On arrival, the patient is found supine in bed.
She is alert and oriented to person, place, and time.
She is anxious and diaphoretic.
Past medical history: Hypertension
Surgical history: One kidney removed (unknown reason)
Medications: Azor
She denies shortness of breath and breath sounds are clear bilaterally.
Onset: 1 hour prior to EMS arrival
Provoke: Nothing makes the pain better or worse
Quality: Severe "pressure"
Radiate: The pain radiates down the left arm
Severity: 10/10
Time: No previous episodes of similar pain or pressure
Vital signs:
RR: 18
Pulse: 76
NIBP: 114/71
SpO2: 98 on RA
The cardiac monitor is attached.
A 12-lead ECG is captured.
How would you treat this patient and why?
Move lead V4 to 5th Intercostal Space in the right mid-clavicular line and check for RV4 ST Elevation. If evidence of RV4 ST elevation treat for inferior MI with right ventricular involvement.
ReplyDeleteIV Fluids, Analgesia, Anti-Coagulants & Anti-emetics
Transport to angioplasty centre
If No ST Elevation present, treat for inferior MI
agreeeed..check for RV infarction in Lead RV4..
ReplyDeleteI'll start with the obvious - there's impressive ST elevation in the inferior leads. Therefore, the most Obvious interpretation is an acute inferior MI, possibly RVMI as well, especially considering the rather low BP. Under this possibility, the lateral changes are reciprocal.
ReplyDeleteAn alternative interpretation, however, is that this lady has taken an overdose of her medicine, which is a combination of a Ca++ ch.bl. and an ARB. This would explain her chest pain (due to inavailability of Ca to the myocardium), as well as the 1st degree block (which may otherwise be completely insignificant). Concurrent electrolyte imbalance (hypokalemia?) would explain the peculiar, widespread ST depression. I know it sounds far-fetched but I am sure there's empirical evidence in the literature for this effect.
In any case, this case warrants caution. I'd refrain from nitro at least until after right-sided leads are preformed. MO, O2 and ASA are OK. I suppose the ER might consider giving her Ca as well.