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55 yo male chest pain

by on June 25, 2015

EMS calls for air medical transport.  EMS give report to air crew stating that they have a 55 yo male patient that is not feeling well. They state that the pt has a hx of HTN and some coronary issues in the past.  Pain is 8/10 with shortness of breath and some nausea.  They have him on 15lpm NRB and have ran a 12 lead and they report inferior MI.  They have started one IV in the hand running at KVO rate.  They report BP is 150/80.

No NTG given per the crew due to the Inferior MI.  They wish for the Air Crew to continue treatment and transport.

EKG

20150625_195550-1

What do you Think about this call? Do you think the EMS crew should have given the patient NTG?

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From → Case File

4 Comments
  1. Christian O permalink

    Are these medics or EMTs doing the hand off.

    Did they check right side leads? Rarely see a BP of 150/80 w/ right sided involvement in my experience.

    Nitro administration should be used with caution but is not contraindicated.

  2. If one follows the current of injury (the ST elevation), it is pointing down toward the inferior surface of the heart and thus toward the inferior leads. There is also reciprocal change in aVL because the ST injury vector is more positive than +60 degrees. There is also ST depression in V1 – V3. The ST depression in V1 is very mild compared to the other two leads. To see why, we just look at the ST injury vector in Lead I. There is ST depression there and that is because the ST injury vector is pointing to the right of +90 degrees and thus straight at the free wall of the right ventricle. Had right-sided chest leads been done, I’m sure one would have seen STE in V4R. There is probably some ST elevation in V1 due to the right ventricular infarction, but it has been counterbalanced by the ST elevation posteriorly (or actually, laterally). Thus there is a very mild ST depression in V1 because of the cancellation of the right/anterior ST injury vector. Therefore, the answer is “No, NTG should not have been given.”

  3. Anonymous permalink

    i definitely agree with Jerry W Jones MD

  4. JHT permalink

    The elevation in lead III is greater then lead II which is indicative of right ventrical involvement. Also note the depression in the right precordial leads this is further evidence that there is posterior wall involvement. No nitro was the correct treatment.

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