Morphine + OMI is a bad combination

This is written by Magnus Nossen, with some edits by SmithThis ECG diagnosis will be obvious to the majority of the readers of this blog. It is not obvious for the majority of doctors or even cardiologists. A 50 something male was seen in the emergency room due to typical chest pain. The pain had started the same day about two hours prior to medical contact. Previous medical hx notable for type II DM. The first ECG is shown below.The medical care providers ascribed the patient ' s chest pain to new onset atrial fibrillation with rapid ventricular response after having viewed the ECG. Do you agree?The presentation ECG does show atrial fibrillation. I think for medical providers not familiar with OMI ECG findings, this ECG can appear quite " normal " . If you are familiar with the OMI/NOMI paradigm the diagnosis is obvious to you and is made without any delay. I showed this to some of my colleagues and they were not able to confidently say that this is an acute coronary occlusion. Back to the case. Initial troponin I returned elevated at 84 ng/L (ref value<34 ng/L). Fluids and morphine had been given and the patient had spontaneously converted to sinus rhythm.Then when in sinus rhythm (right after morphine) the patient denied chest pain. The following ECG was recorded.Guidelines say that if a patient has ACS but refractory pain, the patient should go emergently to the cath lab.  This patient ' s pain did indeed resolve.  But it only resolved with morphine...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs