A 40-Something male with a " Seizure, " Hypotension, and Bradycardia

This is by one of ouroutstanding 3rd year residents, Aaron Robinson, with some edits and comments by SmithEMS responded to a reported seizure in a 42 year old male. Per bystanders, he went down after some intense sporting activity, and had “shaking” type movement. He reports no personal or familial history of seizures.One of our EMS Fellows along with a Senior EM Resident were on duty that evening, and arrived on the scene with the Fire Department. When the physicians approached him, he was ashen, diaphoretic, and appeared in shock. Fire was able to obtain a BP of 60/palp and a pulse in the 40s. The physicians quickly recognized that this was not a seizure and likely cardiac in nature. When the paramedics arrived, they obtained a 12 lead ECG and confirmed the unstable vital signs. EKG is pictured below:What do you think?There is an obvious inferior STEMI, but what else?Why is the patient in shock?Besides the obvious inferior STEMI, there is across the precordial leads also, especially in V1. He was in profound cardiogenic shock. Smith comment: I suspect lead reversal of V2 and V3: the STE is high in V1, lower in V2, and high again in V3. This STE is diagnostic ofRight Ventricular STEMI (RV MI). In fact, the STE is widespread, mimicking an anterior STEMI. It really is an anterior STEMI, but of theRight Ventricular Anterior Wall, not the LV anterior wall.When there is inferior and anterior STE, the differential is:1. inferior + RV MI due to RCA occlusion v...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs

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Source: Journal of Adolescence - Category: Child Development Source Type: research
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Source: Biochimica et Biophysica Acta (BBA) Molecular Basis of Disease - Category: Molecular Biology Source Type: research
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Source: The Journal of Invasive Cardiology - Category: Cardiology Tags: J Invasive Cardiol Source Type: research
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Source: The Journal of Invasive Cardiology - Category: Cardiology Tags: J Invasive Cardiol Source Type: research
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