Identifying Acute STEMI in the Presence of Paced Rhythm

EMS responds to a local coffee shop for a 77-year-old male who has reportedly fainted. While en route the call is upgraded to an unconscious patient and an engine company is dispatched for backup.
On arrival the patient is conscious but lethargic. He appears acutely ill. The skin is pale and diaphoretic. His past medical history includes hypertension, dyslipidemia, myocardial infarction, a coronary artery bypass graft and heart failure. His current medications are aspirin, metoprolol, atorvastatin, lisinopril and furosemide.
Upon further questioning he admits to chest discomfort. His OPQRST assessment is as follows:
≫ Onset: 15 minutes prior to EMS arrival;
≫ Provoke: Nothing makes the pain feel better or worse;
≫ Quality: Dull;
≫ Radiate: The pain does not radiate;
≫ Severity: 7/10; and
≫ Time: No previous episodes.
His vital signs are a heart rate of 74, respiratory rate of 22, blood pressure of 116/67, oxygen saturation of 88% on room air and a temperature of 98.4 degrees F.
The patient is relocated to the ambulance and undressed from the waist up. A well-healed surgical scar is noted from previous open-heart surgery as well as an implantable medical device in the upper-left chest. Other notable findings include jugular venous distention and breath sounds that reveal crackles in the lung bases.
Figure 1: Initial rhythm

Figure 2: Ventricular paced rhythm

Source: JEMS Special Topics - January 18, 2016 Category: Emergency Medicine Authors: Tom Bouthillet, NREMT-P Tags: Special Topics Patient Care Cardiac & Resuscitation Source Type: news