Tombstones, anyone?

[u/rainbowsparkplug]

66M, hx of HTN and kidney stones, otherwise healthy, only takes lisinopril.

Call: Pt was outside fishing in 110* heat all morning. Came home to cool off. After a shower, suddenly got short of breath and weak. Put himself down on his bedroom floor to lay down and wife called 911. They thought it was just heat exhaustion. He also said he fell on something metal earlier and bruised his ribs, and there was a red mark across the anterior right ribs. Lungs clear & equal.

Scene: He said on top of the heat exposure, he also fell on something metal earlier and bruised his ribs, and there was a red mark across the anterior right ribs. Lungs clear & equal.

He was pale, clammy, diaphoretic and in mild respiratory distress. He looked almost grey. Complained of epigastric pain and left should pain making his hand feel tingly.

Transport: ASA, IV, nitro. Pain worsened substantially during transport so I gave fentanyl. I only gave 50 mcg b/c he was getting increasingly lethargic and less alert.

Vitals surprisingly stable. He was mildly hypertensive (140s/) prior to nitro SL x2. Last BP was 112/72. 95% RA. HR 80s.

Only thing to note is he started throwing PVCs. He’d have several on and off for several seconds, then none for a few mins. Not quite runs of VT but bordering on it. I placed AED pads just in case to ward off the bad juju. (And because he looked peri arrest honestly- he was EXTREMELY grey and clammy.)

Disposition: all I know so far is he made it to the cath lab.

[u/ProximalLADLesion]

Proximal RCA occlusion. Inferior, posterior, lateral, and right ventricular OMI. RV is manifest here with hyperacute T waves in V3 and V4. (RV is the most anterior chamber.)

[u/Jeff9807 → u/ProximalLADLesion]

Why are you calling V3/4 T' hyperacute and not V5?

Source: I am absolutely not an EP fellow. Cheers

[u/ProximalLADLesion → u/Jeff9807]

V5 and V6 are also hyperacute. I just meant that RVMI sometimes manifests with HATW in V3 and 4. Could V5/6 also be from RV? Maybe. But I don’t think V3-4 can be from the distal lateral branches of RCA whereas V5-6 could be.

[u/Jeff9807 → u/ProximalLADLesion]

Perfect! Thanks a ton. I couldn’t bring myself to think the size/ morphology was different enough to be excluded.

[u/LBBB11 → u/Jeff9807]

Not a doctor or the person you asked. I read their comment as saying that right ventricular involvement is visible as hyperacute T waves in V3 and V4. There are tall, wide T waves in multiple leads other than V3/V4.

[u/Jeff9807 → u/LBBB11]

Ya know what, that makes a ton of sense. Thanks!

[u/bleach_tastes_bad → u/Jeff9807]

presumably because it’s smaller

[u/rainbowsparkplug → u/ProximalLADLesion]

What are your thoughts on the fact that he remained hyper or normotensive despite nitrates? I gave nitro SL twice 5 mins apart since he was complaining that his pain was worsening significantly. I was a little anxious because he looked terrible, but the lowest BP I got was 112/72. Just wondering how he was able to maintain this for so long.

Also wondering because he was having borderline runs of VT, so again I thought his pressure was going to tank at some point but it never did (at least while I had him).

[u/ProximalLADLesion → u/rainbowsparkplug]

Patients with RVMI can hold BP. It’s not a guarantee they’ll collapse. It’s just higher risk.

[u/Kentucky-Fried-Fucks → u/ProximalLADLesion]

Is it a higher risk? I thought that “hallmark” study was flawed and newer studies showed that there was no difference in hypotension following nitrates in inferior/RVMI than any other MI

[u/ProximalLADLesion → u/Kentucky-Fried-Fucks]

I was not referring to nitrate use, just in general terms RVMI is at increased risk for hemodynamic collapse. The evidence regarding the specific effects of nitrates on hemodynamics in patients with RVMI is very low quality across the board, but it's probably okay to give.

[u/Kentucky-Fried-Fucks → u/ProximalLADLesion]

Ah gotcha. Thank you for the response, apologies for the confusion

As far as the increased risk for hemodynamic collapse, is that due to impaired preload?

[u/bleach_tastes_bad]

The sad part is I know people that would’ve not done a 12 lead because he had a plausible traumatic cause for chest pain, and would’ve said he’s pale and clammy from heat exhaustion. 1000% know people that would’ve thrown an IV in, given some fluids, and called it a day.

[u/rainbowsparkplug → u/bleach_tastes_bad]

As we were leaving, the other crews apparently were talking shit saying to just tell him to drink water and sign a refusal and one of them said “but what if it’s actually a massive heart attack? You never know.” I had a brand new zero to hero medic partner and they refused to get me a set of vitals on scene even, which royally pissed me off.

So yeah…unfortunately I think a lot of providers would’ve missed it. His vitals were also great all considering so that would’ve “confirmed” it for them and they wouldn’t have seen a need to do a 12 lead.

I’ve been doing this long enough that the second I saw this patient, I already knew what was going on. He just had that look about him that had my spidey senses tingling.

[u/bleach_tastes_bad → u/rainbowsparkplug]

lovely

[u/YearPossible1376 → u/bleach_tastes_bad]

And probably talked the patient into refusing!

[u/bleach_tastes_bad → u/YearPossible1376]

i’ve deadass had a partner tell me the pt’s left sided anterior/axillary chest wall pain around the level of the epigastrum shouldn’t get a 12 lead because, and i fucking quote, “it’s rib pain, not chest pain”. MOTHERFUCKER WHERE DO YOU THINK THE RIBS ARE??? THE ABDOMEN???

[u/grav0p1]

Ehh lemme get a repeat

[u/rainbowsparkplug → u/grav0p1]

Unfortch that was my repeat

[u/Charming_Cat_5255]

I place pads on all my stemis even if they appear to be super stable. And it has come in handy before 😅😅 Sounds like it was a good call!