August 2009 EKG Case

 An 82 year old male presents with dizziness, chest pain and diaphoresis for one hour. He has no past medical history.  His Blood pressure is 80/40.  The nurse wants you to give him something for the pain.  What does the EKG show and what is your diagnosis?

Rate:    45

Rhythm:  junctional bradycardia

Axis:    normal

PR:    no p waves seen

QRS:   < 0.12

ST: 1-2 mm ST elevation  II, III, AVF, ST depression in V2,V3,V4

EKG Diagnosis: ST elevation MI

Clinical diagnosis:  Acute inferior wall myocardial infarction

       Cardiogenic shock

Treatment: oxygen, aspirin, atropine, (consider transcutaneous pacemaker if no response to atropine), intravenous fluid NS bolus, plavix, emergent cardiac catheterization (thrombolytics if cath unavailable)

• - hold beta blockers secondary to bradycardia
• - hold morphine with BP 80/40 and pulse 45 due to possible preload reduction
• Practice Points: - Inferior wall MI is often associated with right sided infarcts as well due to occlusion of the right coronary artery. These patients are dependent on preload and therefore treatment requires increasing preload by giving IV fluids to increase their BP.

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