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Learning Station 1 Cardiovascular Emergencies Case 3 Extra Credit

1999 American Heart Association


Case 3. 45-Year-Old Construction Worker

Time = 10:45 AM

Complaint: sudden-onset chest pressure; weakness, syncopal episode, resolved lying down Medic response: in ED <30 minutes from pain onset Vital signs: T = 97.9F, RR = 20/min, HR = 55 to 60 bpm, BP = 75/55 mm Hg Physical exam: drenched in sweat; mild bilateral rales; no murmur

How would you approach this man?


Case 3. 45-Year-Old Construction Worker

Primary ABCD: CPR/defib = not indicated Secondary ABCD: O2, IV established, lungs getting wet Medications: is MONA indicated? Differential diagnosis: a 12-lead ECG was obtained

What is your interpretation? (next slide)


Case 3. 45 y/o construction worker, ECG 5 minutes after arrival

What are the 2 most critical findings? What is the next action for you to take?

Major problems: 1. Inferior AMI 2. Advanced heart block

Critical action: get right-sided ECG
1. Significant ST-segment elevation in inferior leads: II, III, aVF

2. Type II 2nd degree? Vs complete heart block?

Associations Between Changes on 12-Lead ECG and Cardiac Anatomy

I lateral


V1 septal

V4 anterior

II inferior

aVL lateral

V2 septal
V3 anterior

V5 lateral
V6 lateral

III inferior

aVF inferior

Right coronary artery

Posterior descending artery

Significant ST Elevation in V4R: Proximal Right Coronary Artery Occlusion

Right-sided ECG V4R lead: + ST elevation

Would MONA be appropriate now? What intervention is now indicated?

Intervention of choice: acute angiogram and reperfusion Findings: total occlusion proximal right coronary artery and artery to SA and AV nodes (block). Rx: angioplasty, stent


Note: flow back to RCA and artery to SA and AV nodes


Right coronary artery

Point of occlusion Note branch to AV node

Posterior descending artery


15 minutes after angioplasty and stent

Immediate pain relief Complete HB gone

Sinus bradycardia No ST-segment elevation

Sinus bradycardia ST-segment elevation gone