Chest pain, pelvic and abdominal pain, hypotension, and severe ischemia on the ECG

An elderly male was lethargic at the nursing home and complained of some pelvic pain, but then also chest pain and abdominal pain.  He was hypotensive.  His medications include beta blockers.BP on arrival was 66/31, pulse 80, saturations 90% room air.  The patient was lethargic and shocky.An ECG was recorded:There is severe diffuse ST depression of subendocardial ischemia, with the obligatory reciprocal ST Elevation in aVR.One might also think there are hyperacute T-waves in inferior leads, with reciprocal STD and T inversion in aVL.  A bedside echo showed good LV function, no pericardial effusion, and normal right ventricle.  There were no B lines and the inferior vena cava looked somewhat flat.Is this Acute Coronary Syndrome?  What do you think?The cath lab had been activated by the time I walked into the critical care area and saw this.However, I was skeptical that this was ACS.  Not all severe ischemia is due to ACS.  Shock/Hypotension can be the cause of ischemiaor the result of ischemia.How do we differentiate?If ACS is the cause, then shock/hypotension is cardiogenic shock.  Cardiogenic shock has 3 etiologies:1. pump failure2. dysrhythmia (too fast or too slow)3. valve dysfunctionThe rhythm is sinus.  The bedside echo showed good pump function.  There was no evidence of valve dysfunction on our bedside echo.Because of the above considerations, I thought ACS was very unlikely.  I suspected some other catas...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs

Related Links:

A middle-aged male had sudden chest pain and called 911.  First responders arrived.  Then the patient arrested.  Chest compressions were started immediately.  Paramedics arrived a few seconds later and found the patient in ventricular fibrillation.  He could not be defibrillated after 3 attempts.  He was intubated, given epinephrine and amiodarone, and transported.He arrived in the ED 35 minutes after arrest.  He remained pulseless and in V Fib.Defibrillation was not successful.Cannulation for ECMO (Extracorporeal life support -- ECLS) was begun.He was debribrillated again and had brief (...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
This is written by Brooks Walsh.https://twitter.com/BrooksWalshA 30 year-old woman was brought to the ED with chest pain.It had started just after nursing her newborn, about an hour prior, and she described it as a severe non-pleuritic “pressure” radiating to the back.She had given birth a week ago, and she had similar chest pain during her labor. She attributed the chest pain to anxiety and stress, saying " I'm just an anxious person. "A CXR and a CTA for PE were normal.The ECGsAn initial ECG was obtained as the pain was rapidly resolving:Minimal upsloping ST Elevation in III, with a steeply biphasic...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
An 80 year old presented with a couple days of SOB, weakness, and diaphoresis.  There was no chest pain.Here was her initial ECG:What do you think?-There is a paced rhythm. -There is some concordant ST Elevation (STE) in V5 and V6. -There is ST depression in V2. -There is minimal concordant ST depression in V3 (remember there should be, if anything, appropriately discordant STElevation).The treating physician did not think that there was sufficient concordant STE in V5 and V6.  He saw the ST depression in V2, but did not see it as concordant or excessively discordant because the R-wave and S-wave w...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
Post by Smith and MeyersSam Ghali (https://twitter.com/EM_RESUS) just asked me (Smith):" Steve, do left main coronary artery *occlusions* (actual ones with transmural ischemia) have ST Depression or ST Elevation in aVR? "Smith and Meyers answer:First, LM occlusion is uncommon in the ED because most of these die before they can get a 12-lead recorded.But if they do present:The very common presentation of diffuse STD with reciprocal STE in aVR is NOT left main occlusion, though it might be due to subtotal LM ACS, but is much more often due to non-ACS conditions, especially demand ischemia. ...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
ConclusionThe severity of scorpion envenomation results mainly from left cardiac dysfunction with pulmonary edema and/or shock. Adrenergic myocarditis, toxic myocarditis and myocardial ischemia are the main mechanisms.
Source: Archives of Cardiovascular Diseases Supplements - Category: Cardiology Source Type: research
This was sent by an " avid reader. "  The case was from his hospital, which does not have a cath lab.  He was very frustrated by the care the patient received from his partner, and the absence of an appropriate openness to learning by those in his department.CaseA 60-something male was sent in from a cardiologists'office after presenting there with chest pain.  The office ECG is unavailable.The pain had been intermittent for a few days, but worse on the day of admission.Here was the initial ECG:To me, and to him, this is an obvious acute LAD occlusion.There are hyperacute T-waves, especially in V2,...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
Written by Pendell MeyersAn elderly female with known CAD and multiple stents, pacemaker, stroke, and COPD presented with 2 hours of midsternal, nonradiating chest pain at rest. Apparently on arrival to the ED the patient described her pain more as " crampy " abdominal pain, but also chest discomfort.Here is her initial ECG during active symptoms:What do you think?There is dual chamber paced rhythm (atrial and ventricular pacer spikes) with resulting LBBB-like morphology. There is massive excessively discordant STE in II, III, aVF, as well as V4-V6. There is reciprocal excessively discordant STD in I and aVL. Add...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
Conclusions When high sensitivity cardiac troponin testing is performed widely or without previous clinical assessment, elevated troponin concentrations are common and predominantly reflect myocardial injury rather than myocardial infarction. These observations highlight how selection of patients for cardiac troponin testing varies across healthcare settings and markedly influences the positive predictive value for a diagnosis of myocardial infarction.-----------------------------------------------------------Comment by KEN GRAUER, MD (2/5/2019):-----------------------------------------------------------Exce...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
Written by Pendell MeyersA 76 year old man with history of CHF, moderate aortic stenosis, insulin-dependent diabetes, hypertension, stroke, CAD s/p stents, CKD, PVD, OSA presented to the ED with shortness of breath and chest pain off and on for 2 weeks. This afternoon his symptoms intensified so he called EMS.In the ED he appeared acutely ill, with HR 100-115, RR 20-25, BP 93/52, hypoxic to 88-92% on 5L nasal cannula, afebrile.Here is his presentation ECG, followed by his baseline ECG on file:Presentation ECG.Baseline ECG.The presentation ECG shows ventricular paced rhythm at rate of approximately 120 bpm. The J-point in V...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
A 60-something presented with hypotension, bradycardia, chest pain and back pain.She had a h/o aortic aneurysm, aortic insufficiency, peripheral vascular disease, and hypertension.  She had a mechanical aortic valve.  She was on anti-hypertensives including atenolol, and on coumadin, with an INR of 2.3. She was ill appearing.  BP was 70/49, pulse 60.A bedside echo showed good ejection fraction and normal right ventricle and no pericardial fluid. Here is the initial ECG:What do you think?This ECG actually looks like a left main occlusion (which rarely presents to the ED alive):  ST Elevation in...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
More News: Beta-Blockers | Blogging | Cardiogenic Shock | Cardiology | Depression | Heart | Learning | Nurses | Nursing | Pain | Universities & Medical Training