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89 year old male, “I’m sore here!”

by on January 9, 2012

Dispatched at approximately 1700 to Sick Person for an 89 year old male. On scene, patient’s family tells us the patient, “just isn’t acting right.” Patient is CAOx3, but rambles on when he talks, which family says is unusual for him. He has a history of CHF and HTN, and we’re unable to get any further info from family. He initially says “there’s nothing wrong with me,” but after some further questioning he states “I’m sore here” and drags his hand across his chest from one shoulder to the other. He has weak, irregular radial pulses, and is diaphoretic. Placed on O2 via NRB and moved to the unit, where 12-lead was acquired. The attached file was the first 12-lead, showing diffuse depression in multiple leads, and having the ominous >>>Acute Ischemia<<< message. By this point he had also lost a radial pulse, but maintained his level of consciousness. We kept him sitting up due to his history of CHF, but raised his legs. We gave him 324mg of ASA, started an IV, and gave him 250cc of NS. We ran another 12-lead about 10 minutes later, and it showed very few changes, except the Acute Ischemia message was gone, and the depression wasn't as severe. He had a radial pulse and palpable BP by the time we got to the ER.
About 5 minutes after he got to the ER, he arrested. They got him back, transferred him to ICU, and unfortunately he died at 2 in the morning.

What do you suspect is going on with this patient?

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From → Case File

19 Comments
  1. shalom permalink

    Has the patient been taking digoxin for his a-fib? this looks like digitalis toxicity…

  2. Anonymous permalink

    i cant zoom in to see if there are p waves, but it is irregularly irregular..kinda looks like 2nd degree type 2 hb to me, but i cant enlarge 12lead to see..also has left ventricular hypertrophy.. but if you march out other complexes its too regular for a fib. maybe a few runs of afib but not the prob..

  3. Great ECG!
    This ECG shows diffuse ST segment depression in at least 6 leads (V3-V6, I, II, aVF) and ST segment elevation in aVR. This could represent either an LCA lesion or severe triple vessel disease. In an 89 year old this is almost certainly severe triple vessel disease, and the treatment would be either palliation or CABG.
    Dr. J

  4. Anonymous permalink

    irregularly regular..is what i meant

  5. Anonymous permalink

    ***irregularly regular*** is what i meant to put…

  6. robin permalink

    AAA….(.2nd to rapid changes n bp caused anurism to disect)

  7. Eric permalink

    agree with dig tox. would think left main disease would be more elevation in aVR. Also has S1, Q3,T3 suggestive of a PE especially when you factor in the a fib and sudden arrest.

  8. robin permalink

    Sooo when are you gonna tell us??

  9. unfortunately I do not have a final diagnosis of this patient unless my training department gets some feedback from the hospital. I am suspecting that there is LMCA occlusion or 3 vessel disease due to ST elevation in lead AVR and V1 with diffuse ST depression in eight leads. I am thankful for all the different posts on this case and appreciate all the different diagnosis. I will post any additional information that I get on this case, if any.

  10. ECG definitely looks ischemic, with or without dig on board.
    As others have pointed out, it definitely fits the description of a tracing for left-main or triple-vessel disease. That’s my top concern, but I’m also worried about other causes of global myocardial ischemia, especially if you combine them with underlying coronary arteries disease. Based off his presentation, chief among those would be occult bleeding or aortic dissection, which could lead to reduced oxygen delivery to the heart and an ischemic ECG in the face of CAD without an acute occlusion.
    In any case, saldy, there probably wasn’t much that could be done for the guy.

  11. Dave B permalink

    Also, don’t overlook the QTc of 501… that puts the patient at immediate risk for VT, and sure enough he arrested. I’m not saying that is the cause, but if we risk stratify, that factor is up there with the rest of them.

  12. AJO permalink

    I agree with Dr. J. And it is very sad that he wasn’t treated? Was there more to the story?

  13. Anonymous permalink

    since when do you go by what lead aVR reads?? It is a lead that you do not look at or diagnose from…

  14. Anonymous permalink

    aVR is not a contiguous lead…it reflects no certain aspect of determining diagnosis.

  15. @Anonymous, don’t overlook the importance of lead AVR, which is often overlooked by prehospital providers. AVR can and does give us valuable information. You can read more about lead AVR by Dr Smith here. http://hqmeded-ecg.blogspot.com/search/label/aVR

  16. This post is added at the request of Dr. Aaron Johnston
    BSc, MD, CCFP EM,

    Think of lead aVR as the Rodney Dangerfield lead, it just can’t get no respect!

    aVR is often ignored because it does not represent a specific anatomic area or vascular distribution of the heart. However there is data showing both that ST elevation in aVR in the setting of ACS is associated with a poorer prognosis and that ST elevation in aVR associated with widespread ST depression elsewhere on the ECG is associated with 2 specific anatomic lesions, LMCA lesions, and severe triple vessel disease.

    aVR is also the lead we look to to see the slurred treminal R wave that is the first evidence of cardiotoxicity in tricyclic antidepressant overdose.

    So aVR is far from useless, though it is often taught to ignore this lead, it is actually quite useful. Here are some resources with more information.

    http://hqmeded-ecg.blogspot.com/2011/04/st-elevation-in-avr-with-widespread-st.html
    http://lifeinthefastlane.com/2010/05/another-widow-maker/

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