ECG of a case today

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Smellypaddler

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70yoF who presented with 9/10 central chest pain, associated diaphoresis and vomiting.

Pain described as stabbing in nature, worse on inspiration and palpation.

The Zoll auto-diagnosis only states "moderate ST depression" no finding of infarction.

I'm just wondering what others would think of this ECG and how they would treat based on the ECG and presenting symptoms?

No other tricks or funny business: Nil Phx, Nil meds, normally fit and well, NKDA.

Vitals stable:

BP= 140/systolic
RR = 16
Afebrile



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luke_31

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Could be a septal infarction. Would treat as cardiac to be on safe side. Females can present different than the typical presentation.
 
S

StCEMT

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I agree on the septal infarct. Treatment will just be the standard for cardiac calls.
 
Gurby

Gurby

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Looks like clear J-point elevation to me, and increased pain on inspiration/palpation doesn't fit. I doubt it's an MI, but in a 70yo female with chest pain I suppose we treat as cardiac until proven otherwise. ASA and nitro, re-evaluate and pain meds if the nitro didn't help. I'd have a bunch of questions and differentials to explore, but I don't think there's much that would change my management in the field.
 
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Handsome Robb

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You generally can't have an isolated septal infarction. The septum is supplied by the LAD which also supplies the LV. You should see LV involvement if the septum is involved.

With that said, this is a cardiac Pt until proven otherwise. I'm not sure I'd activate the cath lab but I'd definitely be treating for ACS.


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E tank

E tank

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Wonder what the heart sounded like. Acute pericarditis? Either way, treat for acute coronary syndrome.
 
TomB

TomB

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This is a great case. One that Stephen Smith, M.D. would find interesting. This is almost certainly LAD occlusion. First, you have clinical correlation (always a good idea to consider pre-test probability). The T-waves in leads V1-V4 are hyperacute because they are disproportionate to the size of the QRS complex. Plus, R-wave progression V1-V4 is obliterated AND you have ST-depression in lead V6 both of which essentially rule out early repolarization. So what else could it be? The answer is STEMI (or STEMI equivalent). These get missed all the time. Or, they get cathed "late" (after troponins come back positive -- or even the next day!) and then they care thrown out of the STEMI data. So they are almost never considered "missed STEMI". Similar case here: https://www.ecgmedicaltraining.com/acute-anterior-stemi-not-meet-guidelines/
 
cruiseforever

cruiseforever

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I would activate the cath lab. I would do several 12 leads during transport. Would not be surprised to see changes during transport.
 
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Smellypaddler

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Thanks for the feedback. Initially this lady was a bit strange and with the descriprion of her pain I wasn't going to treat as cardiac.

We have only just had the Zoll introduced into our service and have been told the auto-generated diagnosis is greater than 95% accurate and to bekieve what it says.

So, after the ECG I had enough clinical suspicion to treat as ACS. I initially thought this may have been a Septal infarction but wasn't sure. As you can see there doesn't appear to be any inferior involvement so I didn't think about doing a right sided set of leads. On arrival at hospital she had a positive troponin and right leads Rv3-Rv5 had ST elevation. She was thromolysed and secondary transferred to a cath lab.
 
Gurby

Gurby

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Well... Today I learned!

I do remember looking at the T waves and thinking they looked pretty big... I know I have a flashcard somewhere that says if T waves are more than 2/3 the height of the R/S they are likely pathological.... Here the T wave is bigger than the R/S in some leads!
 
VentMonkey

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Gurby said:
Well... Today I learned!
Click to expand...
As did I. Honestly? I'd never heard of the "rule of proportionality", thanks @TomB.

I forwarded the link to a couple of other good paramedic friends as well.
 
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Smellypaddler

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@TomB I'm going to do a bit more digging on this one and see if I can get hold of a copy of her hospital ECG. The computerised statement from the Zoll monitor simply said "Abnormal finding for female >40" & "moderate ST depression". On a subsequent ECG it also said "probable lateral Ischemia".

I am a bit confused with what I thought the hospital stated which is that she had positive ST elevation in Right Sided Leads, whereas the link you posted (which is excellent by the way) talks about this being an Anterior STEMI Equivalent. Anyway I shall do some more investigation when at the hospital next and see what I can find out.

I'll post on here any further updates, ECG's or info that I can gather.

Really glad I posted as I learnt something & hopefully improved my practice for next time. I had the option of pre-hospital thrombolysis and 60min transfer to cath lab or 10 min transport to main regional hospital whose cath lab is closed on weekends. Next time if presented with similar we might consider going straight to the lab. Hopefully by that point in time our 24hr on call cardiologist service will be up and running and we will be able to email the ECG direct to them for on scene analysis.
 
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