**UPDATE** The conclusion to this case is now posted here.
It’s the middle of the afternoon when you are dispatched to the residence of a 59 year old male with a chief complaint of general illness.
When you arrive on scene you encounter a middle-aged man in obvious distress, lying on a couch. He is pale, gray, diaphoretic, and drowsy. He states that he has felt drained for the past 8 hrsâ€”unable to catch his breath or get up off the couchâ€”with a heavy sensation in his chest. 30 minutes prior to your arrival he vomited and felt like he was going to pass-out so he decided to call 911.
His radial pulse is faint, rapid, and irregular, while his skin cold and moist.
- HR – 150 bpm, irregular
- SpO2 – Unable to get a clear waveform
- BP – 72/42 mmHg
- RR – 26, labored
- Temp – 36.6 C (97.9 F)
Breath sounds reveal crackles bilaterally.
Multiple 12-lead ECG’s are performed but suboptimal due to the patient’s increased work of breathing and inability to stay still. This is the best of the bunch:
BGL is 156 mg/dL.
He is a bit lethargic but properly oriented and answers questions appropriately, albeit slowly.
- S – As above
- A – No known drug allergies
- M – None
- P – Appendectomy @ 24yo
- L – Soup 45 min prior, which he vomited soon after
- E – Can’t recallâ€”states he has felt terrible “all day.”
Regarding the chest heaviness…
- O – Gradually through the morning
- P – Nothing makes it better or worse
- Q – Heaviness
- R – None
- S – Unable to quantify
- T – Worsening x 8 hrs
What are your management priorities for this patient?
What is your interpretation of the ECG?
Â ***UPDATE (2015/6/29/ 14:00 EDT)***
After carefully transferring the patient to the ambulance and finding him a position of comfort (head-of-bed at 60 degreesâ€”he doesn’t like to lie flat), you succeed in obtaining a cleaner EKG. Does this change your approach to the case?