EMS is dispatched to a 47 year old female complaining of chest pain.
On arrival paramedics find the patient seated on the floor. She appears acutely ill. Her skin is cool, pale, and diaphoretic.
The patient confirms that she is experiencing severe, sub-sternal chest discomfort.
Onset: 15 minutes prior to EMS arrival
Provoke: Nothing makes the pain better or worse
Quality: "Very bad" (language barrier)
Radiate: The pain does not radiate
Severity: 8/10
Time: No previous episodes
She is also complaining of palpitations.
First responders initially suspect symptoms of anxiety based on her young age.
The patient's son relates that the patient is a diabetic and hands paramedics a bottle of lisinopril and glipizide.
Paramedics ask the patient if she has a history of heart problems. She says "yes" but can not give specifics other than "blood pressure."
Due to the patient's poor appearance the EMS crew immediately loads her for transport.
In the back of the ambulance vital signs are assessed.
RR: 18
HR: 80
NIBP: 240/120 (confirmed with manual BP)
SpO2: 97 with NRB @ 15 LPM
Breath sounds are clear bilaterally.
The cardiac monitor is attached and a 12-lead ECG is captured.
What is your impression and what should the EMS crew do next?
STEMI
ReplyDeletestart M(morphine)O(oxygen)N(nitro)A(aspirin) immediately.
Acute STE anterior wall MI
ReplyDeleteseptal and anterior wall MI
ReplyDeleteantnteroseptl MI
ReplyDeleteleft ventricular hypertrophy with acute or old LBBB,need to do the troponin test
ReplyDeleteUnstable angina. Occluded nondominant RCA. Cornell criteria fits for LVH. I don't see a bundle branch block. Troponin won't begin to rise for several hours after the MI begins, so the test would be moot at this point, as her symptoms only began 15 minutes PTA EMS.
ReplyDeleteAnterior & septal STEMI. EMS obviously cant wait for troponin to decide if its unstable angina or MI, thus treat as STEMI!!!(there is ST elevation in anterior leads and for sure no LBBB)
ReplyDeleteAnteroseptal and inferior STEMI (ST elevation in V1 V2 V3 V4 D2 D3 avF).
ReplyDeleteMorphine, Oxygen, NFH, Aspirine, and Thrombolysis?
+/- measure of the troponin
:)
profound septal STEMI , but wthe question is what is the culprit artery? Cx, RCA or LAD III ?
ReplyDeleteSR, biphasic p wave, Prolonged PRI, STE V1-V4, STE aVF, qwaves III, avF, ST-T wave changes aVL>I. Consider (1) AWMI with culprit artery being LAD distal to the first diagonal branch. Consider also (2)aortic dissection considering BP is very high.What about (3) pericarditis considering PR depressions and PRE (?) in aVR.
ReplyDeletewe are here in face of many hypothesis : 1) anterior STEMI 2)aortic dissection 2)Pericarditis 4)myopericarditis
ReplyDelete