Triage note: 50 year old female with sore throat and nausea for 1 week. Intermittent, burning. Unrelieved by tylenol or antacids.vitals: 95/70 99F HR 65 RR 16 95%

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

PMH: GERD, DM

PSH: tonsillectomy

Meds: metformin

Allergies: NKA

Family: thyroid cancer

Social: alcohol socially, former smoker, no IVDU

ROS: +fatigue, nausea

GENERAL APPEARANCE: Anxious and uncomfortable.

HEENT: PERRLA. Oropharynx clear.

NECK: Supple without LAD or tenderness.

HEART: RRR. no mumurs.

LUNGS: Clear to auscultation b/l.

ABDOMEN: Soft, nontender, nondistended.

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

NEUROLOGICAL: No focal deficits.

Skin: Diaphoretic.my jaw and right arm feels funny!

..

40% STEMIs are inferior (II, III, aVF), reciprocal depression in aVL40% of inferior STEMIs involve RV infarctsSTE in V1STE in III>II

..Right sided leads

Right Ventricle MIWhy you care:increased mortality (hemodynamic & nodal dysfunction/brady)

How you know:hypotension, distended neck veins, clear lungsEKG findingsECHOhelps distinguish from pericardial tamponade or PEhelps guide treatment if combined RV and LV dysfunction

What you doABCsCardiac monitorO2 (only if SpO2

repeat EKG

What to do now(atropine) transcutaneous pacing

So youre not caught unaware..recognize atypical MI groups: DM, female, elderlynausea, fatigue, back/neck/jaw pain prodromal symptoms up to a year before MIin the absence of chest pain (6%), craniofacial pain (throat, mandible, tmp joint, teeth) is predominant symptom in both sexes

Resourceshttp://emedicine.medscape.com/article/157961-treatment#d10http://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.

underlying stressor in our pt? nstemi, hypovolemia from dialysisesrd/low albumin?underlying stressor in our pt? nstemi, hypovolemia from dialysisesrd/low albumin?underlying stressor in our pt? nstemi, hypovolemia from dialysisesrd/low albumin?underlying stressor in our pt? nstemi, hypovolemia from dialysisesrd/low albumin?