Station - Instructions for candidate
You are an intern working in the Emergency Department of a tertiary hospital in Perth with an on-site cardiac catheterisation laboratory.
Jose Dela Cruz, a 58-year-old bus driver, has been brought in by ambulance with 70 minutes of central crushing chest pain that started while he was watching television. He is sweaty and nauseated. The paramedics have handed over his observations and a 12-lead ECG recorded on arrival, printed below. He is on a monitored bed in the resuscitation bay and a nurse is with him.
| Ambulance handover | Pain 8/10, central, radiating to the jaw, onset 70 minutes ago at rest. Smoker. On perindopril for blood pressure. Took two of his wife's aspirin tablets at home (dose unknown). No allergies. |
|---|---|
| Observations on arrival | Heart rate 58 /min regular, blood pressure 98/62 mmHg, respiratory rate 18 /min, SpO2 96% on room air, temperature 36.6 degrees C, GCS 15, weight 82 kg |
Results provided:
12-lead ECG on arrival
| Item | Value | Reference range |
|---|---|---|
| Rate | 58 /min | 60-100 /min |
| Rhythm | Regular; a P wave before every QRS, upright in II | Sinus |
| Axis | +30 degrees | -30 to +90 degrees |
| P waves | Normal morphology | Normal |
| PR interval | 210 ms, constant | 120-200 ms |
| QRS duration and morphology | 90 ms, narrow; no pathological Q waves | <120 ms |
| ST segments | Elevated 3 mm in III, 2 mm in II and aVF, convex upwards; depressed 1.5 mm in I and aVL; elevated 0.5 mm in V1; isoelectric in V2-V6 | Isoelectric |
| T waves | Tall and broad in II, III and aVF; inverted in aVL | Concordant with QRS |
| QTc | 420 ms | <450 ms |
ecg - read aloud by the examiner
A standard 12-lead tracing at 25 mm/s. The rhythm is regular and slow at about 58 per minute with a normal upright P wave before each narrow QRS complex and a PR interval a little over one large square. In leads II, III and aVF the ST segment rises well above the baseline - about three small squares in lead III and two in II and aVF - with a rounded, upward-convex shape merging into tall broad T waves. In leads I and aVL the ST segment dips about one and a half small squares below the baseline and the T wave in aVL is inverted. Lead V1 shows a slight rise of the ST segment of about half a small square; V2 to V6 are at the baseline with normal T waves. There are no Q waves. The QT interval is normal.
Look up an example image: LITFL inferior STEMI right ventricular infarction ECG
Your tasks are to:
- Interpret the ECG provided, describing your findings systematically to the examiner.
- State your most likely diagnosis and the differential diagnoses, with justification.
- Outline your immediate management to the examiner, including who you would call and the drugs you would give, with doses, and any you would withhold.
- The examiner will ask you two questions at the end of the station.
- You do NOT need to take a history or examine the patient; the ambulance handover and observations are provided.
- You may request further investigations from the examiner; results will be provided if available.
- State drug, dose and route for each drug you would give.
This is a 10-minute station, with 2 minutes of reading time.