a 42 year old male presents via ambulance with chest pain following an motor vehicle accident.
He reports being in a moderate speed MVA approximately 90 minutes ago where he was side-swiped, but bought his car to a controlled stop. What followed can only be classified as ‘road-rage’. People were assaulted (not the patient) and there was significant emotional tension.
His pain started shortly after this…
This is his ECG…
- ~63 bpm.
- Sinus. Regular.
- + 27* (normal)
- PR ~ 200 msec
- QRS ~ 70 msec
- QTc ~ 420 msec (Bazett)
- ST elevation (concave up) – leads I & aVL (2mm), V5-6 (1mm) & V4 (1/2 mm).
- ST depression – III, aVF, aVR & V1.
- Large, bulky, asymmetric T-waves (V3, +/- V2 & 4) w/ straightening of ST-segment ?Hyperacute T-waves.
High-lateral STEMI which meets reperfusion criteria.
So, you go into his history in more detail & it turns out he carries a few risk factors.
- Hypertension (on ACEi)
- Hyperlipidaemia (not treated…)
- Strong FHx of ischaemic heart disease (older brother, father, uncles x2).
He consistently reassures you that the accident “was nothing at all” and he didn’t sustain any injuries…
Would you thrombolyse this guy if PCI was NOT available ??
- No absolute contraindications for thrombolysis.
- However, given the recent MVA (a relative contraindication), is a normal examination & a patient who’s reassuring you enough to give the drug…
Fortunately for us (and him) our Cath-lab was available & off he went for PCI 30 minutes after arriving to ED….
- Angiogram – 100% proximal first-diagonal occlusion.
- Successful angioplasty…
Take Home Point.
“Chest pain following an MVA” was an immediate distraction in this case. If we are not careful we can, at times, be automatically taken down the completely wrong path.
It is easy to get distracted by the immediate events leading to a patients’ hospital presentation. Just last week I saw a patient with “delayed epigastric pain post-MVA” where her chest did hit the steering-wheel; Final diagnosis = acute cholecystitis.
We owe it to ourselves (& our patients) to pause, just for a moment, & ensure that all the pieces to their puzzle are coming together….