The Case of Smokey Marlborough

You are working in the Emergency Department (ED) of a busy tertiary care center when you are asked to see a patient presenting with a complaint of chest pain.  You pick up the RN notes and chuckle when you read the name - Smokey Marlborough.  The RN tells you that Mr. Marlborough (hereinafter referred to as Mr. M) is a 62 year old man who was brought to the ED via Emergency Medical Services (EMS) after his daughter called EMS when she became alarmed at her fathers' complaint of chest pain.

 

You immediately take a look at the triage vital signs (VS) of Mr. M are.  They are as follows:  heart rate (HR) 99; respiratory rate (RR) 20; blood pressure (BP) 153/98; and an oxygen saturation of 94% on room air (ORA).  Somewhat comforted by these findings, you make your way over to the bedside of Mr. M.  When you arrive, you notice that he is looking rather uncomfortable and breathing more rapidly than you expected.  Unfortunately, you do not see any cardiac monitors on the patient and thus, have no idea of what his current vital signs or EKG rhythm might be.  

You immediately ask the RN to get "cardiac monitors and oxygen saturation" on the patient.  While the RN is getting things in order, you take the opportunity to measure the patients pulse and notice that it is now approximately 111 bpm and the respiratory rate has increased to approximately 24 bpm.  The RN finished getting cardiac monitors on and you notice and unusual pattern to the rhythm strip as well as lower oxygen saturation of approximately 88%.  The automatic blood pressure cup finally displays a blood pressure of 97/62.

You identify the patient as being in shock, likely cardiogenic.  Additionally, you quickly run through a brief differential diagnosis of chest pain (in no specific order) - acute MI; spontaneous pneumothorax; aortic dissection; esophageal rupture and pulmonary embolism.  Looking at Mr. M you notice that he has a rather ashen looking appearance, is short of breath and is holding a clenched fist over the center of his chest.  He is not looking well and you have a strong suspicion that he is suffering from an acute coronary syndrome - specifically, acute myocardial infarction.  You complete a rapid assessment of the patients airway, breathing and circulation, order IV access and fluids, and order a stat EKG.  

As you are waiting for the EKG you order morphine for comfort and oxygen via nasal prongs.  Also, you take the opportunity to obtain a history from Mr. M.  You first ask when the pain began and he responds "approximately 35 minutes ago".  When asked to described the pain, he tells you that it feels like he has a tightness in his chest that is radiating to his shoulder.  He reports that he is also feeling short of breath.  

Cardiac risk factors are crucial to ask any patient presenting with a complaint that could be cardiac in origin.  The critical cardiac risk factors are:

(i) age > 45 (male or > 55 female)

(ii) male sex

(iii) prior CAD or MI

(iv) 1st degree relative with MI < 65 (female) or < 55 (male)

(v) lifestyle factors - smoking history, sedentary lifestyle and poor diet

(vi) hypertension

(vii) hypercholesterolemia

(viii) diabetes mellitus. 

 

After obtaining Mr. M.'s history, you realize that he has all of these cardiac risk factors. 

 

The EKG has returned and it looks as follows:

You resist the temptation to immediately jump to the obvious and run through the usual approach - rate, rhythm, axis, deviation, P before every Q, etc.  However, once quickly running through your approach you turn your attention to the obvious - ST elevations in leads V1 - V5.