spenac Posted May 16, 2007 Posted May 16, 2007 What was his orthostatic vitals ( supine, sitting, standing )?
p3medic Posted May 16, 2007 Posted May 16, 2007 This is not a STEMI, its acute pericardititis in my humble opinion. As for tx for hyperkalemia, there is nothing about this 12ld or the pts hx or complaint that would lead me to believe this is hyperkalemia, so the short answer is "no".
AZCEP Posted May 16, 2007 Posted May 16, 2007 "Global ST changes" The T-waves are not elevated, nor are they "peaked" I'm okay with the ASA and the NTG to this point, but this patient does not warrant fibrinolytics or a cath lab.
akflightmedic Posted May 16, 2007 Posted May 16, 2007 Well I did consider pericarditis but then I ruled it out as he does not have the tachycardia, recent viral infections, anitbiotic use, and the CP just didnt quite fit the pain with pericarditis. In addition the ECG did not have PR depression or notching. I could be wrong but just reasoning out my thought processes. With the elevations present, I was leaning towards a inferolateral MI but there seems to be a more significant involvement such as elevation in the V2 thru V6 leads which makes it an apical MI. Apical MIs are typically misdiagnosed as pericarditis and with the patients youthfulnees and health history, I assume just about anyone would lean towards that diagnosis as well intially. The only other differential dx is an aortic dissection. Not likely but worth investigating further. Check for unequal pulses, other diagnostic findings would have to be done in an ER with radiology. So this leaves me with apical MI at this time. Reperfusion therapy is indicated and in a major way as there is a lot of heart involved and this patient will die without aggressive therapy. . I have had young patients with MIs before so I learned early on never let age be the factor that says this is not a MI. It will burn you. If I am wrong and this is pericarditis, oops I probably just killed or did major harm to my patient, but that is why we practice. I wont mess up next time..
Just Plain Ruff Posted May 16, 2007 Posted May 16, 2007 If I am wrong and this is pericarditis, oops I probably just killed or did major harm to my patient, but that is why we practice. I wont mess up next time.. AK that made me laugh so loud that I have people asking me what is so funny. I think I peed my pants.
ERDoc Posted May 16, 2007 Posted May 16, 2007 OK, so we have shortness of breath, some chest pain, a decreased pulse pressure that is getting worse and JVD despite the hypotension. The EKG seems to be swaying people to different directions. I think we all agree that there is ST elevation in more than just the inferior leads. Is there anything else you notice about the EKG? I agree, there is no evidence of hyperkalemia. What are the heart sounds? Any recent illnesses?
akflightmedic Posted May 16, 2007 Posted May 16, 2007 OK, so I missed the obvious. Maybe a little pleural decompression will reverse a lot of the symptoms we are seeing. I am thinking he is male, athletic, maybe thin side? Spontaneous pneumos are common in this group (thin males, athletic). We have the dyspnea, narrowing pulse pressures and now JVD. I cant recall what the lung sounds were or what they are now at this stage but he may need immediate decompression. Once we have done this, lets repeat the 12 lead and see whats going on, once the vena cava and heart are not being pushed on by surrounding structures they may show a pretty picture.
Just Plain Ruff Posted May 16, 2007 Posted May 16, 2007 Yeah I missed that too. I was looking at the trees man, I swear!!! I didn't see the forest.
ERDoc Posted May 16, 2007 Posted May 16, 2007 Yeah I missed that too. I was looking at the trees man, I swear!!! I didn't see the forest. I could be wrong, but you guys may still be barking up the wrong tree.
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