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50 year old male woke up with chest pain

by on April 8, 2011

Sorry about the poor quality of this ECG, This copy found at a local ER.

0638 EMS arrives on scene to find approximately 400 lb man sitting on the edge of his bed at home. He states that he was sleeping when he was awaken by sever chest pain. He looks pale and appears in anxious. Skin is w/d, lungs clear = bilateral. He has a history of Coronary artery disease and coronary artery bypass grafting in 2003.

BP is 140/70
RR is 20
no other information available

Non PCI center is 10 mins away, PCI center is 30 mins away. What’s going on and how do you treat?

From → Case File

  1. bashir hussein permalink

    myocardial infarction…..

  2. thanks bashir, how would you treat?

    • Toyanna Frye permalink

      There is definite elevation in II, III, and aVF with st-depression in I and aVL and there appears to be t-wave inversion in V4-6. Definitely an Inferior MI. High flow O2, 324mg of ASA PO, 3 SL nitro sprays as long as he maintains his stable B/P, and possibly morphine en route if the pain does not decrease. I would transport on to the PCI center for definitive care!

  3. Tanee Thomas permalink

    I agree w/ Miss Toy’s treatment, granted it is not a right sided MI. I see elevation in II, III,AVF with depression in the high lateral leads. Jeff, tell me again the significance with the T wave inversion in I and AVL. And what leads go where to show a 15 lead, to see if a right sided MI is a valid concern. Your awesome for doing this! Thank you!!!

  4. Tanee, to obtain a 15 lead ekg, just take v4 and move it to 5th intercostal midclavicular on the right side to get V4r. Knowing if a person has a posterior wall MI in the presents of a inferior MI is really not that important. The most important is identifying RVI. Being prepared for BP drop after NTG administration by either giving a fluid bolus before administration or by having IV lines in place. Also remember it would be safe to assume RVI is involved if the pt has an inferior MI and the rate is brady and the BP is low or marginal and the lungs are clear with no JVD present.

  5. aetheranobis451 permalink

    I see elevation in II, II, aVF, with reciprocal depression in 1 and aVL which is classic for Inferior wall MI. I also see some T-wave inversion in the lateral precordial leads. Oxygen, ASA, right sided 12-lead to rule out RVI, and if none, NTG SL (as long as no ED drugs taken) and off for the 30 minute ride to the PCI center. With transmission of the ECG to the receiving center if possible.

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