This case is courtesy of paramedic Jason Cameron, who works for Stratford EMS in Connecticut.
The ALS unit had been dispatched for an older female with “chest pain.” Upon arrival, however, the 80 y.o. patient denied any pain or pressure, and only endorsed some mild “heartburn,” localized to the epigastrium, non-radiating, and rated it at a 2/10. It had started about 30 minutes prior, and had not been relieved by Maalox. Her husband had called 911. The patient denied all other symptoms, and specifically denied any jaw, arm, or back discomfort, and denied any dyspnea or sweating.
Her medical history was significant only for mild hypertension and elevated cholesterol. She took a statin and an ACE inhibitor
- HR – 40
- BP – 118/72
- RR – 18
- SaO2 – 98% RA
The physical exam was unremarkable.
The paramedic obtained an ECG:
Aspirin was given, but nitroglycerin was withheld. An IV was established, but the patient did not became hypotensive.
Suggested Discussion Points:
- Do you believe that this patient requires PCI for acute coronary occlusion?
- If so, what was the likely site of the occlusion?
- Are there any other management concerns, given this ECG pattern?
- Should you routinely obtain ECGs in patients who complain of GI symptoms, but who deny any chest pain, pressure, or discomfort?
- Lastly, although the local protocols do not require that the computer interpretation display ***MEETS ST ELEVATION MI CRITERIA *** in order to activate the cath lab, they limit activation to patients with “active chest pain and/or dyspnea.” In that context, how should the paramedic have proceeded?
I will have follow up posted within 48 hours!