EKG Case Study #11: Mid-40s Male C/O Weakness

This run was submitted to us by a friend of the podcast; this friend works in an urban EMS service. 

You and your partner are dispatched to an illness at a private residence for a mid-40s male that states he has been feeling weak off an on all day. He had just gotten back from work that day, when he grew weaker and decided to lie down on the couch. After about 30 minutes, the weakness grew worse still and he became nauseated. The patient is actively vomiting when you walk into the room. The patient tells you that he doesn’t know of any medical problems that he has been diagnosed with, and denies taking any prescription medications or having medication allergies.

INITIAL ASSESSMENT

  • Patient is a GCS of 15 w/no neurological deficit noted
  • Skin is ashen, cool, and diaphoretic
  • Weak/regular/slow radial pulses detected
  • Respirations appear eupneic, pain free, and quiet w/clear and = L/S noted throughout
  • No obvious indicators or trauma noted

INITIAL VITAL SIGNS

  • BP: 104/62
  • HR: 52/regular
  • SpO2: 96% on R/A
  • RR: 20bpm
  • Blood Glucose: 136mg/dl

I won’t insult the intelligence of you guys, anymore. After all, this is an EKG blog. Your partner turns on the monitor, and you can only imagine what you can find.

INITIAL 4-LEAD AND 12-LEAD

EKG Case Study #11 4-Lead 001

EKG Case Study #11 001.jpg

What part of the heart is affected? Is this patient a candidate for a right-sided 12 lead

TREATMENT

Crew immediately administered 324mg PO Aspirin, and had no access to any other types of platelet aggregant inhibitors or anticoagulants. Patient was loaded on the stretcher, and transport was initiated to closest PCI (about 10 minutes away). Successful large bore IV access gained and 250ml 0.09% NS bolus initiated due to borderline blood pressure. Patient received 4.0mg ondansetron and three rounds of 0.4mg SL nitroglycerin with a blood pressure of 168/100 on delivery to the ED physician. No other 12-leads were provided and no other interventions were done. Follow up with the ED physician reveals that the patient had an 80% LAD occlusion and a 100% Circumflex occlusion. The patient had three stents placed, and was sent home after a short ICU stay.

DISCUSSION

  • This crew did not give oxygen to the patient; no complaint of dyspnea or distress was noted. What are your thoughts on whithholding O2 to the STEMI patient that is not in distress?
  • What would you have done differently?
  • What are your thoughts on fluid therapy in the presence of STEMI?
  • Would your care have changed if you were in a rural setting?

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