56 year old female CC: Short of Breath

Many thanks to an anonymous reader who submitted this great case! As always, some details have been changed to protect provider and patient privacy.

You're dispatched to the parking garage of a busy shopping mall for a 56 year old female whom a 3rd party caller relates is, "short of breath".

Upon your arrival you find an engine crew out with the patient, who is seated on the running board under the pump panel on their engine. The firefighters have placed her on a nasal cannula and are attempting to talk with her through a bystander.

The captain on the engine relays that she doesn't speak much English, but what they gather is that she was walking back to her car and became short of breath and dizzy. The patient states she felt better sitting and on oxygen.

Your partner relays the first set of vitals:

  • Pulse: 130, regular
  • BP: 132/80
  • RR: 28
  • SpO2: 89% on r/a, increasing to 94% @ 4 L/min by NC
  • Lungs: clear and equal bilaterally

The bystander helps translate her history:

  • Allergies: None
  • Medications: None
  • PMHx: None
  • Last ins/outs: Some urinary incontinence handled through PO restriction
  • Events: Walking to her car, became short of breath and dizzy, denies loss of consciousness, she is visiting from another country and was on a "long flight" last week

You ask if the patient would like to go to the hospital and she nods her head. When the crew stands her up to help her to your stretcher, she becomes dizzy and clutches her chest. Once on the stretcher your partner places her in trendelenburg as you move her to the unit.

Inside, your partner places her on the monitor while you complete a physical assessment. Her skin color appears fine, but you notice some pedal edema. Old scars are present on her knees which the patient states was from surgery. She denies pain to palpation of her chest wall and her lung sounds remain clear bilaterally. Her physical exam appears largely unremarkable.

Her radial pulse is a bit weaker and has slowed to 120 bpm. She remains tachypneic, but denies chest pain once she was laid down. Her SpO2 has increased to 97% on 4 L/min and her respiratory rate has decreased slightly.

Breathless View - Initial Rhythm

As you start an IV, your partner acquires a 12-Lead.

Breathless View - 12-Lead

Your partner asks if you need anything else before you head enroute to the hospital.

  • What is the patient's rhythm? What does the patient's 12-Lead show?
  • Does this patient require any interventions before going to the hospital?
  • What type of hospital does this patient need?
  • What do you think is wrong with this patient?


  • h deezy says:

    Rhythm: Sinus at 118. Short pr by definition, but not clinically significant IMO. Otherwise normal intervals. Normal axis.
    DDx: PE
    Why PE? Well, glad you asked.
    -RBBB (while incomplete, S1Q3T3 and RBBB is pretty specific for PE according to the internets)
    -Sudden onset of unrelieveable dyspnea
    -Hx of long flight (think embolus/thrombus)
    -Flat T's/Inverted T's in precordials
    This ECG is CLASSIC for pulmonary embolism. As soon as I saw dyspnea, I looked in leads I and III and then looked for either right axis or RBBB and saw the RBBB and I feel extremely confident of a PE.

  • h deezy says:

    also of note is the initial hypoxemia and tachycardia which I had neglected to mention, also classic in PE.

  • Danny says:

    I agree with “H Deezy”. Sinus w/ apparent S1Q3T3 present. Sudden onset, tachycardic, clear lung sounds, long flight. This seems to be classic PE.

  • Ed Eno says:

     That's a PE. Sinus Tach with prolonged ST. High flow O2 non-rebreather, IV normal saline and transport.

  • Chee Yong Chuan says:

    This is interesting. 

    Sudden onset dyspnoea while walking towards her car+ tachycardia+significant hypoxemia 89% under room air+history of long haul flight+ previous knee surgery(not sure how long ago)+pedal edema with clear lung fields all point to a POSSIBLE pulmonary embolism
    When I approach a patient with shortness of breath, ofthen I run through the d/dx. Is it a problem involving the upper airway? lower airway? lung parenchyma? V/Q mismatch? disordered control of breathing eg unconsciousness, metabolic.
    The lungs are quite clear as stated. There are lots of d/dx that could fit her eg. acute exacerbation of bronchial asthma, COPD but the fact that the lungs are clear with good air entry bilaterally makes lung parenchyma disease unlikely. What to explain the profound hypoxemia? 

    ECG wise. There is sinus tachycardia. But as far as I am concerned, there is NO S1Q3T3! Which is pathognomonic of PE. T wave inversion is not profound in lead III and the small tiny Q waves can be normal in lead III, i.e not pathological! Axis is normal with no right axis deviation that you would expect in P.E
    However, other than the sinus tachycardia, I do notice that there is also RIGHT ventricular strain pattern. There is 1-2mm horizontal ST depression observed over lead II,III, and aVF, most profound over lead III as it is the most rightward facing lead. There is also an incomplete bundle branch block as evident by an rSR pattern in V1-V3 but a NORMAL QRS duration of <120ms. The ST depression with T wave inversion observed over the right precordial leads V1-V4 could either be 
    1) right ventricular strain pattern
    2) repolarization abnormality due to bundle branch block.
    Anyway, with acute onset dyspnoea, profound hypoxemia, tachycardia and a right ventricular strain pattern on the ECG, P.E must be exluded. Furthermore, she has the risk factors. 
    A bedside ECHO would be useful in the ED, definitive investigation would be a CTPA, D-Dimer

  • Kel says:

    Looks like acute PE with poor sats.

  • Michael says:

    Very subtle.  I like it. There are subtle P waves most clearly notable in V1 V2 V3 but if you follow it through you can see them in all the leads. Atrial Rate is 300 which makes this an A-Flutter! 

  • Michael says:

    There are subtle P waves most clearly notable in V1 V2 V3 but if you follow it through you can see them in all the leads. Atrial Rate is 300 which makes this an A-Flutter! 
    Plus, as previously mentioned there is an S1Q3T3 with sudden dyspnea and low SPO2 so I'd also have to suspect PE. 

  • h deezy says:

    s1q3t3 IS present,  RV strain is secondary to too much afterload/RV engorgement.
    The S wave is pronounced in I
    Q's aren't as pronounced in III but they are there, and there is a definite flipped T in III.
    I'm thinking the ECG changes aren't THAT obvious due to this being prehospital and EMS being immediately summoned…may be too early for such big changes.

  • Matt says:

    I’m with the PE dx. I’m not as learned on the 12 lead interpretation as you all appear to be. However, I had a pt present exactly like this once. He was a late 50s make that had been having episodes of severe SOB. On arrival, he was sitting down in a chair on home O2 and stated he was feeling much better. Thinking not alot of it, he walked about 5 feet to the stretcher and in that time, began having severe SOB. This again calmed down after a few minutes of rest and high flow O2. I worked for a rural service at the time and we had a moderately lengthy transport time. He did fine until I opened the back doors of tha unit and he coded right there in the bay. Point being, we found out later that everytime he moved, do did the emboli. Which then made him have the SOB suddenly but could be easily relieved with rest and O2. Like this woman in this scenario

  • Mike M. says:

    Sinus tach with prolonged QT. 12 lead shows s1q3t3.
    En route, I'd bump her up to a NRB at 15lpm. 
    She needs to go to a facility where she can get some thombolytics (stroke center).
    I think she's having a PE. Her history is almost textbook for one. Long flight. She clenched her chest like she's having pain when she was moved. Sudden onet. yada yada yada…

  • Robert says:

    Interpretation: upright p waves I, II, II, and avf and negative p wave in avr.  S1Q3T3, Incomplete RBBB, inverted T waves in anterior/inferior leads, RAD.
    >Sinus Tachycardia w/ Right Ventricular Strain Patterns suggestive of PE.
    S1Q3T3 is 15% suggestive of PE, but when accompanied w/ incomplete RBBB and T wave inversions in anterior/inferior leads it is highly specific.
    Lets get some Heparin on board!

  • Daniel Dodd says:

    History of recently long hall travel, and sudden onset dysapnia points towards PE. Hypoxemia present also.

    ECG Findings:
    Sinus Tachycardia
    Right Atrial enlargement

    Imp: PE

    IV Access
    15L O2
    Pre-Alert to Hospital

  • Dustin says:

    I am going to have to go with a PE. Pretty classic case of traveling long periods and sudden onset of dyspnea. S1Q3T3 also is evident. At the minimum she is going to require more tests to confirm PE along with Heparin and TPA. She should be transported to a facility that can offer these tests and interventions. It would be best to transport to a facility that offers surgical interventions for PE.

  • jjrod says:

    Although I am only a basic the signs of the patient and history are enough to put PE at the top of my list and just happy my process of elimination was correct I gathered my assessment from the long flight mixed with shortness od breath. What would appear with out the ECG to be a case of angina however with the long flight you have to start thinking out side of the box looking at the side affects of long flights and the post surgury not knowing how long ago it was peformed on the patient.

  • Lonnie says:

    I think she has a PE.

  • Scott says:

    Ok I’m also thinking PE but for those of us that we’re doing this with the old life pack 4 with out the luxury of an in field 12 lead you had to access the Pt not the toys. Same thing I tell my interns yes the toys are nice but always treat the Pt and her physical signs and symptoms state possible PE

  • Austrian Paramedic says:

    Hi! I´m a paramedic from Austria, i very much enjoy this site – so i give it a try…

    I would also go with PE. First i would do a structured Score, evaluate the risk scores (CVRF) and, of course, a Differential Diagnosis. Here´s how i would do this case:

    Symptoms – examination:

    Patient almost collapsed (pos.),
    Dispnea (pos.),
    Tachycardia (pos.),
    Tachypnea (pos.),
    Chest pain or discomfort (pos.),
    Hypotension (neg.),
    Hemoptysis (neg.),
    Jugular vein ingurgitation (?),
    CVRF (?),
    EKG Abnormity – right ventricular strain pattern (pos.);


    Oxygen (4 to 10 l/min until she reaches 92 % SpO2)
    Central venous access
    Infusion NaCl 0,9% 500ml
    Heparin Bolus i.v. (5000 IE)
    Aspirin i.v. (125mg)
    Morphine i.v. (2mg)
    Catecholamine i.v. (if she shows signs of shock), Syringe Pump Dopamine 250mg/50ml – 10 μg/kg/min
    Fibrinolysis i.v. (if she goes into shock or cardiac arrest), Syringe Pump Tenecteplase 0,5 mg/kg
    Acute Sonography

    Transport to a Hospital with intensive care unit. Pre Alert intensive care unit. If it´s a long way to the hospital maybe helicopter transport.

  • Mike B says:

    While I agree PE is highly suspect given the pt’s history, one cannot obviously diagnose this with a 12-lead ECG and certainly not without a previous ECG on the patient for comparison. However, I agree with Michael above. The ECG is Atrial Flutter.

  • Robert says:

    The Austrian paramedics got quite a nice scope of practice! Jealous!

  • Jon Levine says:

    NOt sure what others are seeing, as to S1Q3T3 while there is a S wave in I, and T wave inversion in III neither is overwhelming and III Q wave is far from pathologic levels. I don’t see a significant R axis deviation ( ~ 8*) the RBBB is partial ( not sure to source of reference as partial RBBB and S & t waves are HIGHLY SPECIFIC would like to see). Though the history of air travel is classically susceptive of PE ( like other anecdotal it’s not quite that common) Before patient gets big PE paradigm I would consider more consideration of the possible STE changes in aVR and V lead changes, and add ACS to differential. Maybe atypical presentation of ischemia. Note 56 y/o female SOB on exertion.

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