Triage note: 50 year old

female with sore throat and

nausea for 1 week. Intermittent,
burning. Unrelieved by tylenol or
antacids.

vitals: 95/70
16

95%

99F

HR 65

RR

Ddx anterior neck pain

infection (pharyngitis, retropharyngeal abscess)

vascular (carotid artery dissection, referred pain from ACS)

autoimmune/inflammatory (thyroiditis)

malignancy (thyroid, spine)

functional (laryngospasm, gerd)

trauma (larynx, cervical spine, esophageal rupture)

ingestion/inhalation (caustic agent, foreign body)

H&P
GENERAL APPEARANCE: Anxious and uncomfortable.

PMH: GERD, DM

HEENT: PERRLA. Oropharynx clear.

PSH: tonsillectomy

NECK: Supple without LAD or tenderness.

Meds: metformin

HEART: RRR. no mumurs.

Allergies: NKA

LUNGS: Clear to auscultation b/l.

Family: thyroid cancer

ABDOMEN: Soft, nontender, nondistended.

Social: alcohol socially, former

smoker, no IVDU

EXTREMITIES: Cold to touch. Pulses intact b/l.

ROS: +fatigue, nausea

NEUROLOGICAL: No focal deficits.

Skin: Diaphoretic.

my jaw and right arm feel

..

40% STEMIs are inferior (II, III,

aVF), reciprocal depression in
aVL

40% of inferior STEMIs involve

RV infarcts

STE in V1

STE in III>II

Right sided leads

..

Right Ventricle MI
Why you care:

increased mortality (hemodynamic & nodal dysfunction/brady)

How you know:

hypotension, distended neck veins, clear lungs

EKG findings

ECHO

helps distinguish from pericardial tamponade or PE

helps guide treatment if combined RV and LV dysfunction

What you do
RV specific:

ABCs

Cardiac monitor

1 L fluid bolus

O2 (only if SpO2 <90%)

dopamine 5 mcg/kg/min

IV access and labs

ASA 162 to 325 mg, chewable

intra-aortic balloon pump

Cath team

NO nitrates, morphine, diuretics, betablockers, CCBs, or bladder caths!

repeat EKG

What to do now

(atropine)

transcutaneous pacing

So youre not caught

unaware..

recognize atypical MI groups: DM, female, elderly

nausea, fatigue, back/neck/jaw pain

prodromal symptoms up to a year before MI

in the absence of chest pain (6%), craniofacial pain

(throat, mandible, tmp joint, teeth) is predominant
symptom in both sexes

Resources

http://emedicine.medscape.com/article/157961-treatment#d10

http://lifeinthefastlane.com/ecg-library/right-ventricular-infarction/

Stub, D., Smith, K., Bernard, S., Nehme, Z., Stephenson, M., Bray, J. E., ... & Kaye, D. M. (2015). Air Versus Oxygen in ST-Segment Elevation Myocardial Infarction.
Circulation, CIRCULATIONAHA-114.
Kreiner, M., Okeson, J. P., Michelis, V., Lujambio, M., & Isberg, A. (2007). Craniofacial pain as the sole symptom of cardiac ischemia: a prospective multicenter study. The
Journal of the American Dental Association, 138(1), 74-79.
Lvlien, M., Johansson, I., Hole, T., & Schei, B. (2009). Early warning signs of an acute myocardial infarction and their influence on symptoms during the acute phase, with
comparisons by gender. Gender medicine, 6(3), 444-453.
Prevalence, clinical characteristics, and mortality among patients with myocardial infarction presenting without chest pain.AUCanto JG, Shlipak MG, Rogers WJ, Malmgren
JA, Frederick PD, Lambrew CT, Ornato JP, Barron HV, Kiefe CISOJAMA. 2000;283(24):3223.