# Chest Pain (12-lead)



## 18G (Dec 22, 2012)

Interfacility transfer of a 75 y/o male from a small, rural ED to a tertiary hospital as a direct admit. Pt. has been experiencing chest pain for the past week which has been occurring with mild activity and relieved with rest and a nitro patch. Early in the AM, pt. developed chest pain at rest and did not go away which prompted pt. to go to the ED. 

Pt described chest pain as a "great heaviness" over the left upper chest. He presented to the ED with radiation into the neck. Pt. is bradycardic with rate of 45-48. Pt. states normal HR is upper 50's (beta blocker use is noted for HTN). Pt becomes very nauseated while preparing for transport and nausea continues during my care. Labs were drawn only once for cardiac enzymes on pt's first arrival which were normal (CK-MB and troponin I). I got there two hours after. 

Pt. has a history of HTN, angina, cardiac stent x1 six years ago. Pt. was treated in the ED with ASA, Plavix, SL NTG x2, morphine (4mg) O2 via N/C and Zofran. 

Vitals are: 120-30's/50's, HR: mid 40's, RR: 18, SPO2: 97% (2lpm), TEMP: afebrile. Chest x-ray was normal. All labs are normal. 

I acquired this 12-lead: 







Chest pain increases early in the transport to a 7/10 so I treat with SL NTG x3 which reduced pain to a 1/10. I also applied an inch of NTG paste. Not too long after pt. makes statement that chest pain is coming back so I give morphine (2mg). 

With the persistent chest pain, ischemic changes in inferior leads, bradycardia and nausea, I was very concerned about this patient. I didn't feel the criteria was met to call a STEMI alert but thought something was definitely evolving. I consulted with ED physician who felt it was a good idea for pt. to be seen in the ED and wasn't stable enough for a direct admit. 

I tried to call the ED to follow-up and see what the cardiac enzymes were and the patient's disposition after I left but the nurse wasn't available.

What is everyone's opinion on opting to take the pt. into the ED instead of the arranged plan for direct admit? Would you have made the same decision? What do you think of the 12-lead in conjunction with the exam findings? This was now about 4hrs since the labs were drawn for cardiac enzymes.


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## VFlutter (Dec 22, 2012)

I can't see the EKG. Also, where are they getting direct admitted to? On my Cardiac floor we sometimes get direct admits / transfers who are fairly unstable and bypass the ER.


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## 18G (Dec 22, 2012)




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## 18G (Dec 22, 2012)

The patient was getting admitted to a cardiac floor at a regional medical center with a cath lab. However, for an acute problem the wheels don't turn nearly as fast on the floor as they do in the ED at this hospital. 

I was concerned that its been 4hrs since cardiac enzymes were last tested and this patient is still having chest pain.


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## VFlutter (Dec 22, 2012)

Do you know where his previous stent was? 

I see a Q wave in III with very slight elevation in III, maybe a little in aVF,  then depression in I/aVL. I would like to see a V4R just to rule things out.


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## 18G (Dec 22, 2012)

Not sure what vessel the stent was placed in. It wasn't specified.


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## FLdoc2011 (Dec 22, 2012)

18G said:


> The patient was getting admitted to a cardiac floor at a regional medical center with a cath lab. However, for an acute problem the wheels don't turn nearly as fast on the floor as they do in the ED at this hospital.
> 
> I was concerned that its been 4hrs since cardiac enzymes were last tested and this patient is still having chest pain.



Depends on the facility and local "politics", but certainly reasonable for the patient to go to the ER and be seen by a physician there.   Like what you mentioned, if something changes it may be easier/quicker to get something going from the ER.

I'm not as concerned about the timing and rushing to get the next cardiac enzyme set.   He already has very suggestive symptoms, clinically it looks like unstable angina.  I certainly wouldn't be surprised if the next set is positive, not really going to change much of what I'd do, regardless he's getting treated for ACS.  

Sounds like he's going to the cath lab, only question is when.


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## johnrsemt (Dec 23, 2012)

Been awhile since I worked in the ED,  but I thought Cardiac enzymes were drawn every 8 hours (first entered ED, +8hrs, +16hrs).


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## d_miracle36 (Dec 23, 2012)

I think it looks like a early mi and probably deserves Cath lab. Did you say there was dynamic ekg changes? I think with the changes in I and avl its pathological. Would rather Christopher or tom comment on the ecg though.


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## Aprz (Dec 23, 2012)

I can't find the case, I believe it was on ems12lead, but (sometimes?) the first sign of MIs are reciprocal changes, not STE. I believe the case was similiar to the 12-lead you posted, the t-wave in aVL was retrograde.

If you saw EKG changes, I kinda feel like that is proof of something pathological. I've read it so many times "if only we had an old EKG to compare to", although I usually hear it with cases when the patient has a LBBB, but I think the same for 12-leads without LBBB, and you had it.

I hope taking the patient to the ER will get things going for the patient versus the cardiac floor... to me, that sounds like some EMS voodoo thingy majig no offense.


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## JPINFV (Dec 23, 2012)

18G said:


> I was concerned that its been 4hrs since cardiac enzymes were last tested and this patient is still having chest pain.



For ACS it's an EKG and enzymes q8.


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## KellyBracket (Dec 23, 2012)

Good decision to go to the ED. 

Aprz, d_miracle36, I think you're on target with your evaluation. I'm guessing that this was an RCA, given the STE inferiorly, and the pronounced reciprocal changes in aVL. Getting V4R, as mentioned, might corroborate that, but there's still plenty of evidence here already.


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## 18G (Dec 23, 2012)

JPINFV said:


> For ACS it's an EKG and enzymes q8.



I've seen every 4-6hrs or sooner depending on presentation. The ED physician was calling for the iStat to check enzymes as soon as we got into the room.


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## 18G (Dec 23, 2012)

Aprz said:


> I hope taking the patient to the ER will get things going for the patient versus the cardiac floor... to me, that sounds like some EMS voodoo thingy majig no offense.



?????????


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## Brandon O (Jan 6, 2013)

KellyBracket said:


> I'm guessing that this was an RCA, given the STE inferiorly, and the pronounced reciprocal changes in aVL. Getting V4R, as mentioned, might corroborate that, but there's still plenty of evidence here already.



Agreed... with the really classic clinical picture and subtle but quite consistent injury pattern, I would call this a diagnostic ECG.


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## Christopher (Jan 7, 2013)

Aprz said:


> I can't find the case, I believe it was on ems12lead, but (sometimes?) the first sign of MIs are reciprocal changes, not STE. I believe the case was similiar to the 12-lead you posted, the t-wave in aVL was retrograde.



On behalf of the EMS 12-Lead Team, we will take half credit; the other half going to Dr. Smith's ECG Blog.


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## firecoins (Jan 7, 2013)

he was taken in the er at the receiving faciliy or were you still as the sending facility?

how long of a transport?


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