EKG Case Study #15: Mowing the Lawn Leads to Chest Pain

HPI

You and your partner are called emergently to a private residence for a 50yom experiencing chest discomfort and shortness of breath. The patient is seated on his front steps, stating that the pain started shortly after mowing his lawn approximately 45 minutes ago. The pain is dull and mid-sternal; the patient also has gerd, and states that he went inside and took “an Alka-seltzer” with no relief. His skin is flush, moist, and warm.

HISTORY

  • Gerd
  • HTN
  • Smoker

MEDICATIONS

  • Lisinopril
  • Pantoprazole
  • Nicotine patches

ALLERGIES

  • NKDA

12-LEAD

STEMI

VITAL SIGNS

  • BP: 168/104
  • RR: 28bpm
    • Unlabored but tachypneic
    • Lung sounds are clear and equal bilaterally
    • Patient able to speak in complete sentences between breath
    • Equal rise and fall
  • HR: 76/equal with a bounding pulse
  • SpO2: 96% on R/A
  • BGL: 139mg/dl

TREATMENT

  • 324.0mg ASA
  • O2 @ 2lpm via cannula
  • Large bore IV start with lab draw
  • 0.4mg SL Nitro with no pain improvement
  • 100.0mcg Fentanyl IV with no pain improvement
  • 4.0mg Zofran IV with improved nausea

FOLLOW UP

  • Crew called a STEMI activate from the field
  • Emergent transport to PCI Center
    • No change in vital signs or mentation en route
  • 100% LAD occlusion
    • PCI performed with full recovery

TALK POINTS

4 thoughts on “EKG Case Study #15: Mowing the Lawn Leads to Chest Pain

  1. Jayson McConnell

    With the 12 lead findings i would have expected a LCA occlusion instead of just LAD occlusion and here is why. 12 lead shows high lateral wall injury(lead I and aVL from one of the diagonal arteries off the LAD) but also anterior and additional lateral wall injury suggestion LCX occlusion as well. Am i worried about progression to VF…..HELL YES, and grab the pads asap. Nitro drip would have been helpful here if it’s in the protocols. Fentanyl IV push for pain relief for cardiac pain i’m still not all the way on board with even though there are studies showing some benefit. I feel like morephine and dilaudid still prove superior in the catigory of cardiac related pain relief.

    Thoughts about bipap support therapy in the presence of STEMI???

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    1. CPR Podcast

      We were a little surprised ourselves looking through the follow up on the call about it being solely LAD and not LCA. Nitro drips are fantastic for their ability to be titrated. As far as BiPAP in the presence of a STEMI, I like to think of the adage, “don’t exchange a real problem for a hypothetical one”. If someone needs pressure support, give them pressure support. I think overoxygenating our STEMI patients is an epidemic and needs to be corrected, however, I wouldn’t probably hesitate to do it if someone needed it.

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  2. ResusMedic

    All my AMI patients are quickly monitored via defibrillator pads with concurrent limb leaf placement [should pacing become indicated]
    I agree that over-oxygenatuon is an epidemic that few services consider. “SpO2 greater than 94, what do we need it for?”
    When I see a 12-lead that doesn’t quite match the injury pattern, I often wonder about their collateral blood flow. I’m just kind of riffing here, but I suspect that a gradually worsening cardiac muscle has time to compensate with increased collateral blood flow. Thus a subsequent acute broken plaque/thrombus event causes an obscured infarct pattern.
    Just my thoughts; I’ll be interested to find some more research on the subject.

    Liked by 1 person

    1. CPR Podcast

      Those are all fantastic insights; I am happy to see the introduction of provisions within standing orders to see clauses like that now.

      Like

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