59 year old male: chest pressure – Conclusion

This is the conclusion to 59 year old male: chest pressure, be sure to read the case study first!

When we left off, we’d loaded our 59 year old male patient with 10 of 10 chest pressure into the back of our unit with the help of a local volunteer EMT. The patient appeared acutely unwell and was hypotensive and bradycardic. We had the following initial ECG:

Uh Please Standby - Initial 12-Lead

Before we discuss this ECG in depth, let’s show a serial 12-Lead the crew obtained shortly after leaving the scene:

Uh Please Standby - 12-Lead 2

The importance of serial ECG’s cannot be understated. Using only one prehospital ECG could miss nearly 20% of all STEMI patients!

At this point we can see an obvious inferoposterior STEMI, likely due to an RCA occlusion. Also of note is a new right bundle branch block, which is an ominous sign. These changes were not lost on the crew, and the receiving facility, a PCI center, was made aware.

However, during their radio report a rhythm change was noted on the monitor:

Uh Please Standby - Rhythm Change

A single R-on-T PVC is seen initiating ventricular fibrillation. Thankfully, the crew elected to use a driver and had two sets of hands in the back. The defibrillator was charged while CPR was initiated, and a 200J shock was delivered after a period of chest compressions:

Uh Please Standby - Rhythm Defibrillation

A rhythm change was noted, however, as no pulses were present chest compressions were continued:

Uh Please Standby - Rhythm Post Defibrillation

Within a minute the patient awoke during CPR, and regained full consciousness. A repeat 12-Lead was obtained:

Uh Please Standby - 12-Lead 3

This ECG shows sinus tachycardia, right bundle branch block, and the evolving inferoposterior STEMI. Upon arrival at the PCI center, the patient was pit stopped in the ED’s resuscitation bay due to his recent ventricular arrhythmia. While there, he experienced another VF arrest. He was again resuscitated and moved to the cath lab for PCI.

Could we have predicted this series of events from the initial ECG? Yes and no.

Yes, the initial ECG provided all of the findings necessary to determine that the patient was experiencing a coronary artery occlusion. Reciprocal changes or T-wave inversion in aVL is an earlier and more sensitive finding than inferior ST-elevation during acute inferior STEMI.

No, the VF arrest is not as predictable. The R-on-T PVC which initiated ventricular fibrillation was the only PVC found on the full cardiac monitor report prior to the arrest! However, it is a best practice to place multifunction electrode pads on any STEMI patient in anticipation for these events.

Sometimes it pays off to read the computerized interpretation.

Sometimes it pays off to read the computerized interpretation.

Looking back the initial ECG we can see why the arbitrary criteria of 1 mm  ST-elevation is not nearly sensitive enough to catch every coronary artery occlusion:

  • Hyperacute T-waves dominate the inferior leads
  • T-wave inversion in aVL
  • ST-depression in I, V2, V3, and V4
  • Subtle ST-elevation relative to the PR-segment in III, aVF, and V6 (the actual isoelectric baseline)

Remember, ST-depression due to ischemia does not localize. Localized ST-depression is a reciprocal change until proven otherwise!

During PCI the patient was found to have a 99% occlusion of the LCX and received one stent.

99% occlusion of LCX

99% occlusion of LCX

Post pPCI.

Post pPCI.

Even with two VF arrests, the time from first medical contact to balloon was 61 minutes! If you do not believe in a system of care which begins with dispatchers, first responders, and EMS, travels through the hospital, and ends up back with EMS through continuous quality improvement feedback, perhaps this case can change your mind.

References

  • Verbeek PR, et al. Serial prehospital 12-lead electrocardiograms increase identification of ST-segment elevation myocardial infarction. Prehosp Emerg Care. 2012; 16(1):109-14. [PubMed]
  • Smith SW. Inferior Hyperacute T-waves. Dr. Smith’s ECG Blog, published 26 August 2009. [Free Full Text]
  • Smith SW. Inferior hyperacute T-waves. The clue is T-wave inversion in aVL. Serial ECGs evolve to ST Elevation. Dr. Smith’s ECG Blog, published 8 February 2011. [Free Full Text]
  • Smith SW. A Male in his 60s with Chest pain. What is the ECG Diagnosis? Dr. Smith’s ECG Blog, published 13 December 2013. [Free Full Text]
  • Smith SW. Five Primary Patterns of Ischemic ST depression, without ST elevation. Some are STEMI-equivalents. Dr. Smith’s ECG Blog, published 12 February 2012. [Free Full Text]
  • Hanna EB, Glancy DL. ST-segment depression and T-wave inversion: Classification, differential diagnosis, and caveats. Cleve Clin J Med. 2011; 78(6):404-14. [Free Full Text]

Discussion for 70 Year Old Male: Short of Breath

 

This is the discussion for “70 Year Old Male: Short of Breath“.

Tough case.  Lots of excellent comments and observations from our readers.

Right off the bat, the patient’s presentation offered a major distraction: the recent eye surgery resulting in the old “eye patch presentation”.  Confounding the situation further was the lack of any cardiac history, and lack of chest pain.

 

Let’s review the 12 lead:

ECG4.14orig

Sinus Tach, 115 bpm. Physiologic left axis deviation. Left Bundle Branch Block.

 

Clearly, the moderate dyspnea and basilar crackles were red flags, as was the sinus tach at about 115 bpm.  What are we most concerned about?

  • ACS
  • PE
  • Hypvolemia
  • Infection

This is not an exhaustive list to be sure, but these seemed to be the most likely concerns.

While ACS was a primary concern, how about PE? I wouldn’t think it likely from cosmetic eye surgery, but stranger things have happened. What about subendocardial ischemia due to hypovolemia? Could the patient be dehydrated? He hadn’t had much to eat or drink since his surgery. How about infection? He denied recent illness, but post-surgery an infection is on the table too.

Even so, when a patient with no history of respiratory disease experiences the onset of shortness of breath with crackles severe enough that he can not speak in full sentences, this is highly concerning. Throw in the family’s description of “wheezes” (no asthma/COPD history remember) and we should be concerned about CHF.

 

What can we tell from the 12 lead?

ECG4.14

 

We have LBBB present, so to look for a STEMI equivalent, we turn to our Modified Sgarbossa Criteria:

 

Sgarbossa

 

Any concordant ST elevation?

  • Probably not, although aVL is very close (blue arrows).  At the least, it looks abnormal. There should be discordant ST depression, and that is not there.

Concordant ST depression in V1, V2, or V3?

  • I would say yes, in V3. I have drawn a line from the J point in V1 that is most visible down to V3 to if and how much ST depression there is. By my eye, it is at least 1 mm.

How about excessively discordant ST elevation?

  • I do not see anything that meets this criteria.

Other abnormalities?

  • There are concordantly depressed ST segments in leads III and V4 (blue arrows).  While these do not meet Sgarbossa, they are abnormal and concerning. The depression in lead III may be reciprocal to the abnormal finding in lead aVL.

It seems to meet Sgarbossa. It is still possible that it is subendocardial ischemia, but transport the lab is a reasonable course of action. Some comments referenced that thought that the LBBB may be new, but this is not really relevant any longer. The AHA has removed presumed LBBB from the list of STEMI equivalents.  Nevertheless, the abnormal ECG findings in this case were found and noted by the Medic.

 

What happened next?

This was called in to Med Control for consultation about cath lab activation (in this system, activation must come from a Med Control physician). Although the ECG findings were shared, the decision was made to transport the patient to the local hospital due to the closer distance and the “equivocal” findings.  A line was started, but no fluids given due to the crackles (debatable, small NS bolus may have helped).

Some will ask about NTG or CPAP. In this system, they are not options if the SBP < 120.

The patient was transported without a change in status to the local hospital. Another serial ECG was mostly similar.

Upon arrival at the local hospital, the Medic reported his ECG findings to the ED physician in charge. The ECG changes were not appreciated in the ED.

The patient was moved to a room for observation and labs.  After a time (exact time lapse unknown), troponins came back  markedly elevated.  The staff determined he was having an MI. Concurrent with these results, the patient experienced flash pulmonary edema and had to be intubated and put on a vent.  Transport to the PCI center was arranged.

However, it was also discovered that the patient also had an infection. Due to this finding, transport to the PCI center was postponed, and the patient was admitted to ICU. No further follow up is available.

What are your thoughts about this case? 

Do you agree with the ECG findings?

Would this case have been handled differently in your system? How?

 

 

59 year old male: chest pressure

It’s a hot summer night in the suburbs, most of which you’ve spent on standby for a local baseball game. After clearing up you’re put on a chest pain call a few blocks from your quarters. The local volunteer fire department has a squad on scene which is advising you to, “continue on emergency.”

Upon your arrival you find the patient seated on the porch, on O2 via a non-rebreather, in moderate respiratory distress. The volunteer EMT relays that the patient, a 59 year old male, is having 10 of 10 chest pressure which started yesterday. He’s administered 324 mg of aspirin and withheld nitroglycerin because of the patient’s blood pressure. You’re handed a quick trip sheet as you take over patient care.

  • Pulse: 50, weak at the radials
  • BP: 80/40
  • RR: 24, labored, lungs clear and equal bilaterally
  • SpO2: 90% on room air, 94% on 15 L/min via NRB

Your partner starts putting on the electrodes for a 12-Lead while you get a quick history.

  • PMHx: hypertension, hypercholesterolemia, GERD
  • Medications: lisinopril, lipitor, omeprazole, “vitamins”
  • Allergies: penicillin, sulfa drugs, levitra
  • Last ins/outs: normal dinner

The patient appears acutely unwell, ashen gray, and diaphoretic. He states the pain is, “pretty constant now,” and that he feels it in, “my shoulder blades and running down my spine”. Your partner hands you the initial 12-Lead:

Uh Please Standby - Initial 12-Lead

The EMT helps you and your partner place the patient on your stretcher and move the patient to your unit. Your partner asks you what you think about the 12-Lead and if you’ll need a driver.

  • What does the 12-Lead show?
  • Should this patient be taken to the local hospital, about 10 minutes away, or the cardiac center, about 25 minutes away?
  • Do you need a driver?

Masters Case #01: 50 Year Old Male – Severe Chest Pain

Most of our cases here at EMS 12-Lead are designed to strike a balance between challenging experienced prehospital providers while also highlighting a couple of specific teaching points for those seeking to learn. It’s a difficult line to walk. We want to showcase EKG’s with specific findings that are apparent enough to make good teaching tools, but we also want them to be subtle enough to make our practiced readers work.

At this point I’m sure there are a few folks out there who have been following us (and related blogs) for long enough to be familiar with a lot of the major tropes we often discuss, so to keep things challenging I’m starting up a new case series: the Masters Cases. These ECG cases are designed to challenge even our most advanced readers, with no limit to how subtle or multi-faceted the findings can be. While no-one here at EMS 12-Lead claims electrocardiographic mastery (holo-chat us in 30 years, maybe…), this series will feature some of the toughest diagnosable EKG’s we’ve come across after collectively reading tens-of-thousands of tracings.

To kick things off, here’s our first “Masters Case” courtesy of Dr. Bojana Uzelac from Serbia…


A 50 year old male presents with a chief complaint of sudden-onset severe chest pain x 45 minutes. The pain began at rest and has been constant, if not worsening. He is pale, diaphoretic, and fairly lethargic; although he still answers questions appropriately. He states he feels weak, short of breath, and just can’t find the energy to move. His radial pulse is weak but present and you hear rales in the lung bases bilaterally. Past medical history is significant for type II DM, heavy smoking, obesity, and hypertension. He has never been diagnosed with COPD, coronary artery disease, or MI.

Vitals: HR 90 bpm and irregular, RR 22/min, SpO2 94% on room air, BP 90/50 mmHg, and temp 36.5 C.

The following EKG is captured upon first EMS contact.

Masters Case: 50yo M - Severe Chest Pain


Here’s the rub: your job is to read this EKG as completely as possible. If you leave me a one-sentence comment I’m just going to delete it. Whatever abnormalities you find should be supported by reasoning. If you think the patient has pericarditis, you’d better list the findings supporting your diagnosis. If this patient is having a STEMI, I want to know where the lesion is and your rationale. I’d also like a brief overview of your treatment plan, though not as in-depth as the interpretation. Take your time and be thorough; these aren’t spot-diagnoses.

As a final general hint, when it comes to these Masters Cases you can rely on the EKG to tell the story. We aren’t going to try and trick you by slipping small clinical clues in the case description. For example, in the above case you would be right to consider aortic dissection if you met this patient in real life, but this is an ECG blog and I promise you the patient is experiencing acute coronary syndrome. Don’t over-think the descriptions but do dive deep into the ECG.

Good luck!


Masters Case #01: 50 Year Old Male – Severe Chest Pain

Most of our cases here at EMS 12-Lead are designed to strike a balance between challenging experienced prehospital providers while also highlighting a couple of specific teaching points for those seeking to learn. It’s a difficult line to walk. We want to showcase EKG’s with specific findings that are apparent enough to make good teaching tools, but we also want them to be subtle enough to make our practiced readers work.

At this point I’m sure there are a few folks out there who have been following us (and related blogs) for long enough to be familiar with a lot of the major tropes we often discuss, so to keep things challenging I’m starting up a new case series: the Masters Cases. These ECG cases are designed to challenge even our most advanced readers, with no limit to how subtle or multi-faceted the findings can be. While no-one here at EMS 12-Lead claims electrocardiographic mastery (holo-chat us in 30 years, maybe…), this series will feature some of the toughest diagnosable EKG’s we’ve come across after collectively reading tens-of-thousands of tracings.

To kick things off, here’s our first “Masters Case” courtesy of Dr. Bojana Uzelac from Serbia…


A 50 year old male presents with a chief complaint of sudden-onset severe chest pain x 45 minutes. The pain began at rest and has been constant, if not worsening. He is pale, diaphoretic, and fairly lethargic; although he still answers questions appropriately. He states he feels weak, short of breath, and just can’t find the energy to move. His radial pulse is weak but present and you hear rales in the lung bases bilaterally. Past medical history is significant for type II DM, heavy smoking, obesity, and hypertension. He has never been diagnosed with COPD, coronary artery disease, or MI.

Vitals: HR 90 bpm and irregular, RR 22/min, SpO2 94% on room air, BP 90/50 mmHg, and temp 36.5 C.

The following EKG is captured upon first EMS contact.

Masters Case: 50yo M - Severe Chest Pain


Here’s the rub: your job is to read this EKG as completely as possible. If you leave me a one-sentence comment I’m just going to delete it. Whatever abnormalities you find should be supported by reasoning. If you think the patient has pericarditis, you’d better list the findings supporting your diagnosis. If this patient is having a STEMI, I want to know where the lesion is and your rationale. I’d also like a brief overview of your treatment plan, though not as in-depth as the interpretation. Take your time and be thorough; these aren’t spot-diagnoses.

As a final general hint, when it comes to these Masters Cases you can rely on the EKG to tell the story. We aren’t going to try and trick you by slipping small clinical clues in the case description. For example, in the above case you would be right to consider aortic dissection if you met this patient in real life, but this is an ECG blog and I promise you the patient is experiencing acute coronary syndrome. Don’t over-think the descriptions but do dive deep into the ECG.

Good luck!


70 Year Old Male: Short of Breath

 

Good morning sports fans!

You are dispatched to the residence of a 70 year old male, complaining of “shortness of breath”.

You pull up to a well kept home, and are met at the front door by the patient’s wife. She tells you that her husband came home from the hospital yesterday after cosmetic eye surgery.

You are led into the kitchen, and find your patient sitting in a chair at the kitchen table. There is an eye patch over his right eye. He appears to be in moderate respiratory distress. His color is ok, but you note he can only speak in short sentences.

He tells you that he was fine until this morning when he suffered a sudden onset of shortness of breath. His wife describes it as “wheezing”. You ask about any Asthma/COPD history, and he says he has none. He also denies any cardiac history. He tells you he also had bouts of “coughing up phlegm”, and felt “very weak”.  As the day went on, his breathing worsened, so EMS was called.

You listen to his lungs and note basilar crackles. His history is significant for hypertension, repaired AAA, and skin cancer.

His vitals:

  • Pulse: 116 and weak
  • BP: 102/70 (patient states his systolic is normally in the 120-130 range)
  • RR: 24 and labored
  • SpO2: 92% on room air, and 97% on O2
  • Skin: unremarkable

Here is his rhythm strip:

rs4:4

and 12 Lead ECG:

ecg4:4

ECG interpretation?

What could be wrong with your patient?

How do you want to treat him, and where do you want to take him?

 

The nearest hospital is the local hospital 20 minutes away, and the nearest cardiac center is 50 minutes away.

Let’s hear it!