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Written by Pendell Meyers A man in his 40s called EMS for acute chestpain that awoke him from sleep, along with nausea and shortness of breath. Learning Points: Currently by definition, there is unfortunately no such thing as a formal diagnosis of STEMI or STEMI criteria in the setting of RBBB and LAFB.
Written by Jesse McLaren Two patients in their 70s presented to the ED with chestpain and RBBB. Patient 1 : a 75 year old called paramedics with one day of left shoulder pain which migrated to the central chest, which was worse with deep breaths. Do either, both, or neither have occlusion MI? Vitals were normal.
The VSR is what is causing the cardiogenicshock! It has been estimated that in the aggregate, they occur at a rate of about 3 per 1000 patients with acute MI, and most of these events occur in patients with STEMI. Not all patients with acute ( or recent ) MI have chestpain with their event.
Bad chest pressure with severe left shoulder pain 3 nights ago. Now appears to be in cardiogenicshock." However, cardiogenicshock usually takes some time to develop, so it is probably subacute." This can only be due to STEMI. I was texted these ECGs. Then SOB and nausea the next day.
Written by Kaley El-Arab MD, edits by Pendell Meyers and Stephen Smith A 61-year-old male with hypertension and hyperlipidemia presented to the emergency department for chest tightness radiating to the back of his neck that has been intermittent for the past day or two. Here is his triage ECG which was obtained at 20:34 during active pain.
A 50-something man presented in shock with severe chestpain. The patient was in clinical shock with a lactate of 8. There is an obvious inferior posterior STEMI(+) OMI. Results Of 149 patients with inferior STEMI , 43 (29%) had RVMI and 106 (71%) did not. He appeared gray in color, with cool skin.
This 54 year old patient with a history of kidney transplant with poor transplant function had been vomiting all day when at 10 PM he developed severe substernal crushing chestpain. At first glance, it seems the patient is having a STEMI. ACS and STEMI generally do not cause tachycardia unless there is cardiogenicshock.
A middle-aged patient with lung cancer had presented to clinic complaining of generalized malaise, cough, and chestpain. Symptoms other than chestpain (malaise, cough in a cancer patient) 2. I have always said that tachycardia should argue against acute MI unless there is cardiogenicshock or 2 simultaneous pathologies.
[link] A 30 year-old woman was brought to the ED with chestpain. She had given birth a week ago, and she had similar chestpain during her labor. She attributed the chestpain to anxiety and stress, saying "I'm just an anxious person." examined SCAD presenting as STEMI (unlike Hassan et al.
The following are the KEY clinical and ECG features that establish the diagnosis of W ellens ' S yndrome : There should be a history of prior chestpain that has resolved at the time the defining ECG is obtained. The ChestPain required for the definition of Wellens' Syndrome occurred at the time of coronary occlusion.
Case submitted by Rachel Plate MD, written by Pendell Meyers A man in his 70s presented with chestpain which had started acutely at rest and has lasted for 2 hours. The pain was still ongoing at arrival. He was in cardiogenicshock requiring an impella for several days after cath.
Edits by Meyers and Smith A man in his 70s with PMH of hypertension, hyperlipidemia, type 2 diabetes, CVA, dual-chamber Medtronic pacemaker, presented to the ED for evaluation of acute chestpain. Code STEMI was activated by the ED physician based on the diagnostic ECG for LAD OMI in ventricular paced rhythm. Limkakeng AT.
The conventional machine algorithm interpreted this ECG as STEMI. Taking a step back , remember that sinus tachycardia is less commonly seen in OMI (except in cases of impending cardiogenicshock). See this post of RV MI with both McConnell sign and "D" sign: Inferior and Posterior STEMI. Both were wrong.
This 51 yo male complained of chestpain, then had a v fib arrest. He was in cardiogenicshock. As you will see, this results in the discovery of ST elevation in V2-V4 and I and aVL, diagnostic of anterolateral STEMI. The patient died 8 hours later of cardiogenicshock.
A man in his 60's presented after 4 days of chestpain, with some increase of pain on the day of presentation. Exact pain history was difficult to ascertain. Thus, this is BOTH an anterior and inferior STEMI in the setting of RBBB. How old is this antero-inferior STEMI? There was some SOB. How acute is it?
A man in his 70s with past medical history of hypertension, dyslipidemia, CAD s/p left circumflex stent 2 years prior presented to the ED with worsening intermittent exertional chestpain relieved by rest. This episode of chestpain began 3 hours ago and was persistent even at rest. Troponin was ordered.
The patient in today’s case is a previously healthy 40-something male who contacted EMS due to acute onset crushing chestpain. The pain was 10/10 in intensity radiating bilaterally to the shoulders and also to the left arm and neck. The ECG shows obvious STEMI(+) OMI due to probable proximal LAD occlusion.
Just the fact of chestpain and highly elevated troponin is enough to activate the cath lab, but here you can see just how subtle hyperacute T-waves can be. Troponin T peaked at 2074 ng/L (very high, typical of OMI/STEMI). Post PCI the patient became gravely hypotensive and "shocky". The LV EF was 57% at formal echo.
Jesse McLaren (@ECGcases), of Emergency Medicine Cases Reviewed by Pendell Meyers and Steve Smith An 85yo with a history of hypertension developed chestpain and collapsed, and had bystander CPR. The patient was brought to the ED as a possible Code STEMI and was seen directly by cardiology.
This pattern is essentially always accompanied by cardiogenicshock and high rates of VT/VF arrest, etc. The patient arrived to the ED in cardiogenicshock but awake. Code STEMI was activated. What is the Diagnosis in this 70-something with ChestPain? in-hospital mortality was 18.8%
It was edited by Smith CASE : A 52-year-old male with a past medical history of hypertension and COPD summoned EMS with complaints of chestpain, weakness and nausea. Clinical Course The paramedic activated a “Code STEMI” alert and transported the patient nearly 50 miles to the closest tertiary medical center. What do you see?
A middle aged man had off and on chestpain for 2 weeks, then 2 hours of more severe and constant pain. When the ST vector is primarily posterior, the diagnosis is usually posterior STEMI. Here was his ED ECG, which was identical to the prehospital ECG. He did not get prehospital activation. What do you think?
This has been termed a “STEMI equivalent” and included in STEMI guidelines, suggesting this patient should receive dual anti-platelets, heparin and immediate cath lab activation–or thrombolysis in centres where cath lab is not available. aVR ST segment elevation: acute STEMI or not? aVR ST Segment Elevation: Acute STEMI or Not?
Then the notes mention "cardiogenicshock" but without any reference to a cardiac echo or to a chest x-ray. Now chestpain free. Cardiologist note says: "Elevated troponin explained by type II MI due to her shock." Trop T now very high, well into the range one sees with a STEMI; very unusual in type II MI.
When total LM occlusion does present with STE in aVR, there is ALWAYS ST Elevation elsewhere which makes STEMI obvious; in other words, STE is never limited to only aVR but instead it is part of a massive and usually obvious STEMI. All are, however, clearly massive STEMI. This is her ECG: An obvious STEMI, but which artery?
He was asked multiple times about chestpain or dyspnea, but repeatedly denied any such symptoms. Patient denied chestpain on initial review of symptoms. Was now endorsing chestpain which began 30 minutes ago. Upon further questioning, he states that he has had intermittent chestpain since yesterday.
This was my response: If it is the right clinical situation, such as acute chest discomfort, it looks like proximal left anterior descending occlusion with right bundle branch block and left anterior fascicular block. Because of the tachcardia, I would expect her to be very poor left ventricular function and maybe Cardiogenicshock.
Written by Pendell Meyers An adult man presented with acute chestpain. See our other cases with similar patters, to burn this deep into your brain files: Smith : In my experience, these cases of LAD OMI with RBBB and LAFB are either about to arrest, post-arrest, and/or in cardiogenicshock. He appeared critically ill.
A 69 year old woman with a history of hypertension presented to the emergency department by EMS for evaluation of chestpain and shortness of breath. She awoke in the morning with sharp chestpain which worsened throughout the morning. As her pain worsened, so did her dyspnea. Also see these posts of Type II STEMI.
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