60 year old male CC: Syncope

Here is yet another awesome case courtesy of Christopher Watford who writes the My Variables Only Have 6 Letters blog.

One of these days Christopher is going to say (in his best Darth Vader voice), "Once you were the teacher but now I am the master!" and it will be completely justified.

EMS is called to evaluate a 60 year old male patient who experienced a syncopal episode.

On arrival the patient is found sitting in the front seat of his car. He is ashen gray and cold to the touch.

He is in moderate respiratory distress.

Past medical history: Brochitis
Medications: None

Breath sounds: clear bilaterally

Vital signs are assessed.

RR: 30
Pulse: 118 (weak and rapid)
BP: 108/64
SpO2: 88 on RA (increases to 94 on oxygen via NC @ 4 LPM)

BGL: 79

The patient states that he "can't afford to go to the hospital."

The cardiac monitor is attached.

A 12-lead ECG is captured.

What do you think is wrong with this guy?

*** Update 12/20/2010 ***

This gentleman was diagnosed with bilateral pulmonary emboli. He was admitted to the hospital on Lovenox (enoxaparin). After almost signing out AHA he was persuaded to stay by a doctor and nurse who informed him in no uncertain terms that he would die if he left.

The most suggestive ECG findings were:

• Sinus tachycardia
• S1Q3T3 (S-wave in lead I, Q-wave in lead III, inverted T-wave in lead III)
• Possible beginnings of an acute right ventricular strain pattern in the right precordial leads

It's important to note that the most common ECG abnormality associated with PE is sinus tachycardia.