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
P – HTN
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
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.
Two more things I noticed— the PRI in lead II is long and the slight axis change between the two strips.
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?
Meybe it’s on set MI that strike the LAD but not the CIRCUMFLEX, it’s rare’ but that why there is not any change at 2-3AVF but if you have done RIGHT ECG it was demonstrate RMI. in particular with the allmost AVB and the sinus brady’