Chest Discomfort Scenario

What is the most appropriate first action?

You calm the patient’s breathing and presentation to allow a thorough assessment. Your crewmate begins a primary survey and initial observations while you take a history. The patient explains the pain came on suddenly during chest press, was followed by dizziness, and he vomited once. There are no provoking or relieving factors. He reports the pain radiates into his jaw and teeth. Initially it was 8/10 but has now reduced to 6/10. What element of OPQRST assessment is missing?

The patient describes the pain quality as “tight, like a band around the chest.” Observations: HR 118, BP 144/88, RR 26, SpO₂ 98%, Temp 36.7°C, BM 6.4, GCS 15. 
Within what timeframe does the European Society of Cardiology recommend a 12-lead ECG should be performed after patient contact?

Because of the patient’s age, you remain sceptical of a STEMI diagnosis. What additional risk factors in this population require further questioning regarding cardiovascular risk?

The patient admits to long-term anabolic steroid use, unaware of the potential harmful side effects. What complications can be caused by chronic anabolic steroid abuse?

As anabolic steroids can cause haematological effects such as polycythaemia, is aspirin contraindicated if cardiac chest pain is strongly suspected?

You complete a 12-lead ECG and obtain the following:

What is your impression? 

You suspect the ECG shows possible posterior MI. What should your next action be to confirm this?

What else might you notice on the original ECG that could make STEMI diagnosis more difficult?

Which artery is most likely affected in a posterior MI? 

You complete the posterior ECG and confirm ST elevation in the posterior leads. What treatment should be considered?

You prepare for IV access. If predicting PPCI referral, which side should you ideally use?

On repeat measurement, the patient’s BP has dropped to 102/67. Can GTN be given?

You have worked through the ACS algorithm and are en-route to PPCI, as the referral has been accepted. What other management and/or treatment should you consider during transport?

Left ventricular hypertrophy can result from anabolic steroid use and complicate STEMI interpretation. Is the following ECG an example of anterior MI or LVH?

Research suggests athletes who abuse anabolic steroids often attribute early cardiovascular symptoms to training or drug side effects, and therefore usually present only when serious complications occur.