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74 year old male chest pain

by on September 16, 2011

74 y/o male patient who relates he had sub-sternal chest pain briefly yesterday that went away quickly. He went outside this morning to move gravel to try and help drainage around his house and very quickly developed sub-sternal chest pressure that radiated into his L shoulder and then moved into his R arm and his back. He rates his discomfort at a 5 or 6. He went in an laid down and rested for a few minutes but started feeling very weak. He self-administered 3 81mg ASA and when he started getting very diaphoretic his wife called 911. Upon our arrival he presented lying supine on the couch in his pajama pants, extremely pale, cool and diaphoretic, but with no anxiety. He did not complain of Nausea/vomiting or Shortness of breath, only of the chest pain and weakness. Upon our arrival he had been c/o the symptoms for about 35-40 minutes.

Initial V/S are:
BP 100/60
HR 38
RR 18 and clear
SPO2 98% room air

you obtain an EKG

A 12 Lead is then obtained

From → Case File, Education

  1. Sinus Brady with a 1st degree AVB. Acute inferior infarct with reciprocal changes in I, aVL, & V2. IV/labs, serial 12 leads, ASA (finish the 324mg dose), right-sided & posterior EKGs (Right side prior to any NTG), NTG 0.4mg x3, consult & transmit the strip. Transport to a PCI facility.

  2. Anonymous permalink

    sinus bradycardia…

  3. Anonymous permalink

    O Snap! Where’s that 15-lead?

  4. inferioposterior STEMI, sinus brady with 1st degree AV block, Right sisded and posterior EKGs if time. No SL nitro- Right to low dose nitro drip, fluids. Possibly try some atropine for HR. Other standard ACS STEMI care.

  5. Anonymous permalink

    No nitro for this guy. Inferior MI’s are very fluid dependent. He could probably use 1 liter of fluid (provided his lung sounds are clear). As long as he is not hypotensive or showing signs of AMS, I would stay away from the atropine as well. Cardiac output will improve with fluids. Increasing the rate will increase O2 demand on an infarcting heart. Bad news bears, so if he can tolerate the slow rate, it is permissible until he reaches definitive care!

  6. good points
    Nitro Drips are protocol for right sided MI in my system as they can be titrated and DC very fast.

  7. Anonymous permalink

    ray charles could see this one

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