50 Year Old Male: Chest Pain, Hypotension, Pulmonary Edema

Physician and cardiovascular fellow Dr. Musa A. Sharkawi shared this ECG on Twitter (@MusaSharkawi) and has graciously allowed us to reproduce it here.

A 50-year-old male presents with a chief complaint of abrupt-onset severe chest pain. He is pale, diaphoretic, and ill-appearing—in moderate respiratory distress with extensive biateral crackles and a low blood pressure. Further history is limited by the patient’s condition but listed below:

Onset – 30 min ago
Provocation/Palliation – None
Quality – Severe “crushing” pressure
Radiation – None
Severity – 10/10
Timing – Constant

Signs/Symptoms – The patient ate dinner approximately an hour ago and soon noted that he felt generally unwell. He sat on the couch to rest but then developed severe chest pressure followed by a single episode of vomiting. He currently feels like something is crushing his chest with severe shortness of breath and weakness.
Allergies – No known drug allergies
Medications – Metformin, lisinopril, aspirin, hydrochlorothiazide
Past Medical History – Type II diabetes, hypertension, chronic kidney disease (unknown stage)
Last Oral Intake – Dinner 1 hour ago
Events Preceding Presentation – See above

Temperature – 36.7 C (98.1 F)
Heart Rate – 100 bpm, irregular
Blood Pressure – 86/50 mmHg
Respiratory Rate – 30 /min, labored
SpO2 – 83% (room air)

General – Ill-appearing male in severe distress. Vomit noted on patient’s mouth and chest.
Skin – Pale, cool, and diaphoretic. No rashes seen.
Head/EENT – Unremarkable
Neck – JVD present
Respiratory – Moderate respiratory distress. Extensive bilateral rales with no wheezing or rhonchi.
Cardiovascular – S1/S2 present but difficult to hear. Radial pulse weak and irregular with occasional pulse deficit compared to apex.
Abdomen – Soft and non-tender with no distension or guarding.
Back – Not examined
Pelvis – Not examined
Extremities – Moves all four extremities. No lower extremity edema seen or felt. Calves non-tender to palpation and passive movement.
Neuro – Alert. Oriented to person, place, time, and events. Eyes open spontaneously. Answers all questions appropriately. Follows all commands. Speech clear.

The following 12-lead is performed on scene:

A simultaneous rhythm strip is also obtained:

What’s your next move?

What’s the most likely diagnosis?

Is this patient experiencing a STEMI? What is the rhythm?

 

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Author: Vince DiGiulio

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