12 Lead Fun, Anyone?

[EMSrush]

I haven't posted in a while, but I've been stalking on a regular basis. I've noticed a lot of new people here recently, and lots of good discussion. I've been meaning to post this one for a while:

Call to a memory residence for an 84 y/o male who had fallen. Pt is found on the floor /s visible injury and appears to have a good sense of humor. LOC is unknown. Pt states that he doesn't recall falling, but denies any complaint and would like to be helped up off the floor so he can go play cards. PMS intact, no slurring, droop or drift. Facility staff state that Pt is at baseline. Facility staff also states that Pt has been "almost passing out a few times" over the past two weeks, but "we usually catch him before he falls". Today, no one was around to catch the Pt. Pt has no significant medical hx, meds or allergies. Vitals as follows:

BP: 80/60
HR: 80's, irregular
Resp: 18
LS: Clear
BGL: 120

The 12 Lead is attached. I apologize in advance for the quality (or lack thereof) of the strip. What is your interpretation of the 12 Lead? How would you treat this Pt?

 

[stemi]

A fib, RBBB (I think), severe left axis deviation (assuming leads are good), ST elevation in anteroseptal and lateral leads. I'd like to know what some of the more seasoned guys think, since Im not the most experienced with 12 leads.

 

[Handsome Robb]

Looks like A-fib with a LBBB to me, kinda tough to see though.

No pain whatsoever?

With no medical hx he needs to be transported for a cardiac workup. Without a good history we can presume the AF and LBBB are relatively new on the thought process that it is what's causing the near syncope and syncopes. That would be my take on it.

Any complaints of dizziness before the falls that he can remember? How's his fluid intake and output, any changes? How about diet? Is he orthostatic, although I'd be real careful standing him up to check them? Any recent illness? Any chest pain over the last few weeks? Nausea/vomiting/diarrhea? Abdominal pain? Palpitations? Diaphoresis? Weakness? Does he know what his blood pressure runs at? 80/60 is pretty low but it wouldn't be the first person I've met that sits in the 80s/60s normally.

So far just supportive care, IV and give him some fluids in the range of 250-500 cc and see how that treats him, monitor, position of comfort although I'd like to keep him in fowlers/semi fowlers rather than sitting if that's comfortable for him. Unless something changes I don't see a whole lot we can do in the field.

 

[EMSrush]

No pain whatsoever?

Nope.

Any complaints of dizziness before the falls that he can remember? How's his fluid intake and output, any changes? How about diet?

Staff states that Pt did c/o dizziness prior to the falls, which is how they knew to "catch him". Pt has no recollection of this. Normal intake/output, normal diet.

Is he orthostatic, although I'd be real careful standing him up to check them? Any recent illness?

No orthos were done on scene. No recent illnesses.

Any chest pain over the last few weeks? Nausea/vomiting/diarrhea? Abdominal pain? Palpitations? Diaphoresis? Weakness?

Nope.

Does he know what his blood pressure runs at? 80/60 is pretty low but it wouldn't be the first person I've met that sits in the 80s/60s normally.

No, but facility staff had recent vitals, which indicated vitals WNL. Certainly no hx of hypotension.

 

[EMSrush]

You notice that the Pt's radial pulses have gone from the 80's to the 130's, still irregular. Pt remains asymptomatic and tells you that it's quite silly to take him to the hospital when he's feeling fine. BP marginally improves, but remains hypo.

 

[TomB]

I agree with AF and LBBB (although I'm tempted to call it nonspecific intraventricular conduction defect due to the negative concordance in the precordial leads). Left axis deviation. It's hard to comment on the amount of ST-elevation due to the scan quality although the chief complaint is not exactly screaming ACS. BP of 80/60 is a pulse pressure of 20 (no atrial kick). That alone could explain the syncopal episodes.

 

[Handsome Robb]

You notice that the Pt's radial pulses have gone from the 80's to the 130's, still irregular. Pt remains asymptomatic and tells you that it's quite silly to take him to the hospital when he's feeling fine. BP marginally improves, but remains hypo.

He can say it's silly all he wants but he needs to go, he's well within his right to refuse but you can bet that I am going to spend a lot of time talking him into going. Multiple syncopes causing falls aren't good along with the fact that he needs to be treated for the a-fib before he throws a clot and strokes out.

I feel like I'm missing something big...What's his skin signs like? With the rate change you said he's still hypotensive, still the same general numbers or have they improved a bit? CO = SVxHR so I would assume his BP did improve although he isn't getting good ventricular filling since he's in A-fib. Did the rate change spontaneously or with a change in position? Do these syncopes come out of no where or are they when he changes position? Supine to sitting or sitting to standing?

I'm going to watch the rate, CCBs are out since he's hypotensive. If I can't talk him into going I'd considering calling a doc and letting the pt talk to him/her. If we don't go down the "I'm over my head lets pawn it off on a doc" route, he is definitely going to get a very thorough explanation about why he needs to be evaluated.

 

[jwk]

Looks like A-fib with a LBBB to me, kinda tough to see though.

No pain whatsoever?

With no medical hx he needs to be transported for a cardiac workup. Without a good history we can presume the AF and LBBB are relatively new on the thought process that it is what's causing the near syncope and syncopes. That would be my take on it.

Any complaints of dizziness before the falls that he can remember? How's his fluid intake and output, any changes? How about diet? Is he orthostatic, although I'd be real careful standing him up to check them? Any recent illness? Any chest pain over the last few weeks? Nausea/vomiting/diarrhea? Abdominal pain? Palpitations? Diaphoresis? Weakness? Does he know what his blood pressure runs at? 80/60 is pretty low but it wouldn't be the first person I've met that sits in the 80s/60s normally.

So far just supportive care, IV and give him some fluids in the range of 250-500 cc and see how that treats him, monitor, position of comfort although I'd like to keep him in fowlers/semi fowlers rather than sitting if that's comfortable for him. Unless something changes I don't see a whole lot we can do in the field.

Not sure I'd want to dump 1/2 a liter of fluid on an unhealthy heart. I'm also not sure why you'd want to sit him up with a supine pressure of 80/60, although you might re-create the syncope or dizziness, especially if he kicks up to that 130 rate.

New onset a-fib is a much bigger concern than chronic medically managed a-fib. Besides his rhythm issues, he could be throwing off clots, which could also cause the dizziness/syncope. I assume "no significant history" rules out chronic a-fib and taking blood thinners, so he really does need to go visit the ER and start the big cardiac workup.

It's tough to get these folks away from a big card game.