You are the admitting resident in the ER. The ER doctor tells you there is another admission. The patient is a 36 year old male with no significant medical history who was admitted with "Crushing Chest Pain" that started about one hour ago. His friends brought him in to the hospital after they were "hanging out and doing cocaine" at a friends apartment when he suddenly started to complain of this chest pain. He is currently complaining of nausea and has vomited twice. He still has the chest pain which is 10 out of 10. Before you walk over to the patient you ask to see the EKG and here is what you see.

Click here for better Image of EKG

This is a great EKG to convince you never to try recreational drugs! With the history alone, you should already be very concerned about Myocardial Infarction. Even with normal coronary arteries, people who snort, smoke or inject cocaine are at very high risk for Infarction due to coronary artery spasm. On to the EKG

First off the rhythm. You can clearly see the p waves are of a sinus node origin (up in II,III, AVF and down in AVR) but you can also see that some do not have a QRS complex after them. So the next question is to figure out if there is a regular relationship between the p waves and the QRS complexes. Checking the relationship between the p's that have QRS complexes after them, you can see by using calipers that the P-R is the same for all. This establishes the diagnosis already of Mobitz Type II, because you have a steady P-R and the following p wave with a dropped complex. If there was no steady P-R you would have to call this third degree, however with the steady P-R interval this is clearly mobitz type II

And the next GLARING abnormality is the Massive Inferior ST elevation ACUTE MI. You can clearly see the j point elevations up to 9 mm in III in an inferior distribution with the reciprocal st depression in I and AVL alerting you that this is real and you need to act fast. When ever some one has an inferior wall distribution MI on an EKG it is important to get a Right sided EKG as well because of the fact that most of the time, the Right Coronary Artery supplies the Inferior Wall (Right Side Dominant). The right sided EKG will tell you if there is also RV infarction. Also what may make you think that this is a Right side dominant system is the rhythm changes. There is new AV node disease, and the Right Coronary gives off the AV node branch, which may be in spasm causing these rhythm changes.

And as always, you never want to give anyone with a cocaine MI beta blockers, because of the fact that cocaine is both Beta and Alpha stimulation. Beta in the coronaries causes dilation, while alpha causes constriction. If you block the beta receptors, now you are going to cause even more spasm due to totally un-opposed alpha stimulation.

So DONT DO DRUGS!!!