38 Year Old Male – Chest Pain and Leg Paralysis.

You are called for severe chest pain.

The patient is a 38 year old male who describes the abrupt onset of a severe pain in his chest about 30 minutes before his wife called EMS. While sweat streams off his face, he tells you that he has never felt pain this intense. He isn’t sure if it’s pleuritic, and he endorses some shortness of breath. The pain radiates to his shoulders, back, and epigastrium. Despite the severity of the pain, he is actually far more worried that his left lower extremity is numb, and that he can’t move it – he repeatedly tells you in a loud voice that “Something’s wrong with my leg! What’s wrong with my leg?”

With the assistance of his wife, you find that he takes HCTZ and lisinopril for HTN, but he doesn’t smoke or use recreational drugs. In fact, he’s a coach for a high school cross-country running team, and looks like he’s in pretty good shape.

Vitals signs are

  • HR: 50
  • RR: 30
  • BP: 230/140
  • SaO2: 99%

Besides profound diaphoresis, the exam is unrevealing. An ECG is obtained:

screenshot696You give him aspirin 325 mg, and 3 sprays of nitroglycerin, with neither a change in his symptoms nor in his vitals. In fact, 10 mg of morphine IV (max per your protocol) doesn’t improve the discomfort, and he is still yelling about both the chest pain and his leg. Your partner mutters to you “I’m starting to think this is mostly anxiety…”

It is almost 2300 hours. You have three choices of destination hospital:

  1. A “stand-alone” ED that is capable of delivering tPA for STEMI within 30 minutes. It’s just around the corner.
  2. A small community hospital ED that just started performing primary PCI, but they’ll have to call a team in from home. Despite that delay, they will activate based on a prehospital report, and their door-to-balloon times have been excellent. They are 20 minutes away.
  3. A level 1 academic hospital that is 35 minutes away. They don’t activate the cath lab based on EMS interpretation, since they usually “want to see it for ourselves.”

 

41 Comments

  • Brian Hiestand says:

    So, is this healthy track coach about 6’5″? This smells of dissection to me. Having been the ED doc in each one of the shops listed in the case, this guy needs to go to the academic center, IMO.

    • A recent study found that computer interpretation of STEMI was poorly sensitive, but 100% specific. Also, a number of studies point to the great outcomes in STEMIs treated very soon after onset with lytics, as opposed to delayed PCI. With these aspects in mind, would anyone be worried about the 35 minute transport to the academic ED, plus a D2B time of perhaps 90 minutes?

      • Ben says:

        I think he needs CT surgery not angio. He’s got a focal deficit, he’s grossly hypertensive and reeks of back-dissecting TAA. It’s a balance of risks, delayed PCI if it is a thrombus – but we used to talk about DANAMI and CAPTIM and say secondary transfer was ok, versus taking him to a site that’s going to end up secondarily transfering him with some antihypertensives / rate control and a CXR. This ambulance driver would take the extra 15 minutes.

        Also, if he ends up being cleared for dissectiin and the d2b is terrible ‘lytics in the first hour compare favourably, e.g. STREAM, right?

  • FB says:

    Chest pain and…
    Aortic dissection?

  • Brian says:

    1st degree av block. Bigeminal PJCs as every other beat appears to be missing a P wave. I don’t think there is a STEMI as the normal beats don’t have ST elevation.

    LVH and possibly early repolarization.

    I am leaning towards aortic dissection / abdominal aortic dissection based on BP and occlusion of illiac artery vs an infarction.

  • Ian says:

    Hmm. The clinical picture is very much one of an aortic dissection; sudden onset, radiating to back, sky high BP and it would also explain the leg if it has spread down to his femoral. I’d definitely want a bilateral BP and probably want to take this chap to whichever hospital had vascular.
    The ECG, in the absence of the leg issue looks like a anteriolateral MI with inferior reciprocal changes. Now whether this is from a dissection tracking back to the coronaries… if the hospital also does PPCI all the better!

  • Jason says:

    I’m with Brian on aortic dissection. Mattu did a video on chest pain, anterior ST segment elevation and neuro deficits.

  • Jeremy Smith says:

    What is the presentation of the leg? Is there pedal pulses intact? Based on presentation of the leg, transport to the level one center could be justified. looks like a PJC in the tracing, bifurcated p wave, anterior elevation with depression in aVF, and the tracing meets criteria for LVH. LVH will not explain depression in aVF. My service carries thrombolytics and I would withhold administration based on LVH and possible aortic dissection.

    • moshe says:

      Aortic dissection until proven otherwise.
      The leg and the bp give it away.

      Move fast, as this guy is most likely a walking cadaver if his left leg is already numb.

  • Damon says:

    Sounds to me like a Thoracic Aortic Disection is imminent if not already in the process. Immediate diesel bolus to the academic hospital with high alert prior to arrival. In this case I would speak directly with the Dr. in the ER to not wait any further.

  • Peter says:

    Hypokalaemia can cause this

  • Michael Willis says:

    One of the first comments said he is 6’5″. If that is in fact true (I cant find where it was stated in the original information given)…. does the patient by chance have abnormally long slender fingers and a pointed/peaked sternum?

  • Chappy says:

    I’d agree with the dissection group. Ischemia is definitely a concern here, but not so much as the paralysis.
    If a vascular surgeon is not available somewhere closer, I’d head for the academic center or a Level I.
    Is the paralysis localized to the right leg, or does it spread during transport? How do vitals trend?
    Treatment: high-flow diesel, consult before ASA, NTG and MS.

  • Alan Rose says:

    I had a patient like this a few years ago only it was leg pain instead of numbness after transient chest pain, and before we had 12 lead capability. I took him to my only choice, a rural hospital, that confirmed the dissecting aneurism and quickly flew him to the regional mega-hospital for definitive care.

  • Tex says:

    Anxiety, diaphoresis and abdominal pain are all indicative of Aortic Dissection, with stroke-like symptoms presenting as the Dissection progresses. Pt. needs a surgeon ASAP. 35 minutes is a long ride. Be prepared to go by ground, but get an ETA on Air Medical on the outside chance that they could get your patient there a few minutes faster.

  • Fritz Fuchs says:

    Definitely sounds like a thoracic aneurism to me. Load and go and get to the level one. Early radio report.

  • Bill says:

    Ok if you look like a duct, walk like a duct, sound like a duct treat it as a duct. given the EKG finding and hypertension and diaphoresis, and the ST elevations in V1 V2 V3 and it appears to have reciprocal St depression in inferior leads… the leg complaints could be an anuyerum and ischemic to the spinal tract treat him very carefully before thrombolysis

  • Sarah says:

    I’m new to this page so I don’t know if the right answer is ever given….but if so, what is the right answer? I’d rule #1 out from the getgo….I see pros/cons for both #2 and 3.

    • Welcome to EMS 12 Lead!

      Typically, we wait for a short period before providing the follow-up and analysis. That way, we often get a few different perspectives from people, and perhaps even a fruitful discussion before “the answer” is given.

      In that spirit, what are your pros and cons?

  • Jacob says:

    The standalone ER is going to transfer him to the closest ER or fly him to the academic center. There are two thoughts with differential diagnosis. Multiple clots occurring simultaneously (rare), or root aortic dissection which may involve the valve (mortality rate extremely high) RAD prevents adequate supply of blood to the coronary arteries and also peripherally (the leg). The last time I heard of a case like this there was only one surgeon in our region willing to take the case. If a surgeon will take the case he needs to be flown via fixed wing (pressurized cabin). He needs to have his blood pressure controlled by a short acting medication. The international registry for aortic dissection list 8 American and 1 Canadian hospital that will perform emergent surgery. Hope your patient lives near one!

    From the human side of this case, the patient & physician may consider keeping him comfortable and allowing him to spend his last moments of life with his family around him instead of futile efforts and a surgical team.

  • Chris says:

    Definitely not a stand alone. We don’t take anyone to one anyway.

  • Rick says:

    Looks like a disecting aneurysm. Needs surgery. You would expect the MI due to compromised coronary profusion from his high diastolic pressure. Maybe the deficit is from location of the aneurysm.

  • Steve says:

    Is it common for a thoracic aortic dissection to extend all the way to the iliac arteries?

  • Joe Moore says:

    I don’t know the answer, but I’m going to put something into this discussion related to a pulmonary embolism. I’ve had one. The pain was “tearing, and 10/10 and radiating to the back. Pulse oximeter was 85, and 12-lead suggested ischemia. Fortunately, the local hospital was able to treat, but I spent one long night in miserable pain. Now the percentages are not good for a second PE survival, but the symptoms were beginning the second time, and I recognized them early on. I got heparin shots in the belly and on coumadin for the rest of my life. The leg pain matches. The chest pain matches. Both of these situations convinced me that a PE present like an AMI.

    • For sure, in severe chest pain you must consider PE!

      The vital signs and ecg did not, in this case, support that diagnosis, but patients don’t always “read the textbook.” Read the conclusion, see what you think!

  • michelle says:

    i am with Brian on the aortic dissection. there are a lack of p waves that are possibly due to a 1st. degree heart block.

  • Ventricular pre excitation.

  • iliyas says:

    LVH with strain
    St depression in inf leads
    St elevation in avl ,v1 to v4
    Here major problem is high B.P that causes focal neurological deficiet at the same time effect of hypertension on heart may results in st t changes but imp things here pain that’s not responding so Aortic Disection also kept in mind
    I think control of B.P will clear many things

  • G STARR says:

    #3, drop BP, call chest cutter, fly pt. chest pain + neuro deficit= aortic dissection

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