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ECG -- November 2016

Case presentation

A 60 year old male presents with shortness of breath, nausea, dizziness, and epigastric abdominal and chest pressure radiating to the retrosternal area.  BP 95/45, RR 24, O2 Sat 92%. GCS is 15.

Case study

 

1.

What does this ECG show?

Rate

57

Rhythm

Sinus

ST Elevation?

Yes!

Which Leads

II, III, aVF

Location (if STEMI)

Inferior with Posterior Extension

Reciprocal Changes?

Yes – T wave inversion V1-V3 with ST depressions in V3


                                                                                                                                                                                  

In the following diagrams, the green lines connecting adjacent P waves to T waves indicate the electrical baseline.  ST elevations are shown in II, III, and aVF, representing the inferior wall of the left ventricle.

Case study

Reciprocal changes can be seen in the anterior & septal walls of the left ventricle, noted here as inverted T waves in V1 through V3, with depression of the ST segment in V2 and V3.  Although not always present, the reciprocal changes further support the interpretation of STEMI on this ECG.

Case study

2.

How would you manage this patient? 

This patient should receive Aspirin 162-324mg PO after ensuring that he has no allergies to the medication. With an oxygen saturation of 92% he should be immediately placed on Oxygen by cannula or NRB titrated to an O2 Saturation >94%. He should not be given NTG to treat his chest pain as this is likely to worsen his hypotension and may lead to shock in the setting of an inferior infarct. A fluid bolus of 250 mL (reassess and may repeat) may improve filling pressure and should be given. The patient’s bradycardia is likely responsive to acute ischemia. Therefore atropine should only be given if the patient develops evidence of poor perfusion, such as profound hypotension or altered mental status.

 

The EKG should be transmitted for advance notification and review by the emergency physician and Cardiology team.


By Shira A. Schlesinger MD, MPH, Los Angeles County EMS Agency
Acknowledgements: The EMS Agency would like to thank Dr. Clayton Kazan, Medical Director, Los Angeles County Fire Department, for his contribution of the above ECG