51 year old male patient working covered in black grease but Crew could tell that the patient appeared pale and diaphoretic. Skin was cool to touch. The patient tells the crew that it feels like something is setting on his chest. Pain is 9/10. He appears anxious but denies shortness of breath, nausea and vomiting, or weakness and dizziness. History of coronary issues with 9 to 10 stients and diabetes. BGL was checked 200mg/dl.
He was given ASA 324mg PO and NTG x 3 en route to ER. Pain down to 7/10. IV was established in AC.
V/S
BP 130/80
Pulse 89
Respirations 18-20
12 Lead EKG obtained and transmitted to ER. Is this EKG Normal/Not Normal? What is your interpretation?
Ok here is another 12 captured later in the call. The quality looks a little better. Does this change your mind?
I hope there will be some great discussions on this one.
ReplyDeleteIt's possible depression in Lead I and V2. Do we know where his previous injury was? Me personally. I would like to do a 1`5 lead just to be on the safe side considering the history of stents and nothing jumping out with ST elevation. Treat as chest pain, consider some morphine for pain if no relief with nitro. What was the pt. doing when chest pain occurred? Any further history?
ReplyDeleteGood questions Mike. From what I was told this guy apparently is a Mechanic and was working on a vehicle when s/s started. Nothing makes pain better or worse and He gave no hx on previous heart condition other then numerous stints. I concur a 15 lead would be something I would like to see as well, None was preformed. It should be noted that there were no significant change in v/s with all three NTG doses given. Morphine is great to consider, especially with little relief of pain after NTG,and that the patient was anxious, if time permits and no allergies, No additional hx or medications given. Great post to get us started. Did you noticed anything else that might raise a flag on this ekg?
ReplyDeleteToyanna Frye said: and elevation in aVF too...could be an Inferior (if true elevation in II,II, aVF) I would capture the 12-lead again since the lines wanders so much. There is also t-wave inversion in V1, V2, and aVL... I'd call this bad news bears
ReplyDeleteLooks like there is some questionable inferior ST elevation. Also inverted T waves in leads V1 and V2. I'd like to see a 15 lead as well. With the pt's V/S staying stable even after all the nitro a R sided MI is doubtful, but posterior is still a possibility.
ReplyDeleteThanks DebDeb. I am going to agree there is probably not any Right Side involvement. A 15 lead is always a plus when there is evidence of an Inferior Infart or if a 12 lead is normal. I do not see any ST depressions in the Early V leads nor do I see R>S in those Early V leads either which leads me to think there is probably not any Posterior Involvement yet. But I would want to verify with a 15 lead. So what are you calling this 12 lead. STEMI non-STEMI? Also same question to you....Do you see anything on either the 12 lead ekg or the Diagnostic portion of the ekg that raises a red flag for you?
ReplyDeleteJeff Said:
ReplyDelete12 Lead EKG thanks Toyanna for posting. I like that you want to do a repeat 12 lead, I agree another 12 lead is probably a good idea since there is baseline wandering and artifact in this lead. I do have another better 12 lead that was taken later during the call that I will post. Did you noticed anything else that might raise a flag on this ekg?
Toyanna Said:
Toyanna Frye How bout that infamous j wave most natable in lead III....or does my droid deceive me?...and there is st depression in lead v1 and avl also
Jeff Said:
12 Lead EKG Oh I see I have you thinking now, nice call on ST depression in lead AVL, This is an important find because............. also there is another important finding as well "HINT" look at the diagnostic strip! Also I am adding another strip from later in the call that should be a little better quality
Are you talking about the fact that it says. ""ACUTE MI""??
ReplyDeleteCongrats you are the First to Mention that. Absolutely!! what does (should) this mean to you?
ReplyDeleteThat we need to pay attention! I know that our monitors are very...creative with what they diagnose things, however I don't think I've ever had one say something was an acute MI when it wasn't. I think the ECG changes and the pt's S/S are enough to treat it as a STEMI.
ReplyDeleteDeb, you hit it right on the head. The 12 lead can and will give us lots of false information and most of it is garbage. We can look at what it says and then evaluate the strip ourselves and see it we agree or disagree. On the other hand when you see ***ACUTE MI*** that is a finding that is most likely accurate because the machine does not want to be wrong so it runs a number of different formulas to make that diagnosis. This is why we don't see ***ACUTE MI*** on a large majority of our 12 leads. So with that said, when we see ***ACUTE MI*** we need to raise that reg flag and really evaluate the EKG and the Patient because the monitor is most likely correct! I would treat as a MI and take this patient to a PCI center. That is exactly what the crew running this call did. The pt was placed in the ER but transferred to the Cath lab before the crew left. Great Job EMS Crew! Also FYI ST depression in Lead AVL is often the first sign of an Inferior STEMI and can show up before ST elevation in the Inferior leads began to show.
ReplyDelete