EKG Case Study #18: Slumped Over at the Wheel

You and your partner are dispatched emergently to a  major intersection for a “slumper”. As you arrive on the scene, the fire engine personnel quickly inform you and your partner that the patient, a mid-40s male, is heavily intoxicated, but that do not believe anything else is wrong with him. You inspect the vehicle for damage, and note that there is none. As you begin to interview the patient, he states with significant slurring that he feels “sick to [his] stomach” and felt like he “was going to pass out”. At this point, you move the patient to the back of your ambulance and begin a more detailed assessment.

Vital Signs and Initial Assessment

  • GCS of 15; A/Ox4 with ataxic gait and notable slurring
  • Skin is cool, moist, and pink
  • Strong/regular radial pulses
  • Respirations appear within normal limits and unlabored with clear and equal lung sounds.
  • BP: 158/104
  • HR: 112/regular
  • RR: 20
  • SpO2: 94% on R/A
  • BGL: 91mg/dl

Medications:

  • None

Prehospital 12-Lead

Case Study 17 Picture

Prehospital Treatment

  • 324.0mg ASA
  • 3 rounds of 0.4mg SL nitro with no EKG changes
  • Bilateral large bore IVs
  • Routine vital signs acquisition with no significant divergence from original set.
  • Emergent transport to closest PCI center

Outcome

  • The patient was not having an active MI, in fact all of his labs and later EKGs were within normal limits. He was later discharged pain free with an encouragement to follow up with his cardiologist.

Discussion

  • Look at where the elevation is occurring, granted, not the cleanest 12-lead in the world. What stands out to you?
  • There is marked J-Point elevation in leads V1-V4. While all of these are anatomically contiguous and the presentation is certainly concerning, would you call a STEMI on this 12-lead?
  • This was ultimately chocked up to a case of Benign Early Repolarization (BER); however, BER is not always benign. There is an excellent write-up on Benign Early Repolarization by Life in the Fast Lane that you can access here.

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