Updated: Sep 19, 2019
• Case: Call in from EMS field team. 71 year old male with a history of HTN, HLD , diabetes and 40 pack year smoking called 911 for chest pain and dizziness. Vitals signs are significant for BP 92/54, HR 30-60 irregular, normal O2 saturations. Physical exam significant for diaphoresis, irregular and bradycardic heart sounds with no murmurs appreciated clear lungs on auscultation, no JVD or peripheral edema. She is maintaining her airway but is intermittently confused. EMS say they have a 10 minute transport time to hospital. How will you manage this patient?
• Make the diagnosis!
• Inferior wall STEMI with T-wave inversion in the lateral limb leads. Possible early
high lateral precordial lead STEMI
• Atrial fibrillation
•Management and Learning Points
• Activate STEMI alert for inferior STEMI criteria
• Consider holding nitroglycerin for pain with possible RV wall extension. Can
place right sided leads if clinical suspicion for RV extension and acute RV
failure. Trial morphine as first line agent if needed.
• Cardiac POCUS for visualization of hypokinesis when patient arrives
• Profound bradycardia, high risk for extension of ischemia to cardiac electrical
conduction system and high grade block
• Given patient’s confusion and hypotension, strongly consider
• Put defibrillator pads on early by EMS.
• Prepare for transvenous pacing in ED if necessary
• Intermittent confusion, borderline hypotension
• No signs of acute right heart failure, can support with IV fluids used
• Confusion can be a sign of an inadequately perfusing atrial fibrillation,
consider cardioversion if worsening hypotension refractory to IVF or further
degradation in mental status
• Never forget a fingerstick glucose!
Author: Greg Fischer, PGY2 EM
Residency: Jefferson Northeast