EKG CASE STUDY #7: 60YOM C/O Chest Pain and Dyspnea

This study was donated to us from a friend working in a nearby rural EMS service, and is a treasure trove of conversation topics. Let’s get started. 

HPI

You and your partner are called to a private residence out in the county for a 60YOM complaining of chest. As you arrive on scene, you see the patient seated in his recliner looking obviously distressed and anxious. The patient tells you that he finished his dinner approximately an hour ago and went to sit down and watch t.v. afterwards. While at rest, the patient began to develop significant chest “pressure” that begins to travel down his left arm. As the pain worsens, he decides to call 911.

INITIAL ASSESSMENT

  • Patient is a GCS of 15 with no noted neurological deficits noted
  • Skin is pale, cool, and profusely diaphoretic
  • Weak/regular radial pulses noted
  • No obvious signs of trauma noted
  • Resp rate appears elevated and mildly dyspneic
    • L/S are clear/= throughout

VITAL SIGNS

  • B/P: 124/74
  • HR: 64/regular
  • RR: 20
  • SpO2: 97% on R/A

INITIAL RHYTHM STRIP AND 12-LEAD

EKG Case Study #7 5-Lead

EKG Case Study #7- 1st 12 Lead 001

Upon seeing the first 12-lead, you call for first responders to make your scene for extra personnel to drive you to the hospital. You are approximately 10 minutes away from a community hospital that has no cardiac capabilities, and are about 45 minutes away from a PCI facility. It’s raining outside and no  helicopter will meet you for transport; this is your patient.

INITIAL TREATMENT

  • 324mg PO ASA
  • 18g Saline Lock established in the R forearm
  • 0.4mg SL nitroglycerin
    • Patient states that initial 8/10 pain improves to 5/10
  • 180mg PO Ticagrelor (a platelet aggregation inhibitor) per local protocol
  • Oxygen via NC @4lpm
  • 12-Lead transmitted to receiving hospital; receiving hospital notified about patient and ETA
  • Transport initiated
  • 0.09% NS hung; initial 250ml bolus due to obvious signs of poor perfusion and nitroglycerin administration with a borderline B/P
  • B/P reassessed: 124/74; no gross changes in RR, HR, or SpO2%
  • 0.4mg SL nitroglycerin
    • Patient states that 5/10 pain improves to 3/10
  • Secondary IV access obtain with a 20g in the L AC
  • 0.4mg SL nitroglycerin
    • Patient states that 3/10 pain improves to 2/10

DURING TRANSPORT

The patient states that the relief he was getting from the SL nitro is beginning to dissipate and now his pain waxes and wanes, but is beginning to feel worse than it did before he called 911.

  • Nitroglycerin drip initiated @5.0mcg/min

Crew elects to due a 15-lead due to initial inferior involvement in the initial 12-lead

15-LEAD FINDINGS

EKG Case Study #7- 15 Lead 001

  • Is there any posterior involvement? 
  • Right-sided involvement? 
  • What are the dangers of giving nitroglycerin with r-sided involvement? 

In the not so distant future, we will be doing a blog detailing how and when to do a 15-lead on your cardiac patients, so keep your eyes peeled.

The patient continues to state that his pain is getting worse despite nitroglycerin infusion; drip titrated from 5mcg/min to 10mcg/min. Patient’s blood pressure is sustaining in the 130/90 range with no gross changes in HR, RR, or SpO2. Patient reports that the pain no longer feels like a “pressure”, but states that it is starting to feel like a “crushing” pain.

  • Nitroglycerin titrated to 15mcg/min; BP maintains with no improvement in pain noted
  • 2mg IV morphine with no change in pain noted
  • 8mg of IV ondansetron with mild relief from nausea and vomiting

REPEAT 12-LEAD

EKG Case Study #7 2nd 12-Lead 001

What type of involvement do you see? 

  • Patient given 2mg of IV morphine with no change in pain or vital signs.

On arrival to the PCI center, patient was transported directly to the cath lab with nitroglycerin and 0.09% NS infusion still running; total of 1.88ml of nitroglycerin infused as well as 700ml 0.09% NS.

DISCUSSION

  • Would your treatment modalities changed if you were in an urban setting vs. a rural setting? 
  • Would you have done anything different? Why? 
  • What is the benefit of performing a 15-lead? What did it show here? 

One thought on “EKG CASE STUDY #7: 60YOM C/O Chest Pain and Dyspnea

  1. Pingback: CPR PODCAST

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