66 year old male CC: Chest pain

Here's another great case submitted by Nick Ciaravella of Grady EMS in Atlanta, GA.

66 year old male presents to EMS with chest pain.

S - Chest Pain
A - None
M - Atenolol, HCTZ
L - meal, 7 hours prior to event
E - Mowing his lawn

O - Started while mowing his lawn
P - Provoked while exerting himself, Palliated initially when he sat down to rest
Q - Sharp
R - Substernal, initially radiating to his jaw, when he rested the pain was only in his chest
S - Initially 10/10, upon ems arrival 4/10, en route 8/10, 9/10, and 10/10 upon arrival at ED
T - No previous episodes

The patient initially presented to EMS with 4/10 pain and vitals as follows, 148/84, pulse 72, 18 respirations, SPO2 96%, Lung sounds clear and equal, BGL 103.

The patient was placed on 3 LPM O2 via NC, given 324 mg Aspirin PO, given 0.4 mg Nitro Tablet Sublingual and then 1 inch of Nitro Paste Transdermal. The Patients pain increased en route to the ED and began to radiate down his left arm en route.

12-lead ECG #1

12-lead ECG #2 (about 15 minutes later)

What do you think?

See also:

Anterior ischemia or posterior STEMI?

26 year old male CC: Chest pain

74 year old male CC: Chest pain

50 year old male CC: Respiratory distress, chest pain

48 year old male CC: Chest discomfort, shortness of breath

Pure (Isolated) Posterior STEMI -- not so rare, but often ignored! - Dr. Smith's ECG Blog


Terry said...

The 1st strip looks like and anterior lateral wall MI but when you line the baseline up in the v-leads it is more of an optical illusion. The second strip is clearly inferior lateral wall MI with recipricol changes in V-2 and V-3. Cool strips.Call the cardiac alert.

Terry said...

Two more things I noticed--- the PRI in lead II is long and the slight axis change between the two strips.

N. Adams said...

ECG (1) SR w/1st* AVB. Peaked TW's in anterior leads suggestive of hyperacute phase of an MI. Axis is normal @ approx 60*.

ECG (2) SR w/1st* AVB. ST depression in V1 - V4 suggestive of Ateroseptal Ischemia with lower lateral STEMI (partial occlusion of the LAD with a total occlusion of a diagonal branch)vs. Reciprocal changes to a posterior STEMI in V1 - V4 with lateral extension (LCX occlusion with left dominance. The axis has changed, but is still normal @ 40-50*. Either way, it's still a Cathlab Team Alert. Very good 12 lead. Question: Why did the lateral STEMI NOT produce reciprocal changes in the Inferior leads?