EKG case: Why did a patient's cardiac rhythm change during transport?

What's your assessment and care for a patient who had evidence of a STEMI, but is now pain free?


Article Updated July 31, 2017

As this 12-lead EKG case will demonstrate, it is important to look at the entire picture when responding to a call and to understand why a specific  treatment or no treatment at all may be the best option. Please review the following case and offer your thoughts on potential treatments you would initiate for this patient.

Patient presentation: Female having a STEMI is now pain free

ALS1 is dispatched to a rural medical facility to transport a patient diagnosed with an acute coronary syndrome to the closest cath lab, which is about 55 minutes away. Upon arrival, you are briefed on the current status of your patient: She is a 64-year-old diabetic, hypertensive female, who was brought to the facility an hour ago with evidence of a STEMI.

She arrived within 30 minutes of her symptoms' onset and has been treated with aspirin, heparin and thrombolytics for several minutes now. She reports that she is pain-free and actually feels much better. 

Primary assessment:

The patient exhibits no change in her current condition. She denies feeling any chest pain, dizziness, dyspnea, palpitations or any other discomfort. She is alert, conscious and oriented to person, place and time.

Patient's vital signs: 

Heart Rate: 84 bpm
Respirations 18 rpm
Blood Pressure: 110/80 mm Hg
SpO2: 98 percent  on 3 lpm of oxygen

Past medical history:

Diabetes
Hypertension
Denies any prior cardiac history

Allergies:

No known drug allergies 

Meds:

Metformin 850mg
Enalapril 20mg

On the hospital's monitor, you see a normal sinus rhythm without PVCs. After completing the appropriate paperwork and information regarding the patient, you and your partner attach your cardiac monitor monitor, connect her to your portable oxygen cylinder, load her onto the stretcher and attach the IV bags into the stretcher IV pole.

As your patient continues to calmly talk to you en route, you glance at the rhythm monitor casually and notice a rhythm change.

Initial EKG (click for larger image):

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Complete your own interpretation of the 12-lead EKG using the steps recommended by the EKG Club.

Consider these questions about the patient's condition and best course of treatment. 

  • Given the 12-lead EKG and initial assessment, would you divert the patient to a closer facility?
  • What interventions, if any, would you carry out?
  • What medications may be indicated?

Patient follow-up: What are the 12-lead EKG findings for accelerated idioventricular rhythm

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