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Run of the mill
Can you interpret these ECGs?
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By Tom Bouthillet
| Editor's note: Check out this month's ECG case study and submit your treatment plan in the comments below. Get it right and you could win an EMS1 T-shirt and bottle opener. Good luck! |
UPDATED: 02/24/2011 - Patient Follow-Up Posted. CLICK HERE FOR THE ANSWER
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EMS responds to a fitness center where an elderly female has experienced a syncopal episode.
On arrival, the staff leads a paramedic and her EMT partner to the 68-year-old female who is lying supine next to a tread mill.
She appears pale, diaphoretic, and acutely ill.
A nurse is holding a gauze pad to the patient's forehead. A look under the gauze reveals a laceration and hematoma the size of a silver dollar.
Vomit is noted on the floor next to the patient's head.
The patient is conscious but listless and oriented to person, place and time but not event.
When asked if she has any pain the patient says, "Yes" and then rolls on her side and begins throwing up.
The radial pulse is slow and barely palpable. The patient seems very weak.
She denies neck or back pain. There is no pain or tenderness on palpation of the cervical spine.
The patient is placed flat on the gurney and vital signs are assessed.
Resp: 12 and shallow
Pulse: 40 and regular
NIBP: 81/43
SpO2: 96 on RA
Breath sounds are clear bilaterally.
The cardiac monitor is attached.
A 12-lead ECG is captured.
How would you treat this patient and why? Tell us in the comments below — get it right and you could win an EMS1 T-shirt and bottle opener.
Aaron Craig Friday, April 13, 2012 7:04:45 AM 1. Keep patient warm and comfortable in the supine position.
2. Oxygen delivered via nasal cannula - keep sats as high as possible.
3. Baby ASA
4. Fluid bolus 500mL and repeat after checking breath sounds.
5. Contact closest facility with cath lab to activate code STEMI.
6. Consider asking for orders for heparin or LWMH.
7. Consider pacing if patient becomes unstable with change in mental status, chest pain, shortness of breath, etc.
8. Transport with lights and sirens!
This patient is having an inferior MI as evidenced by ST elevation in leads II, III, aVF with additional elevation in leads V1 and possibly V2, V3. There is reciprocal changes in the lateral leads. Most likely the SA node is involved leading to her bradycardia. In addition, forward flow of blood from the right ventricle to the left ventricle has been compromised thus leading to hypotension - i.e. cardiogenic shock. This would exclude nitro and morphine in management because they would further reduce preload and worsen her systemic blood pressure. It is best to transport quickly to a hospital with cath lab capabilities as this lady's presentation carries a poor prognosis.
Thanks,
Aaron 
