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Archives for acute-inferior-stemi

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47 year old male: Holiday Indigestion – Conclusion

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This is the conclusion to 47 year old male: Holiday Indigestion. Thanks go to a long time reader Nicholas Eisele for this holiday case! Editor's Note: sorry for the delay, it helps to press "publish"!

When we left off, our patient was in the back of the truck with a burning sensation radiating to his back. We had run a 12-Lead ECG and our partner was wondering which facility you wanted him to drive to.

To answer that question, we should look at the 12-lead!

Frightful Weather We're Having - 3rd 12-Lead

This 12-Lead shows a normal sinus rhythm at 70 bpm without ectopy or bundle branch block. A case could be made for incomplete right bundle branch block given a QRSd of ~110ms. Strikingly we have ST-depression in I, aVL, and V1-V5 with ST-elevation in lead III. Anytime you see flat or downsloping ST-depression in aVL you should look for elevation in the inferior leads (typically III). When present, it is almost certainly an inferior wall MI.

Frightful Weather We're Having - 3rd 12-Lead - III and aVL Closeup

Many readers commented that the ST-depression in V1-V5 could be either a sign of a posterior wall MI or a "anterior ischemia". It is important to remember that ST-depression from ischemia does not localize! This concept is so important, I'm going to list it again:

ST-depression from ischemia does not localize.

Traditional evaluation of ST-depression has taught that focal ischemia may cause localized ST-depression, however, this is not the case. Subendocardial ischemia causes diffuse ST-depression and will not be found in a localized pattern. Any time you have localized ST-depression you must consider it to be a reciprocal change first!

In our case, we have ST-elevation in lead III which clinches the diagnosis of an inferior wall myocardial infarction with possible posterior extension. A subsequent ECG revealed evolving ST-elevation in the inferior leads:

Frightful Weather We're Having - 4th 12-Lead

Remember, all patients who receive one 12-Lead should at least receive a second 12-Lead! If you were not comfortable activating a STEMI from the first clean tracing, serial 12-Leads provide improved diagnostic sensitivity. A single 12-Lead may only identify ~80% of STEMI patients.

The paramedics in this case recognized this fact, activated a STEMI alert, and transported the patient to their nearest PCI center. The in-hospital ECG showed continued evolution of the IWMI with the most impressive elevation and depression of the patient's clinical course:

Frightful Weather We're Having - In-Hospital 12-Lead

They achieved an impressive 83 minute first medical contact to balloon time with one stent placed in the RCA.

Frightful Weather We're Having - Cath Pictures

We hope you've enjoyed this case as much as we did, but more importantly this case presents some great teaching points:

  • Sometimes STEMI patients will have atypical symptoms.
  • A single ECG is not enough to detect all STEMI patients, serial 12-Lead ECG's should be acquired on all patients who receive one.
  • ST-depression from ischemia does not localize, localized ST-depression should be considered a reciprocal change until proven otherwise.
Posted by on February 19, 2013 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , ,

79 year old female CC: Chest pain – Conclusion

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This is the conclusion to 79 year old female CC: Chest pain.

Let’s take another look at the 12-lead ECG.

The treating paramedic immediately (and correctly) identified this as an acute inferior STEMI.

But is it also a right ventricular infarction?

Several of you indicated that you would capture a right-sided 12-lead ECG (or at least modified lead V4R).

The treating paramedic did in fact capture a right-sided 12-lead ECG.

So now that we’ve performed this test we need to interpret it! Is this positive for right ventricular infarction?

Let’s take a look at modified lead V4R.

This doesn’t look particularly impressive but we must remember the rule of proportionality! The smaller the QRS complex the lower the threshold for ST-elevation.

The QRS complexes in modified leads V3R-V6R tend to be small (as they are here) so it’s debatable as to whether or not we need a full 1 mm of ST-elevation to be positive for right ventricular infarction.

Let’s take lead V4R and “stretch” it vertically while preserving the ST/QRS ratio.

To me this is borderline. The higher up in the RCA the occlusion (i.e., the more of the right ventricle that is involved) the more ST-elevation we can expect in lead V4R.

You may recall this graphic from previous posts on right ventricular infarction.

Based on this diagram it seems to me that the occlusion is likely to be in the mid-RCA meaning that the majority of the right ventricle has been spared.

Indeed, the heart rate of 80 and blood pressure of 152/84 bear that out.

It’s still an acute inferior STEMI so I would use NTG and morphine cautiously but I would use them as needed. If you’re concerned you can always obtain IV access first!

As a final thought for the original 12-lead ECG you will note that the ST-elevation in lead III is about the same amplitude as the ST-elevation in lead II.

With a true right ventricular infarction you can expect to see ST-elevation in lead III greater than ST-elevation in lead II.

This patient was delivered straight to a PCI center with prehospital activation of the cardiac cath lab with a presumed diagnosis is acute inferior ST-elevation myocardial infarction.

Posted by on March 22, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , , , , ,

53 year old female CC: Chest discomfort and shortness of breath

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Here’s an awesome case submitted by Nathan Stanaway of Grady EMS in Atlanta, GA.

The patient is a 53 year old female c/o chest discomfort and mild dyspnea.

The pain is described as “severe” and she gives the pain a 10/10.

Past medical history is significant for migraine headaches and anxiety.

Patient is a poor historian and does not know what meds she takes.

Drug allergy: ASA

The patient is found sitting in a car in the middle of the road.

Skin: pale and very diaphoretic.

Vital signs:

RR: 24 shallow
HR: 84 R
NIBP: 113/76
SpO2: 98 on RA

Breath sounds: clear bilaterally.

The cardiac monitor is attached.

A 12-lead ECG is captured.

What should the paramedic do next?

Posted by on August 28, 2010 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , ,

58 year old male CC: Chest discomfort

8 comments

Here’s another case from a faithful reader who wishes to remain anonymous.

No, these are not all from the same anonymous reader!

EMS responds to a 58 year old male complaining of chest discomfort.

Onset: 30 min ago while mopping hot tar on roof
Provoke: Nothing makes the pain better or worse
Quality: Dull pressure
Radiate: The discomfort does not radiate
Severity: 4/10
Time: Persistent with no previous episodes

The patient is found supine on the ground appearing acutely ill and diaphoretic.

The patient was moved to air conditioned room, skin dried.

Pt denies SOB, allergies, meds, history.

GCS: 15

Vital signs:

Pulse: 66
BP: 116/78
RR: 16
SpO2: 99 on RA

BGL: 92

Breath sounds: clear bilaterally

12-lead ECG was captured.

Crew initiates CP protocol to include O2, ASA, NTG.

The patient declines intravenous access.

Vital signs remained unchanged.

The patient stated that he felt better and did not want to be transported to the emergency department.

The EMS crew was concerned about the patient’s decision and spent the next 40 minutes persuading the patient to be seen at the hospital.

Finally the patient agreed.

The patient was loaded for transport, the monitor was re-attached, and en route other 12 lead ECG was captured.

Are you noticing a trend here?

Posted by on August 9, 2010 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , , , , , , , ,

81 year old male CC: “Cold and shaky” – Conclusion

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Here is the update to 81 year old male CC: “Cold and shaky”

The patient was sent to the cardiac cath lab where angiography revealed 100% occlusion of the right coronary artery (RCA). A stent was successfully placed and the patient is doing well.

Before

Balloon inflation

After successful stent placement

Diagnosis: Acute Inferior ST-Elevation Myocardial Infarction

Posted by on June 7, 2010 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , , , , ,

58 year old male CC: chest pain

21 comments

EMS is called to the scene of a 58 year old male complaining of chest pain.

On arrival, the patient is found tripoding in a chair. He is pale, diaphoretic, and appears acutely ill. He is anxious but alert and oriented to person, place, time and event.

Onset: Pain started after carrying luggage up stairs.
Provoke: Nothing makes the pain better or worse.
Quality: Pain is described as "burning".
Radiate: Pain is across the center of his chest and poorly localized. Patient denies radiation of the pain but complains that the BP cuff is hurting his right arm, even when it's not inflated.
Severity: 9/10.
Time: About 15 minutes prior to EMS arrival.

He admits to mild dyspnea. He admits to nausea but has not vomited. No JVD sitting upright. No pedal edema.

Vital signs:

Pulse: 64
Resp: 20
BP: 199/98
SpO2: 95 on RA

Breath sounds: clear

Past medical history: dyslipidemia
Meds: Lipitor

The cardiac monitor is attached.

A 12 lead ECG is captured.

Due to equipment and/or network problems, the ECG is not able to be transmitted to the Lifenet Receiving Station for physician evaluation (a common occurrence these days). Update: No longer much of a problem with the new web-based LIFENET.

What is your impression?

How would you treat this patient?

Posted by on May 31, 2009 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , , ,