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Case #43 Woke Up With Severe Cp... Uh Oh...


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#41 jbflightnurse

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Posted 10 September 2008 - 12:01 AM

Just so I'm clear on this cuz I keep seeing people saying that he has illicit drug hx. I thought he answered "NO" to any medications legal or illegal right???
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Jan B.

#42 rfdsdoc

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Posted 10 September 2008 - 07:14 AM

The last 21yo guy with acute anterior STEMI I retrieved to a cath lab swore he did not take any recreational drugs despite his urine drug screen being positive for speed. And he died 3 days later from cardiogenic shock despite lysis and rescue PTCA.

Critically i think what Mike is asking of us now is what do we do in the prehospital setting with this guy given his first EKG? For those who have prehospital thrombolysis in their protocols what are you going to do now?

Even if this was isolated atrial MI which is so rare, you still have to make a decision as to how you are going to relieve his pain and IF YOU HAVE enough information ( and gumption) to offer prehospital lysis?!

All I can see is gross ST elevation in II, III and AVF ( tombstone appearance) which hits you in the face. No one has mentioned what they think the rhythm is? It is difficult to see P waves as I think they are buried in the T wave but it appears regular . In V1-2 it looks as if the PR interval may be prolonged ( first degree heart block which fits with an inferior MI). I think it is sinus rhythm. Could be junctional but at the moment it does not matter.

Lysis or not? How far am I from a cath lab? 90 min or more then lysis if no contraindications and no rapid response to nitrates ( as I would expeect for Prinzmetal's). Less than 90 min then IV access, O2, defib pads on, aspirin, clopidogrel, nitrate spray, IV fentanyl or morphine, call it in for a hot angio on arrival.
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Minh Le Cong
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#43 KingAirNLA

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Posted 10 September 2008 - 11:03 AM

I agree with 1st degree AV block. This would go along with the atrial infarction.

A cath lab would be the best fix in an atypical case like this. However, if this was a prolonged transport (>90 min to ballon time) I would be calling medical control for TNK. Thrombolysis could be done based on the inferior ST elevation alone.
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#44 LZone

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Posted 10 September 2008 - 01:03 PM

All I can see is gross ST elevation in II, III and AVF ( tombstone appearance) which hits you in the face. No one has mentioned what they think the rhythm is? It is difficult to see P waves as I think they are buried in the T wave but it appears regular . In V1-2 it looks as if the PR interval may be prolonged ( first degree heart block which fits with an inferior MI). I think it is sinus rhythm. Could be junctional but at the moment it does not matter.



I am having a hard time with this 12 lead, as MedicNurse already state you must treat the patient and not the monitor, presentation wise (with the exception of his age) this patient is saying I am having a cardiac related event until proven otherwise...then you put him on the monitor and WHOA! WTF. As far as ST elevations, I can't even be sure where his T wave is in the inferior leads, in the precordial leads what may be his Twave is either his P wave or maybe artifact. Either way he is in a really long 1st degree or has a long Q-T segment. All I am seeing is an EKG that I have never seen before and did not realize a 12 lead could present this way. All the elevations in the inferior leads/depressions in V1-3 is immediately prior to his QRS not immediately after, therefore what I am interpreting in this 12 lead in the inferior leads is not ST elevation, rather as stated earlier PR elevation. The R wave progression is non existent, I would check the lead placement and burn another 12 lead and while I am at it take a look at V4R, V8 and V9 and see if that can shed some light on the situation.

As far as treatment plan, MI all the way, but hold off on nitrates, large bore IVs for fluids, put the pacer pads on him, (he already surprised me once with the tracing, I want to get the jump on him if that rhythm gets out of hand) and get flyin to your closest appropriate facility ASAP.

I have to ask, is this a real 12 lead or was it "doctored" to emphasize its originality? It's crazy.
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#45 Speed

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Posted 10 September 2008 - 01:39 PM

OK Mike out of what four or five consecutive post all I can get out of it is positive for smoking and alcohol use? You are dead to me. Just kidding.


All I can see is gross ST elevation in II, III and AVF ( tombstone appearance) which hits you in the face. No one has mentioned what they think the rhythm is? It is difficult to see P waves as I think they are buried in the T wave but it appears regular . In V1-2 it looks as if the PR interval may be prolonged ( first degree heart block which fits with an inferior MI). I think it is sinus rhythm. Could be junctional but at the moment it does not matter.


It's sinus, and yes theres a delay between the sa and av. To say it's straight out 1st degree? maybe? but he's 20 something and also has the ischemia up there as well, maybe associated with that?

The R wave progression is non existent, I would check the lead placement and burn another 12 lead and while I am at it take a look at V4R, V8 and V9 and see if that can shed some light on the situation.


This to me is what's giving something away. I know what elevation is, and in specific leads and patterns... well it's pretty much one thing. The R wave digression is what I'm feeling as more of a clue to whats going on. These two things together is whats making it a circus. If he just had the elevation, easy, it's an infarction. Why not in the usual spot? Well, it wouldn't be plaque, so you think emboli (clot, fat, undissolved gas, foreign fluid?). Even then, if it were something floating around in there it should have gotten lodged somewhere else just based on the odds, flow, and size of the arteries there. His age and vasospasm associated with cocaine use, sure, but it's denied and I'm not seeing/hearing any supporting evidence. Sure he could be a liar, the whole world is a lie, but it would be just the elevation, why the R wave issue. If he was a chronic user you could say it was LVH, but then again this isn't really looking like the usual LVH pattern either. It looks more dampened and acute. In the LVH you see more voltage changes in the positive R without so much in the rest of the whole cycle. Here, all of it is equally(p, qrs biphasically, and t) dampened (pretty much snuffed out to nothing). That's different than what you'd expect from just a big ventricle?

At this point I'm puzzled. If his vitals are maintaining and he's not deteriorating I'd run it as a regular old chest pain patient. He does have ischemia. I know this may not be the best answer, but we trust EMT basics with this stuff so let him have it. I would just be conservative with all treatments with a possible surgical chest in the bask of my mind. Just run it like a EMT would. He really doesn't sound that bad. I would say the most important thing right now is to get blood to that aurical. Let's transport now. Flood him with oxygen, ASA-OK, nitro-OK, analgesia-WAY OK, fluid-OK. I wouldn't do anything else that would complicate him pre-operatively (thromb/firbinolytics or heparins).

Yeah, when I first glanced at it in "mini-me" size it looked like bad placement, but it's right.
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Mike Williams CCEMT-P/FP-C

#46 mtnmedic8

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Posted 10 September 2008 - 07:24 PM

I'm going to agree with Speed here. Let not overlook what we are doing, we need to start transport. We can all agree that there is something going on here cardiac wise pathological, congenital, mechanical ect. I don't think its cocaine chest pain. His rate and pressure is too low. Of course not being able to look at the patient thats just a guess. Lets do what we can't do in flight IE a quality 12 lead/15 lead and get going.

But, from a learning aspect..... I think we have ruled out PE or tension pneumo. It could be as "simple" as an atrial infarct and something else causing the r wave regression and this kid just has terrible luck. :unsure:
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#47 rfdsdoc

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Posted 10 September 2008 - 09:42 PM

If everyone is so keen to do rapid transport to definitive care then why bother doing the EKG in the first place?

Prehospital EKGs are done for several key reasons and I do not need to lecture to this audience about them.

If you are not keen to do any prehospital lysis or early activation of the hot angio team then don't bother doing the EKG!


I agree with one of the previous posts. If not sure call a friend and get a second opinion. And do that whilst en route to a resus bay with four walls and a roof.

But this is likely a time critical condition. You either start definitive care at the scene or move them quickly to somewhere to someone who is going to make that decision to start definitive care for you.

This was a real case so I am sure someone out there was faced with a difficult decision and made a call.

Chest pain and that EKG you would seriously have to ask yourself why aren't I offering lysis if I cannot get him to a cath lab in under 90 min?
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Minh Le Cong
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#48 Speed

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Posted 10 September 2008 - 10:33 PM

I honestly expected the ECG to be "clean", rule out cardiac and rule in aortic tear/tamponade/aneurysm. To have been woken up from sleep as the "event" doesn't leave much to happen in the chest (blunt trauma), especially without a known history or some persistent symptoms leading up to this over time (congenital, tumor, effusion). I also expected to hear muffled heart tones or lung sounds.
So he's got "bad" chest pain and sweaty. NIBP/MAP's not that bad. Would an ischemic atria cause all of that? Sure the chest pain but hypotension and diaphoresis? I would expect a diminished pre-load as with AF, not a sweaty shocky young person (I agree he's not "that shocky" right now. So along with the R wave issue I really think it's more than just a classic coronary artery occlusion (and PR elevation sure "ain't" classic).
If I could pick him up and flip him around like a rag doll, maybe hang him up by his ankles or somehow reposition him I'd bet we'd get some ECG changes. If there were any change in the R waves or PR elevation, he's got something in his chest. That wouldn't happen from an emboli, and if it were a clot forming on plaque I really think it would be in a different location than the end of the RCA or circumflex, too great of odds. Plus these are tombstones. Those usually occur when a great portion of the diameter of a main vessel is blocked. Usually if it's a little bitty clot, air or fat emboli it would lodge in a tiny branch affecting a small area, and would have a greater chance of collateral circulation limiting the size (that's comparing what we have now to routine scenarios, sure anything is possible). This elevation looks "big" to me.
Right now without him deteriorating I'd just hang out and treat him conservatively with nitrates being the most aggressive treatment (still "wishy-washy" on that even, but I ask myself what would a basic without a monitor do? How much harm if it were an aneurysm? We hang Nipride in some, even when they are leaky?). My biggest "pro" for the nitro would be for it's diagnostic ability in this case. I'd get him comfortable as I could with analgesics. Too many questions right now to go out on a limb. ABC's are good. He's not dying with an NIBP holding at 100/systolic. He's got pain, treat it, monitor, and transport. That's where I'd be comfortable. If medical control would take on the liability of anything further... well, we will see I guess. Hey, I'm just an ambulance driver, ask Floridamedic, she'll tell ya.
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Mike Williams CCEMT-P/FP-C

#49 biggravy

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Posted 11 September 2008 - 01:00 AM

Have we looked this guy over REAL GOOD? Was he sleeping with the windows open? .22s leave tiny holes. Agree most likely medical, but it wouldn't be the first time I saw someone shot who didn't know they were shot. If he was laying down there could be a tiny entrance in a strange place...
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#50 Flightgypsy

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Posted 11 September 2008 - 03:13 AM

I am no 12 lead EKG expert so won't comment on the EKG except to say "UH-OH".

I would give a small fluid challenge to see how he responds and give him fentanyl for the pain and help with calming him down. I would also give him aspirin, O2 and 2 IV's and have the pacer pads on him and head for the helicopter. En route maybe we can get more history to decide whether to give him nitro or lysis. I don't carry lysis. Maybe if he responds well to fluids I would try a dose of nitro and see how that helps.

I would definitely be doing some serial EKGs as well.

Some other differentials I was trying to think of:
1) Atrial myxoma with possible embolus
2) Congenital Heart Defect (I always think of ALCAPA with infarction but unlikely unless he is one of the rare lucky ones to make it to adulthood undiagnosed)
3) Isolated Atrial Infarction (cause yet to be decided)
4) Drug related MI
5) Spontaneous pneumomediastinum or possibly induced by drugs, coughing, etc.

Just really thinking out loud here. Very interesting case that is for sure....glad I am reading about it here rather than having to deal with it myself on a call......
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#51 JPatterson

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Posted 11 September 2008 - 01:28 PM

Does the pain change with positioning or palpation? Deep breaths?
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Jeff Patterson NREMT-P

#52 JPatterson

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Posted 11 September 2008 - 01:29 PM

also, have we totally exposed and examined this guy. Someone brought up unknown trauma which is a very good point.
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Jeff Patterson NREMT-P

#53 LZone

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Posted 11 September 2008 - 01:43 PM

Someone please dissect that 12 lead for me.

Where you see what and what it is. Also, explain how you know.


Let me try to break down this 12 lead. There is no rhyme or reason to this method and I will probably miss something but here goes:

Rate: WNL
Regular: Yes
P wave before every QRS: can't with any certainty identify a P wave but whatever is going on over there seems to be consistently before every QRS
PR interval: seems long at over .2 sec but I can't define a p wave, it also appears to be where the problem is, not the timing of the interval itself but how it is presenting.
Axis: can't be sure of the baseline in the limb leads, Lead I seems isoelectric (actually flat) but I will go with indeterminate axis.
QRS complexes: in the precordial leads it seems tight at .08 secs or so but in the inferior leads the PR interval obscures the measurement bleeding over into the R wave. No ventricular hypertrophy, low amplitude with no R wave progression in precordial leads.
ST segement: I can't say with any confidence say that I see a T wave in the inferior leads but in V1-4 there might be a deflection that I can call a T wave, if that deflection is the T wave he would have a long QT, but the T waves are nearly flat and I cannot decide where the isoelectric line is.
No ventricular ectopy.
Rhythm: Sinus or at least supraventricular.

What else?
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#54 LZone

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Posted 11 September 2008 - 01:55 PM

Speed - post 48 - LMAO! But I am probably one of the few that will innocently find it funny.
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#55 RoadieRN

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Posted 11 September 2008 - 04:53 PM

Speed - post 48 - LMAO! But I am probably one of the few that will innocently find it funny.

'Cause physical harm always works well when I want something out of a patient! :lol:

All joking aside, this guy isn't doing so hot. I agree he definitely has big ol' tombstones on EKG. I, by no means, am an expert at EKGs, but this guy has got serious issues here. One thought I had for a differential dx is Marfan's. What does our lad look like? Big hands, FLK at all? Being he is from back East, acute chest syndrome w/SCD is a big potential issue here. I think I have seen one sickler out here in the desert in my 4 years being out here, so it isn't on my front burner like it used to be when I lived in St. Louis or Philly. With that being said, he would not have made it pass 2 yo without some kind of crisis.
This oughta be a nice little zebra coming around the bend!
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Nick Crusius RN, BSN

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#56 Speed

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Posted 11 September 2008 - 06:51 PM

One thought I had for a differential dx is Marfan's


This was one of my first thoughts with a young guy and sudden chest pain. I was hoping that the ECG was normal and bad heart tones, JVD, narrowed pressures, blah, blah, blah, but it doesn't seems to be panning out. Although I can see how a Debakey what? 2? could sit on top of the aorta and catch the coronary arterys (low flow) but wouldn't the effect be more global than isolated to the Atrium? Maybe a "sagging" layer of the vessel pushing down on an artery? To me that's a big imagination. If there was a little blood leaking from it creating a hemomediastenum that pooled on his left side while he was sleeping it could cause the R waves to diminish left laterally leaving normal heart tones and lung sounds?
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Mike Williams CCEMT-P/FP-C

#57 burngirl

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Posted 12 September 2008 - 12:01 AM

I may be TOTALLY in left field...but what about a parasitic infection? That is mosquito country...heartworm?? (feel free to LMAO :D )
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#58 EDMEDIC

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Posted 13 September 2008 - 02:17 PM

the Keep It Simple Stupid ( KISS) usually keeps us from seeing the zebra in Mike's cases. SO, I looked at all of the "not obvious things" I could think of. A low voltage QRS could mean left pneumo, or some type of cor-pulmonale. The P-R elevation that some suggested could also mean that. I don't clearly see a "p" wave, but as RFDSDOC pointed out, does it really matter at this point. My take is there is marked S-T seg elevation in the inferior leads, the pt's V/S are not that far off base, so as not to start treatment for AMI. He at the very minimum is an ACS pt. I think he needs a cath lab pronto. We don't do field lysis here, because we are so close to a number of facilities /c MI alerts and short field to baloon times( usually around 60 minutes)..so My thoughts are, do the 15 leads ECGs ( serial ECGs) 2 PIV's ( maybe a twin cath for one of those) if no allergies, 324 mg ASA po, some IV fluid ( judiciously) hi-flow O2, see how does /c SL NTG ( is he a NTG virgin? probably /s a PMHx of cardiac origin) using caution not to drop his preload down too much and some pain relief, my choice would be fentanyl 50 mcg q 5 until he gets some relief. Burn jet A or diesel ( however we're getting to the closest cath facility)..be prepared to intervene ( RSI/ETI) if his resp effort decreases...my .02, Brian
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#59 Speed

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Posted 13 September 2008 - 02:38 PM

Sounds good, I'll ride with you...but


I think he needs a cath lab pronto.



Surely there'll be a CXR before we stroll into the cath lab, right? I know sometimes it may get deferred, and I may be putting all my eggs in one basket, but I think the radiograph will tell the real story here. This is one I would emphasize a film before we rush into anything.
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#60 Mike MacKinnon

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Posted 13 September 2008 - 02:54 PM

Correct he denies it

Just so I'm clear on this cuz I keep seeing people saying that he has illicit drug hx. I thought he answered "NO" to any medications legal or illegal right???


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Mike MacKinnon MSN CRNA
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It's what we know for sure that just ain't so" - Mark Twain