Serial ECGs highly suspicious for inferior OMI: Give thrombolytics prior to transfer for PCI?

One of my former residents texted this info to me with the EKGs:" I have here a 50 something-year-old female with multiple stents who presents with a concerning pain history. Pain relief with nitroglycerin, and I am starting a nitroglycerin drip. " I ’m worried about a hyperacute RCA infarct. " There is no old ECG available." I have to transfer for PCI, and am wondering if I should give thrombolytics first. "Here is the initial ECG:Inferior STE less than 1 mm, with reciprocal inverted T-wave and STD in aVL  I recorded this one 15 minutes later:Now with straightening of the ST segmentsLooking at it now, it looks like an obvious inferior OMI, but I could not see it as well on my phone, and certainly could not compare them easily on my phone.This was my response:" It is suspicious for sure. But I am not totally convinced. It just does not look entirely right and it could be that there is some LVH.  Is there a history of hypertension? "" Yes. History of Hypertension. "Then I would just activate the cath lab, but I ' m not certain enough to give thrombolytics.So he did not give thrombolytics, but did activate the helicopter and cath lab.Then he obtained this just before transfer:Now it has evolved and is diagnostic of inferior OMIThe physician saw this, and was then going to give tenecteplase, except that he then discovered that the patient had a history of a subdural hemorrhage.Patient was transferred and had an RCA occlusion.Learning points:1. Thrombol...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs