, we treat patients and the ECG of questionable significance becomes a concern with knowledge of the patients symptoms/history.
    He would warrant a visit to a cath lab sooner rather than later

  • Newer EMT-I says:

    Looks Sinus to me with a good rate and rythem.  Some elevation in AVR and V1 and depression in most of the other leads.  I would lean towards some subendocardial ischemia or some 3 Vessel Disease.  This pt needs to be seen at an appropriate facility.

  • His ECG is suggestive of injury. Evolving MI maybe?The depression in leads II, III, and aVF show ischemia and suggest injury, while the increased height of the QRS complexes in all leads bother me. Plus, since he's over fifty, pain in the head and jaw are as suggestive of myocardial injury as chest pain is. Combine it with his hypertension, and he needs to go. If he'll go, I'd get a line and nitro and haul tail.

  • Medic Canada says:

    Tell the pt he is having an MI.
    Do a V4R and V7 V8 V9. 
    Depending on your local protocol primary PCI or clot busters.
    IV O2 nitro drip/spray/patch asa.
    serial 12 leads

  • Alexis says:

    1.- I tell him: You should stay here because your ekg is not normal, we need more tests and watch for a few hours.
    2.- Yes I am…. because he's 63 years old with HTA, he reported chest and jaw pain, in adition the ekg is not normal, there are ST depression in V4-6, so is probably an IMA in the next hours
    3.- Statins, clopidogrel, betablockers at high doses. The subsequent managment will depend of the evolution of ekg and the results of troponines.

  • Daniel Dodd says:

    Based on clinical presentation alone without the ECG there should be a degree of suspicion for a cardiac related issue. The dental work two days prior reduces the specifity of the jaw pain in a cardiac complaint. The presence of substernal chest pain that has an onset during exercise is an important finding. 
    The recent dental work adds suspicion to a PE although the is not clinical symptoms of this. The ecg does not show a S1, Q3, T3. 
     
    The ECG Shows NSR, with no heart block or atrial enlargment. There is no axis deviation noted. There is a RsR pattern in the chest leads indicative of right bundle branch block. There is normal QRS in V4-6 making this an incomlete RBBB.
    The loss of the initail R wave in V1 can be indicative of anterior wall infarction. There is slurred S waves in V6 in line with the diagnosis of RBBB.
    THere is widespread ST Depression, indicative of ischemic changes in the heart. There is not ST Segment Elivation.
    Advice to the patient that it could be something with the heart, based on abnormal ECG findings. 
    Would take patient to a A*E of a hospital that had ability for pPCI. Would not eligable for TNK due to recent operations and the absence of ST elivation in two or more consecutive leads.
     
    Dan (Student Paramedic)
     

  • Rob M. says:

    If this were just jaw pain, and he weren't pale, cool, & diaphoretic the refusal might be on the table.  But he does look bad, plus he has chest pain, and he has HTN which is another risk factor for MI.  The onset was during exertion, the dentist hasn't found any reason for the jaw pain.  It seems that these symptoms are the progression of stable angina a few days ago to unstable angina (as the patient has since stopped exerting himself & is still showing signs & symptoms).  It could very well be 3-vessel disease, however it could also be a LMCA occlusion.  If the LMCA is occluded, this guy could be circling the drain right in front of us.  Tactics I may use to get him to go:
    1. Advise him that he may be able to get a Rx for pain meds for his jaw at the ED.
    2. If that doesn't work, advise him that I believe that he is experiencing a potentially fatal cardiac event & that he should go to the ER as I cannot run labs in the field.
    3. Consult & get the physician to talk to the patient.
    4. Get family members or friends on the phone to talk him into going.
    Depending on my rapport with the patient, I may use the tactics in a different order.  If all else fails, I pull up the refusal form, ask him to read it, and then explain it in my terms.  The key to this is to explain to him that the form releases me from liability if he experiences negative consequences from his decision to refuse.  Usually telling people that they're taking responsibility for their potential death gets them to go to the ER.
    As for treatments, I'm gonna do my best to get him to let me start an IV & give him NTG.  Regardless, he's going to a PCI center based on the EKG.

  • Almost Jesus, PS says:

    He looks pale, and his skin is cool and moist

    This is what concerns me the most. Combine that with the ST depressions and the pain, this is more than likely to be a cardiac event. Id like to take a gander at posterior and right sided leads. Tell the patient that his symptoms are indicative of a cardiac event and he needs to be evaluated, this might be a good time to get the urgent care doctor involved too for assistance with convincing the patient.
    His high blood pressure is a little bit concerning, but rapid control would not be the best idea. Since the symptoms point towards a possible posterior involvement, I have a feeling it would come down fairly quickly with NTG administration. Id make sure to transmit this if I had the capability and divert if that was in my protocols. It would be worth discussing anxiolysis with the medical control doctor. The high blood pressure is only made worse by anxiety.

  • KJ says:

    Im surprised, with the ST depression, that he has no cardiac history. I would question patient for more information, but, as far as what to tell the patient, I am a firm beleiver in honesty. Advise patient that he has, what appears to be "something with his heart" and that going to the ER would be in his best interest. I would continue O2, offer nitro SL, and monitor for discomfort enr to closest cardiac recieving, depending on severety and ETA, request MS for pain.
     

  • Stephen says:

    This man has a CABG in is future.  
    Transport to PCI center.  Standard CP treatment.  No STEMI alert unless he becomes profoundly unstable.

  • Mohamed Wafiq says:

    Incomplete RBBB, ST depression in almost leads , apart of V1& aVR showing mild ST elevation, all consistant with his upper Jew pain & substernal chest discomfort. all these findings clinicaly & EKG findings indicate ACS, that should be followed by immediate admission to the CCU & checking Cr Tr T , & before an IV access to initiate Anti-Ischemic measure, as a step before Cath lab transfere. We should inform him in short & in depth in a simple way that he has a cardiac insult & blod clot is building up, so ,, sooner is better & safty coms first. (This case by Diagnostic coronary angio most probably suggestive of MVD vs Lt main.).

  • BadgerMedic says:

    Interesting. Only two responses mentioned a 15-lead tracing… With all the ST-depression and no reciprocal changes noted on the standard 12; I'd sure as heck would like to see what the RV and posterior looks like. (If nothing else you have a baseline for the 15-lead as well for this event.)
    For my cardiac patients, significantly more of them than not get a 15-lead done; for the extra 30-45 seconds it takes, you get a much more complete look at the heart – and in situations like this one where there is no noted ST-elevation, but widespread depression, I think it is very pertinent.

  • Gm says:

    Perhaps a endocarditis from the recent dental work

  • nossen says:

    there is STE in V1, furthermore there is minute STE in V2, relatively speaking the STE in V2 may be significant b/c of the RBBB. I'd be worried about anterior MI, get to PCI capable hospital.
     
    nossen

  • Nick Adams says:

    First of all, I'd like to address the fact that the 3 lead tracing is of leads II, II, and aVF……Why?  When you monitor II, III, aVF, you are only looking at the same part of the heart (Inferior).  You also can not distinguish ERAD from a pathological LAD in a wide complex tachycardia situation.  I always have my monitor/defibrilator set for leads I, II and III to view two inferior leads and one lateral lead.  This also gives me the ability to distinguish ERAD and LAD……………..just saying.
    12-Lead EKG – SR with a RBBB, normal axis, and RVH.  ST elevation in aVR with global ST depression which is most probable secondary to a partial LMCA occlusion.  The pt's DBP is very high which is evident by having cool, pale and diaphoretic skin and an elevated SBP.  The pt is in shock with a high systemic vascular resistance.  The anterior leads may be showing reciprocal ST elevation from posterior Injury if the patient is left dominent, so a 15 lead EKG is indicated.  Even though I'm pretty sure that this patient's cardiac enzyme levels would come back elevated, a posterior STEMI would cause the pt to go directly to the cathlab.  The ED will sit on this patient and treat him medically if there is only ischemia present, especially if the cardiac enzymes come back normal or boarderline. 
    Psychology – Explain to the patient that i am positive that he is having a cardiac event and that it is not an option to go home at this time.  He needs to be seen at a cardiac hospital, and further tests like blood work need to be done.  If I have to, I will get the family involved, and the the receiving physician to speak with him.  This patient WILL be transported, stopping short of kidnapping….lol.  Explain that the NTG will help his pain and can actually help differentiate between a heart problem, and the many other things that could be causing his pain.  To do this, we need to have an IV established. 
    TX –  Cont. O2, 324mg of ASA even though it sounds more like stable angina which has become unstable as opposed to an ACS, NTG @ 0.4mg SL q 5min followed by a NTG gtt @ 10 mcg/min and increasing to pain level and SBP > 100 mmHg, Morphine Sulfate @ 5mg IVP (slow) q 5min to a max of 15mg / or 1mg/kg of Fentanyl IVP (slow) for pain relief which will reduce myocardial oxygen consumption and demandand.  Serial 12 lead EKG's.  We need to be careful of reducing this pt's preload, while his afterload is so high, and therefore a reduction in preload will drop his CO by reducing preload.  A smaller preload with a High afterload = a total reduction in cardiac output.  The patient already has a reduction in his CO.  Ask the sending doc if they could order a med that could reduce the pt's afterload, like Nitroprusside instead of NTG.  this will reduce preload a little bit, but will reduce afterload more so, increasing overall CO.  Oh yeah……transport to a cardiac hospital with cathlab capabilities and surgery back-up.

  • Bradlee says:

    From what I can see in the 12 lead, I would say that this pt is having an anterior lateral MI going on.  This pt definitley needs to be convinced that he needs to go to the ER and to be taken a hospital that has PCI capabilities.  Start an IV and nitro if his BP is adequate and monitor.

  • Kyra Sweeney says:

    Has anyone thought to treat your pt and not your monitor? He’s pale, cool, and clammy, and has hx ….. non STEMI possibility lurking period, even minus a raging display of elevation. Just a thought.

  • Matt says:

    11/April/2012
     
    I would highly advise this patient to be seen at a local hospital, but we have to remember if the patient is CAOx4, we can not force or kidnap a patient.  No with that being said, I would do my best and every attempt I could to get the patient to be seen.  I agree there is something going on, cardiac ????  I think this person has a extrem ANXIETY issue.  Yes I see a RBB, but there is not much we can do for a BBB,  Contact medical command, patient refusal, and make sure this patient understands the risks and complactions of refusing treatment/transport/.
     

  • doobis says:

    I think it is obvious that we would need to strongly encourage the PT go to the hospital and explain to him the reason for our concerns.  Family, med control, etc, etc . . . though we live in America and ultimately it is his choice.
    As to the hospital, if this took place in an area with many hosptial resources, I'd go to a cardiac center.  I would not necessairly arrange for air xport if there was only a small rural hospital available (not that he'd agree to go on a bird anyways).
    I strongly suspect something cardiac dealing with blood flow in the R Atria is the culprit.  aVr is elevated along with V1 (if I'm not mistaken I read through this website that some cardiologist take this as a + STEMI, but I could be wrong).  Also, in lead II, and I'm probably reading too much into this,  I think he may have P-Pul which could be due to R Atrial enlargement.
    I'd monitor, serial 12 leads, treat PT per ACLS, and adapt as necessary.  I wouldn't call a STEMI or cardiac alert, etc. but I'd discuss my concerns with the ER staff.

  • Chickey LFD92 says:

    Treat your patient, not your monitor.  ECGs in the field are a great "tool in the toolbox", but are relied upon too heavily by people who are not Cardiologists (us paramedics).  What we think we know can actually work against the overall patient care.  YES it does open up doors for further treatments, but it also opens up doors for mistreatment.  If the patient does not want to go, you or anyone else cannot make him.  We can sugges it, and even go as far as being blunt:
    "Sir, what we are concerned about is the possibility that you are having or have had some cardiac injury.  If you do not want to go, I/we cannot make you.  If you do not want me to begin treating your symptoms, further injury will occur."
    That being said, depending upon your distance to the appropriate facility holding off on NTG and having the patient sign your ePCR attesting to his refusal is definately a MUST but may be tolerable.

  • Erin says:

    A great post by Dr Smtih ECH blog re: LMCA disease. Don't forget aVR!
    http://hqmeded-ecg.blogspot.com.au/2010/01/deep-and-widespread-st-depression.html

  • Nick Adams says:

    I've heard a few people say "Treat the patient, not the monitor".  If you have a pt in VT on the monitor, but the patient "seems" to be doing well with it, are you going to just transport them to the hospital to get the treatment that they need?  Are you going to say "They're stable now so I just won't do anything".
    How about that pt who is in SVT, but stable?
    We as prehospital health care clinicians need to start thinking more like clinicians, and not a 16 month "text book" certificate medic.  The cardiac monitor is a tool of the trade to help us come to a logical conclusion as to what is wrong with the pateint.  We need to start paying attention to the monitor too because this small machine gives us a ton of information as to what is going on with the patient, pt history, chances of deterioration, and can help guide us in our treatment(s).  We need to learn more about what we are looking at, because we can't see the whole picture if you do not know.  I came across a great saying by someone (can't remember who), who said that "the eyes can not see what the mind does not know".  We all should be paying more attention to AXIS, heart blocks, fascicular blocks, atrial enlargements, ventricular enlargements with or without strain, electrolyte imbalances, and QT intervals with ectopy, and not just rate, rhythm, and ST elevation or depression.  So yes, treat your patient……..But treat your patient AND the monitor……..that is all.

  • David Baumrind says:

    Nick,

    I have heard Dr. Ray Fowler use that excellent saying many times… It's a great one!

    -David

  • Ben says:

    widespread st depression + st elevation in aVR and v1 = triple vessel disease, as said by someone else above this man has a CABG in his future

  • Chee Yong Chuan says:

     
    Let me know what do you think
    ECG shows:
    1) Sinus rhythm with QRS complexes preceded by P waves
    2) Axis normal(should be normal in isolated RBBB)
    3) HR regular @75 bpm
    4) Wide QRS complexes(>120ms) with rSR" pattern seen in V1 suggestive of a right bundle branch block
    5) Marked diffuse 2-3mm horizontal ST depression over the infero-lateral leads(I,II,III,aVF,V3 to V6) coupled with convex 2mm ST elevation over aVR suggestive of left main artery occlusion/stenosis. It can also be as a result of triple vessel disease
    6) Tiny 1mm ST elevation over lead V1. However, there is no concordant ST elevation seen in other leads
     
    Now, one might argue that the discordant ST-T changes seen over the infero-lateral leads might be due to secondary repolarization abnormalities. I gave it a thought:
     
    1) Diagnosing a STEMI in the background of RBBB is not difficult. RBBB does not come with ST elevation like LBBB. So any ST elevation is pathological. In this ECG, there is no concordant ST elevation. Agree?
     
    2) Discordant ST-T changes in the precordial leads looking at the right side of the heart(V1-V3) can be normal suggestive of abnormal/delayed repolarisation of the right ventricle. It is usually not seen over the leads looking at the left side of the heart(V3-V6,II,III,aVF) because repolarization of the left ventricle is not at all delayed! 
     
    Hence, diffuse ST-T depression over the lateral leads couple with ST elevation in aVR is an omnious sign. ST-T changes over the lateral leads unlikely in RBBB. I would insist that he goes to the hospital for further survey, this is likely to be a cardiac event. What do you think?

  • Para-Student says:

    I just went over cardiology in my Paramedic class, and as soon as I saw this I was reminded what our instructor showed us. I can see the "rabbit ears" and other evidence of a RBBB, but what immediately struck me was the depressions on the septal leads point toward a possible posterior wall infarction, and the depressions on the inferior wall leads lead me to think of a right side infarction. I would want to do a right side and posterior EKG. I would do these on the spot and explain the findings to the patient. Definitely hold off on the nitro until the right side is cleared.

  • Dan says:

    Nick's comment about a stable VT patient is a good one. I am sick of hearing "treat your patient, not your monitor". Needless to say, this is a sick patient who needs medical attention. Nitro, some O2, morphine, ASA, serial 12 leads, call it a day.  I see a cath lab in this guy's future.

  • James says:

    needs a 15 lead, and why not consider a right side ecg as well – you never know. IV, O2, Monitor, series of 12 and 15 leads. My gut tells me he is probably having a non-stemi MI.

  • Paramedic Student says:

    NO NITRO for this patient unless you want to potentially kill the him. Global ST depression with very slight elevation in aVR and V1 suggests right sided MI. Do a 15 lead to confirm, give ASA and start a large bore IV because this patient is getting a cath.

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