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46 year old male CC: Chest Pain

Posted Apr 01 2010 6:08pm
Here's an interesting case submitted by Christopher Watford. Chris is paramedic and computer programmer and a long-time follower of the Prehospital 12-Lead ECG blog.

He is a recent addition to the Paramedicine 101 bloggers and has his own blog called My Variables Only Have 6 Letters .

46 year old male presents to EMS complaining of chest pain.

After sitting down on the gurney the gurney states, "My heart is jumping out of my chest!"

Onset: Sudden while doing yard work.
Provoke: Nothing makes the pain better or worse.
Quality: Heaviness and "jumping" sensation.
Radiate: The pain does not radiate although his hands are numb and tingling.
Severity: Not reported.

The patient is alert and oriented to person, place, time and event.

Skin: mottled, cool, diaphoretic.

Vital signs were assessed.

Resp: 18
Pulse: Too rapid to count
BP: 120/60
SpO2: Not reported.

Breath sounds: Clear bilaterally.

Capillary refill: 5+ seconds

BGL: 140 mg/dL

The cardiac monitor is attached.


A 12-lead ECG is captured.


What is your differential diagnosis?

What is your treatment plan?


*** Update 04/02/2010 ***

The treating paramedics gave 1.5 mg/kg lidocaine.

After administration of the drug the following rhythms were noted on the monitor.



Pay close attention to this rhythm change....


There is a critical clue here, and it has to do with the R-R interval.

Now take a look at a 12-lead ECG of the irregular rhythm.


Was lidocaine the best possible choice?

Is there a safe antiarrhythmic for a patient like this?

Is this patient at-risk for sudden cardiac arrest?

Why or why not?
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