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ECG Challenge: Winter, spring or summer
How would you treat 68-year-old male complaining of chest pain, grayish in color but very warm and diaphoretic?
By Tom Bouthillet
EMS is called to the residence of a 68-year-old male complaining of chest pain.
The patient was working in the yard when symptoms began.
At the time of EMS arrival, the patient appears acutely ill. He is grayish in color but very warm and diaphoretic. He is nauseated and has vomited prior to EMS arrival.
Past medical history: Hypertension, dyslipidemia
Medications: Hyzaar (HCTZ and losartan), Mevacor (lovastatin)
Onset: 30 minutes prior to EMS
Quality: Pressure or heaviness
Radiate: The pain does not radiate
Severity: 9/10
Nothing makes the pain better or worse. The patient says he has had no previous episodes, "at least not like this."
Vital signs are assessed:
- RR: 20
- HR: 74
- NIBP: 110/75
- SpO2: 92 on RA
The patient admits to mild dyspnea although breath sounds are clear bilaterally.
The cardiac monitor is attached.
A 12-lead ECG is obtained.
You are 20 minutes from the local community hospital and 40 minutes from a PCI center.
What is your interpretation of this ECG?
Should you call a Code STEMI?
How would you treat the patient?
Comments
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JR Gardner Tuesday, June 12, 2012 8:06:39 PM JR Gardner · Works at Cataldo Ambulance Service.
This one looks like a STEMI equivalent - one of the few times aVR is diagnostic. In this case, we have ST-depression of 1mm or more in I, II, aVF, v3-v6. In addition, there is elevation in V1 and aVR. aVR elevation is greater than v1. This, together with c/c and pt presentation, makes the PCI Hospital longer run with Cath Lab activation a necessity. ASA, NTG (pressure and IV access complementing), O2 by n/c titrate to 95% saturation. 
Harriet Engle Tuesday, June 12, 2012 10:51:20 PM This guy needs to go to the Cath Lab. If he were here in NM, being warm after yard work makes sense, he'd probably be cool & diaphoretic if he were inside. Wide QRS, abnormal ST height (described in lovely detail by JR Gardner), and the vital signs combine to make this a definite "bad day for the patient". Start with ASA, followed up with an IV of NS, Nitro if his pressure permits, and O2 via nasal cannula to start, looking for 94-95% O2sats. Keep cardiac monitor on, and watch him carefully. I'd call a STEMI code, for sure. 
Troy Hoover Wednesday, June 13, 2012 1:01:12 AM Elevation in lead aVR with STD in leads II, III, aVF, V4-V6 is sensitive for 3-vessel disease AND a proximal LMCA occlusion. STE in aVR is considered a STEMI equivelant and should be treated as such. Make sure not to give Plavix due to increase bleeding if bypass is needed. 
Jeremy Rudrud Wednesday, June 13, 2012 8:43:40 PM This 12 Lead shows a lot of ischemic changes, but no definitive STEMI. The ST depression and T wave inversion, with the story, shows signs of Cardiac Disease. Great explanation by JR Gardner. As far as treatment, start with ASA, Nitro (as everyone says watch the pressure), Morphine for continued pain control. From where I work with that long of a transport time a Nitro IV Infusion is initiated. I would also consult our Vital heart response team - usually reserved for STEMI, but with story and 12 lead changes, a consult with the cardiologist for PCI activation would be in order. 
Byron Wanstall Thursday, June 14, 2012 5:25:09 AM What do you suppose the cause of the left axis deviation is in this context? 
Lance Johnson Thursday, June 14, 2012 6:55:54 PM ACC/AHA guidelines recommend a door-to-balloon interval of no more than 90 minutes. So "STEMI alert.
Tx: IV TKO, O2 3lpm consider ASA, Nitro, and Morphine. Recheck B/P Lung sounds monitor SP02 and preform additional ECG's throughout the transport to a Cardiac center with Cath Lab. Remember the 30-30-30 rule the goal of achieving a 90 minute door-to-balloon time and divides it into three equal time segments. Each STEMI care provider (EMS, the emergency department, and the cardiac cath lab) has 30 minutes to complete its assigned tasks and seamlessly "hand off" the STEMI patient to the next provider. In some locations, the emergency department may be bypassed altogether. Lance Johnson Thursday, June 14, 2012 7:01:52 PM R/O Acute MI pattern: Anterior:ST elevation in, V2, V3, V4 ST depression in II, III, aVF. Troy Hoover Thursday, June 14, 2012 7:21:50 PM Byron,
The left axis deviation is do to a left anterior fasicular block 
Casey Lewis Saturday, June 16, 2012 7:57:40 PM Sinus rhythm at a rate of 75 with left axis deviation secondary to a LAFB, with ST elevation in aVR and widespread up-sloping ST depression across multiple lead groupings and T wave inversion in II and aVF. Differential diagnosis of ST depression includes subendocardial ischaemia, reciprocol changes from ST elevation, Pseudo ST depression from poor ECG contact, hyperventilation, secondary to tachycardias, right or left ventricular hypertrophy, BBB's, digoxin, hypokalemia, CNS disease (particularly sub arachnoid haemorrhage). Obviously many of these can be quickly excluded, and based on his presentation and history an ACS cause should clearly be suspected. I would initiate treatment as such (Aspirin, GTN, Morphine, Ondansatron, oxygen titrated to SPO2 >94%). I would also perform a 15 lead ECG to look for posterior ST elevation. As for destination, while I don't think a diagnosis of STEMI is possible this patient could well benefit from PCI and hence should be transported to the PCI facility, I would not call code STEMI based on my services guidelines on activating PCI but I would call through to ED to expect my arrival. 
Casey Cardwell Saturday, June 16, 2012 8:45:58 PM These are textbook De-Winter T-Waves. Highly specific for acute proximal LAD occlusion. To my mind, they should definitely go to the cath lab. Whether or not your cardiologist will be amenable to cathing the patient is a whole other thing. 
Yubraj Sedhai Wednesday, June 20, 2012 5:41:56 AM Please note the de-Winter T waves in V2 thru V6. THe forth finding is proximal LAD occlusion presenting acutely, needs to go to a cath lab. 
Allen Ramsey Thursday, June 21, 2012 5:06:54 PM I agree with Casey. These are de Winter T-wave changes which are suggestive of acute injury to the heart muscle (J-point depression in the precordial leads that upslope to a Peaked symmetrical T-wave). I would also like a 15-lead EKG in hopes that I can find standard criteria to call this a STEMI. If I don't find anything on the 15-lead EKG I don't think that I would call a STEMI on this patient because not everyone is aware of the criteria for de Winter changes on an EKG. I would consult with an ED physician and ask their advice on what they would like for us to do. I would go ahead and take the patient to the PCI center because this is where he needs to be. I would also stress to the physician that the patient truly needs a cath emergently and explain to him why. As far as treatment the pt would get O2 to keep his SaO2 above 94%. IV's at least two with normal saline at a KVO rate. The pt should receive 325mg of ASA if he hasn't already taken it. Nitrates as long as the patients BP allows. Morphine for continued pain control if Nitrates are not successful. 
