# Tell me a time a 12-lead actually mattered for you....



## ExpatMedic (Jan 5, 2010)

Everyone loves telling war stories, so with that said, I'd like to hear some calls you've ran where a 12-lead actually made any difference in your patient care.  If you have the actual strip to post, that'd be great.


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## VentMedic (Jan 5, 2010)

Just one time? Actually made a difference? War story? Are you kidding? 

A 12-lead is an invaluable tool and it is a shame not all EMS agencies have that capability or know what to do with it if they do have it.


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## EMSLaw (Jan 5, 2010)

Wouldn't it make a difference any time there was a patient with an MI?


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## reaper (Jan 5, 2010)

Countless times that you are called for a minor problem and revel major ones, just by doing a 12 lead.

I will preform a 12 lead on lots of Pt's that may not normally call for one. just out of gut feeling, that something else is going on.

The expense of a few electrodes is worth a Pt's health.


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## TomB (Jan 5, 2010)

In no particular order:

* Within a regionalized system of care, identifying acute STEMI in the prehospital setting allows paramedics to bypass the local non-PCI hospital so the patient can receive primary PCI.

* Even when bypass is not an issue, early notification allows the cath team to be called in from home during off hours (nights, weekend, holidays). That parallel processing leads to significant time savings which translates into decreased mortality.

* A prehospital 12-lead ECG taken with the first set of vital signs establishes a baseline so that changes can be identified with serially obtained ECGs. These changes in QRS/ST/T morphology suggest the dyanamic supply vs. demand characteristics of ACS, which can help establish the diagnosis of acute STEMI in the presence of confounders like LBBB and paced rhythm.

* Sometimes MONA "cleans up" a 12-lead ECG, leaving the prehospital 12-lead ECG as the only evidence that the patient was in fact experiencing cardiac-ischemic chest discomfort. This could prevent inappropriate early discharge from the hospital.

* 12-lead ECGs can be instrumental in the differential diagnosis of arrhythmias, and especially tachycardias. Capturing the rhythm in 12-leads is essentially a "fingerprint" of the arrhythmia which can be useful to the cardiologist after the arrhythmia breaks (or is successfully converted by the paramedic).

* 12-lead ECGs can help identify certain drug overdoses or electrolyte derangements, which might change treatment decisions. For example, sodium bicarb for TCA overdose or calcium gluconate for hyperkalemia.

* Oftentimes syncope patients don't want to be transported to the hospital. A careful screening that includes a 12-lead ECG allows the paramedic to look for signs of long QT syndrome, Brugada's syndrome, hypertrophic cardiomyopathy, acute ischemia, or other cardiac problems allows the paramedic to assess the risk of the refusal so the patient can make a more informed choice.

* An underlying prolonged QT interval is the only way to distinguish between polymorphic VT and Torsades de Pointes, for which you may wish to give magnesium sulfate and lidocaine instead of amiodarone.

Hows that for a start?

Tom


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## Akulahawk (Jan 5, 2010)

EMSLaw said:


> Wouldn't it make a difference any time there was a patient with an MI?


12 Leads are good, and not _just_ for diagnosing MI. There are other conditions that can be picked up by a 12 Lead. If all you have is a 3 lead, they can be easy to miss. A former partner of mine used to claim that all she needed to see could be seen in lead II. With our "old" LP-10's, I'd use the MCL's to get a "poor man's" 9-lead... (no AVL/AVF/AVR) but at least I'd have more of an idea what I'd be dealing with, and perhaps see if RVI was occurring.

She and I went rounds on that one... She was my supervisor, so... :blink: you can guess what happened (ultimately) there.

Oh, and thanks for posting TomB!! I _know_ you could go on from there!


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## Medic744 (Jan 5, 2010)

45 year old male new onset chest pain while digging post holes, no medical history but family history with dad dying of MI at age 45.  12 lead= very beginning of MI.  Doing that immediately and hauling booty got him to the cath lab within the window to save his life and minimize damage.


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## ExpatMedic (Jan 5, 2010)

TomB said:


> In no particular order:
> 
> * Within a regionalized system of care, identifying acute STEMI in the prehospital setting allows paramedics to bypass the local non-PCI hospital so the patient can receive primary PCI.
> 
> ...



Yup, thats a decent start.  The kind of answer I was looking for.  

Not so much with the 'are you kidding me' or 'To diagnose an MI!' responses. 

For the MI responses...  Assuming you have ruled out other possible causes, such as SVT, would your treatment have changed with no STEMI present?  Studies are conflicting, but I've read more than one article that suggests as little as 50% of patients presenting with an active MI, actually show any sort of ST elevation what so ever.  It's been a couple years, but I can do some digging for those articles if anyone is interested.  

Point is, there are people and studies that claim (statistically speaking) actual patient outcome and quality of life does not change due to the presence or absence of pre-hospital 12 Lead EKG's.  I would like to make a solid and educated argument against those claims.  So, again, I thank the above poster for his response.


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## ExpatMedic (Jan 5, 2010)

Medic744 said:


> 45 year old male new onset chest pain while digging post holes, no medical history but family history with dad dying of MI at age 45.  12 lead= very beginning of MI.  Doing that immediately and hauling booty got him to the cath lab within the window to save his life and minimize damage.



The chest pain is present, as well as the risk factor, as such, I would be hauling booty and following a chest pain protocol, regardless of what my monitor suggested.  

"Treat the patient, not the monitor."

EDIT - With that said, in the presence of a STEMI, does your system allow you to bypass the ED and head directly to the cath lab?  We don't have that option, unfortunately.


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## VentMedic (Jan 5, 2010)

ExpatMedic said:


> The chest pain is present, as well as the risk factor, as such, I would be hauling booty and following a chest pain protocol, *regardless of what my monitor suggested. *
> 
> "Treat the patient, *not the monitor*."


 

What do you for patients that do not present with the classic EMT textbook "having an MI chest pain"? That includes the elderly, diabetics and women. There are many times where a 12-lead EKG can show what the patient is not.

If your monitor "suggested" an MI, even if the patient is not "text book" it still requires further evaluation. 

And yes of course if the patient has chest pain, it would be prudent of you to follow your protocols for that also.


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## ExpatMedic (Jan 5, 2010)

VentMedic said:


> What do you for patients that do not present with the classic EMT textbook "having an MI chest pain"? That includes the elderly, diabetics and women. There are many times where a 12-lead EKG can show what the patient is not.
> 
> If your monitor "suggested" an MI, even if the patient is not "text book" it still requires further evaluation.
> 
> And yes of course if the patient has chest pain, it would be prudent of you to follow your protocols for that also.



In the case of the elderly, diabetic, female who is feeling 'down and out', I would obviously hope that my monitor shows me a STEMI.  That is, assuming she is experiencing an MI.

I already had that on my list of examples, but you do bring up a good possible use.  Thanks.


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## EMTinNEPA (Jan 5, 2010)

Like VentMedic said, only one time?

If STEMI's negative, the patient still gets MONA... nitro and oxygen help with angina too.  At the same time, the patient could be experiencing an NSTEMI, which wouldn't present with the tell-tale ST elevation.  If the 12-lead DOES show ST elevation, the location of the infarction could effect your treatment as well, especially when it comes to giving nitro to inferior STEMIs.

In my student ride time, I've seen four STEMIs, one of which was a "silent" MI (no chest pain).  If it weren't for 12-lead capabilities, a keen eye, beginner's luck, and a gut feeling, it would have gone completely unnoticed and the patient would have arrived at his preferred destination (a little "Doc In a Box").  He would have sat there for 45 minutes while the doctor did his assessment, the hospital performed their own 12-lead, the doctor interpreted it, arranged transfer to the hospital with an interventional cath lab, then called us to transport him.  In the meantime, he would have been sitting there and myocardium would continue to die.  Instead, we bypassed the Doc In a Box and the emergency room and went straight to the cath lab.

Every time an ambulance bypasses a local hospital in favor of one with an interventional cardiologist, the 12-lead was worth its weight in gold and more.  Every time someone has chest pain and calls an ambulance, the 12-lead makes a difference.


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## Medic744 (Jan 5, 2010)

ExpatMedic said:


> The chest pain is present, as well as the risk factor, as such, I would be hauling booty and following a chest pain protocol, regardless of what my monitor suggested.
> 
> "Treat the patient, not the monitor."
> 
> EDIT - With that said, in the presence of a STEMI, does your system allow you to bypass the ED and head directly to the cath lab?  We don't have that option, unfortunately.



I was the student and I was the one that caught it confirming it with a 12 lead.  I have yet to treat a monitor other than smack it when it gets in my way.  That was a quick recap of what happened not the whole 3 page narrative that I turned in.

And yes, every system in the area of a 24hr, we never close Cath Lab only has to call, give report and they have the team and the elevator waiting for us.  It is a very nice perk of being so close to a few of the top cardiac centers in the state.


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## JPINFV (Jan 5, 2010)

ExpatMedic said:


> In the case of the elderly, diabetic, female who is feeling 'down and out', I would obviously hope that my monitor shows me a STEMI.  That is, assuming she is experiencing an MI.
> 
> I already had that on my list of examples, but you do bring up a good possible use.  Thanks.



If the patient is having an atypical MI presentation ("silent MI") that is confirmed by 12 lead, wouldn't treating it be treating the monitor and not the patient?


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## reaper (Jan 6, 2010)

Hahaha  That is good!


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## firemedic1563 (Jan 6, 2010)

ExpatMedic said:


> Yup, thats a decent start.  The kind of answer I was looking for.
> 
> Not so much with the 'are you kidding me' or 'To diagnose an MI!' responses.
> 
> ...



I have not seen the statistics, or met a critic, but I know one patient who benefited from a 12 lead with his life:

Patient presents with chest pain only, otherwise asymptomatic. C/O "I am having a heart attack". Followed standard C/P protocol, 12 lead just prior to leaving scene. I do have a copy somewhere, when I can dig it up one day I will scan it. Classic inferior. As I am moving leads to check right side, pt goes into VF. Through pads on and defib within 30 seconds, converted to NSR, and spoke to me. Went with him to cath lab, watched him go into VT w/ pulse there, complete RCA blockage, opened up, was back at work in a month.

So how did the 12 lead make the difference? Well, he was OBVIOUSLY unstable after going into VF and later VT. However our scene to balloon time, was only 72 minutes. Door to balloon was about 45. This was a Sunday night with the team on call. The closest member lived 30 minutes away (required to be within an hour). No team is going to be activated with/ every chest pain patient until it is confirmed by 12 lead or blood work. SOOOO, had the team not been activated 15 minutes prior to his arrival thanks to my 12 lead and consult, they probably would not have for at least 10 after arrival with time to get a 12 lead and/or bloodwork. So we would be looking at an additional 20-30 minutes delay in his cath at best, which quite possibly would not have been quick enough.


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## MasterIntubator (Jan 6, 2010)

JPINFV said:


> If the patient is having an atypical MI presentation ("silent MI") that is confirmed by 12 lead, wouldn't treating it be treating the monitor and not the patient?



Well... I suppose that is where your level of training should kick in, and figure out if these are acute changes.  And yes, I have treated SOME pts based on what the monitor has told me. ( sometimes you gotta pick your battle.. again.. training ). Kinda like the 86 y/o with stroke symptoms, but then the machine tells me a BG of 24mg/dL.  Yeah, I'm gonna treat the pt accordingly based on what the machine tells me.

Somewhere I have some 12 leads I will try to post up, showing an inferior MI occuring in real time.  Basically, it was NsR as I was watching it, then pain would increase, then the ST segs starting increasing to about 3-4mv above isoelectric.  Yes... it was transmitted enroute, which bought us a free ticket to the cath lab without any stopping in the ED.  And THAT is one big reason 12 leads make the difference in the pt.

Thats some good stuff right thur.... yes sir.


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## JPINFV (Jan 6, 2010)

MasterIntubator said:


> Well... I suppose that is where your level of training should kick in, and figure out if these are acute changes.  And yes, I have treated SOME pts based on what the monitor has told me. ( sometimes you gotta pick your battle.. again.. training ). Kinda like the 86 y/o with stroke symptoms, but then the machine tells me a BG of 24mg/dL.  Yeah, I'm gonna treat the pt accordingly based on what the machine tells me.



So you used a tool as a tool to help make a proper assessment.  

I think that saying "treat the patient, not the monitor" is just as extreme as becoming fixated on a *tool* without regard to what the patient's physical exam and history is telling you. Information from all sources (history, physical, diagnostic tools) should be combined to give the medical provider a more complete picture on what is occurring inside the patient.


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## ExpatMedic (Jan 6, 2010)

JPINFV said:


> If the patient is having an atypical MI presentation ("silent MI") that is confirmed by 12 lead, wouldn't treating it be treating the monitor and not the patient?



In that specific case, yes.  But, I believe my response was to a scenario that involved chest pain, not a 'silent MI'. Valliant effort, though.

With that said, the common "silent MI" is often accompanied with some, and/or all of the following: difficulty breathing, nausea, vomiting, diaphoresis, and anxiousness.  These symptoms, combined with the risk factors associated with diabetics, elderly, and/or females (as mentioned before) will automatically raise my suspicion of an occurring infarction. At that point, of course, I would use the tools available to not only help confirm my suspicion, but also to justify my treatment.

Generally speaking, I don't blindly apply a 12 lead to every patient with an upset tummy or bucket full of puke. As in the case above, I would treat the signs and symptoms of the patient, not the monitor.

Try not to read into my quote too literally.  It's simply a phrase one can remember in order to not fall into tunnel vision, which many new EMTs do.  Remember, there should be more tools in your box than the latest and greatest piece of electronics; those tools lie within your head.  God forbid, your basic forgets to charge the batteries, right? 

Semantics.


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## MrBrown (Jan 6, 2010)

had a bunch of chest pains with ST changes on 12 lead ECG


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## rhan101277 (Jan 6, 2010)

Hospitals and Doctors finally realizing that paramedics can interpret these fairly accurately and get the cath team ready saves lots of time.


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## reaper (Jan 7, 2010)

ExpatMedic said:


> In that specific case, yes.  But, I believe my response was to a scenario that involved chest pain, not a 'silent MI'. Valliant effort, though.
> 
> With that said, the common "silent MI" is often accompanied with some, and/or all of the following: difficulty breathing, nausea, vomiting, diaphoresis, and anxiousness.  These symptoms, combined with the risk factors associated with diabetics, elderly, and/or females (as mentioned before) will automatically raise my suspicion of an occurring infarction. At that point, of course, I would use the tools available to not only help confirm my suspicion, but also to justify my treatment.
> 
> ...



That is the major problem. Most Silent MI's will have none of the symptoms you described. You may have the nice old lady that has just been feeling off, with no other signs or symptoms, that is having a silent MI.

One I remember, from working in ED. Pt was a 78 yo F, CC of toothach. Pt walked into triage and was telling me that she had a toothach. Had been going on all day. Pt had went to her dentist earlier that day and he found nothing wrong with her teeth. This threw a big red flag for me. I placed her in a wheelchair and took her to a room. Preformed a 12 lead, which showed 2.5mm of elevation in v3,v4, and v5. This sweet little old lady was in middle of major STEMI and had no classic signs. She had denied any chestpain,SOB, aches or N&V. Just a toothach that was bothering her all day.

So yes, those simple pt's do require 12 leads! Follow your assessment and your gut feeling on the simple calls.


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## redcrossemt (Jan 7, 2010)

reaper said:


> So yes, those simple pt's do require 12 leads! Follow your assessment and your gut feeling on the simple calls.



Absolutely agree...

Any patient that needs a "3-lead" needs a 15-lead as far as I'm concerned. Weakness, dizziness, not feeling right, mental status changes/confusion, SOB/DIB, ABD pain, obviously CP, and pretty much any other problem "nose to navel" gets one from me.

Note that you can not diagnose V-Tach v. SVT w/aberrancy without a diagnostic ECG, which your 3-leads are not. Also can't see ST changes, not always seeing T/U waves or how big they really are, etc.

Also, with thanks to Bob Page, I now monitor in V1/MCL1. A much better lead than II to have on the home screen of your monitor.


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## redcrossemt (Jan 7, 2010)

Oh and my recent personal story...

Ran on a middle-aged gentleman for SOB. He was acutely dyspneic with labored breathing, accessory muscle use, history of COPD, so I was getting out a nebulizer while my partner gets vitals. Turns out his pulse was 26 (carotid and 3-lead) and his BP was not so great (maybe 70 systolic). So, anyway, tried atropine with no result, and started pacing...

Well, I was obviously not on my game that day, and forgot to get a 12-lead while we were doing the IV and atropine... so whatever, doesn't matter, right?

We get to the hospital, the guy stops breathing, he's tubed and they acquire a 12-lead (which we had to stop pacing for)... Turns out this guy is hyperkalemic with HUGE t-waves! He missed a few dialysis treatments and forgot to tell us. After bicarb, calcium, D50, and insulin; the guy was able to come off the pacer and was extubated later that day.

This is one of the only cases I've ever had a regret about. If I had done a 12-lead, we could've starting treating this guy enroute, and probably would have been able to stop pacing by the time we arrived at the hospital. He wouldn't of needed the ETT (most likely), etc.


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## ExpatMedic (Jan 7, 2010)

redcrossemt said:


> Oh and my recent personal story...
> 
> Ran on a middle-aged gentleman for SOB. He was acutely dyspneic with labored breathing, accessory muscle use, history of COPD, so I was getting out a nebulizer while my partner gets vitals. Turns out his pulse was 26 (carotid and 3-lead) and his BP was not so great (maybe 70 systolic). So, anyway, tried atropine with no result, and started pacing...
> 
> ...



Which leads were required or used to notice those T waves?


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## mycrofft (Jan 7, 2010)

*I had the opposite, a 12 lead NOT to use in care.*

Pt c/o CP/dysp, pulse rapid and not of uniform amplitude to palp, shirt off, leads on...normal sinus rythm. Says so right here on the interp.
Oh, wait. Radial pulse doesn't match QRS on EKG, whole different rate.

The machine (W.A. AT-2 Plus) was repeatedly replaying AND interpreting an EKG in memory. Pt went to hospital, AT-2 Plus went to biomedical repair.


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## Akulahawk (Jan 8, 2010)

redcrossemt said:


> Absolutely agree...
> 
> Any patient that needs a "3-lead" needs a 15-lead as far as I'm concerned. Weakness, dizziness, not feeling right, mental status changes/confusion, SOB/DIB, ABD pain, obviously CP, and pretty much any other problem "nose to navel" gets one from me.
> 
> ...


The 3-lead monitors I used DID have diagnostic quality... but you had to tell it to do it... and it'd print you the strip. You'd never see diagnostic quality tracings on the screen... I'm also a fan of V1/MCL1. I used to put the 3-lead in the normal config... cycle through Leads I-III, then reconfigure for MCL1. One of the monitors we had was a 5-lead. That one was usually set to show V1.


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## TomB (Jan 8, 2010)

If you're talking about using QRS morphology (Wellens or Brugadas criteria) to differentiate between VT and SVT with aberrancy, I don't think it really matters whether or not the low frequency / high pass filter is set to 1 or 0.05 Hz. On the other hand, I think it's crazy to classify a wide complex tachycardia as SVT with aberrancy based on QRS morphology regardless of what mode you're in. "Ruling in" VT is fine, because that should be your default diagnosis anyway. But failure to "rule in" VT does not "rule out" VT! I personally think these criteria do more harm than good. "Wide and fast" is VT until proven otherwise, and QRS morphology is not proof, because VT can mimic the typical BBB and bifascicular patterns! 

Tom


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## redcrossemt (Jan 8, 2010)

TomB said:


> If you're talking about using QRS morphology (Wellens or Brugadas criteria) to differentiate between VT and SVT with aberrancy, I don't think it really matters whether or not the low frequency / high pass filter is set to 1 or 0.05 Hz. On the other hand, I think it's crazy to classify a wide complex tachycardia as SVT with aberrancy based on QRS morphology regardless of what mode you're in. "Ruling in" VT is fine, because that should be your default diagnosis anyway. But failure to "rule in" VT does not "rule out" VT! I personally think these criteria do more harm than good. "Wide and fast" is VT until proven otherwise, and QRS morphology is not proof, because VT can mimic the typical BBB and bifascicular patterns!
> 
> Tom



Ahh, but with a 12-lead you can also look at the overall axis, the direction in V1 and V6 tells a lot, and there is the often characteristic downward slur when V1 is negative. I agree that QRS morphology is not proof, but with the other things mentioned above, you can be pretty certain of V-Tach v. SVT.


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## redcrossemt (Jan 8, 2010)

ExpatMedic said:


> Which leads were required or used to notice those T waves?



Don't remember... but it was not obvious on lead II, either on the screen or the paper.


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## redcrossemt (Jan 8, 2010)

Akulahawk said:


> The 3-lead monitors I used DID have diagnostic quality... but you had to tell it to do it... and it'd print you the strip. You'd never see diagnostic quality tracings on the screen... I'm also a fan of V1/MCL1. I used to put the 3-lead in the normal config... cycle through Leads I-III, then reconfigure for MCL1. One of the monitors we had was a 5-lead. That one was usually set to show V1.



Cool... Poor man's 12-lead right there! Just a lot of moving stickers and acquiring to do...


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## TomB (Jan 8, 2010)

redcrossemt said:


> Ahh, but with a 12-lead you can also look at the overall axis, the direction in V1 and V6 tells a lot, and there is the often characteristic downward slur when V1 is negative. I agree that QRS morphology is not proof, but with the other things mentioned above, you can be pretty certain of V-Tach v. SVT.



Yes, you can look at the axis, and a right superior axis is strongly suggestive of VT. You can look at lead V1 and if you have RBBB morphology and the "left bunny ear" is taller than the "right bunny ear" it's strongly suggestive of VT. If you have LBBB morphology and there is a Q-wave in lead V6, it's strongly suggestive of VT. 

Like I said, when morphological criteria are used to "rule in" VT, it's not a problem. It's when you take the next step and decide that failure to "rule in" VT effectively "rules out" VT that you can make a fatal error. There is no algorithm that can safety classify a wide complex tachycardia as SVT with aberrancy.

Tom


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## redcrossemt (Jan 8, 2010)

TomB said:


> There is no algorithm that can safety classify a wide complex tachycardia as SVT with aberrancy.



Agreed.


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## dave3189 (Jan 8, 2010)

*A little off the subject*

I was wondering if I can pick the brains of some of you experienced folks out there with a question I have been researching but can't seem to find.  I am a recently certified Basic and I dont recall this being addressed in my course.  Question is, when you are able to get someone back to a rythem from cardiac arrest (VT/VF) with CPR & defib, what is the typical presentation?  I'm guessing the LOC doesn't change much initially but vitals do?  Any help with this is much appreciated!  Thanks all!


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## fma08 (Jan 8, 2010)

TomB said:


> Yes, you can look at the axis, and a right superior axis is strongly suggestive of VT. You can look at lead V1 and if you have RBBB morphology and the "left bunny ear" is taller than the "right bunny ear" it's strongly suggestive of VT. If you have LBBB morphology and there is a Q-wave in lead V6, it's strongly suggestive of VT.
> 
> Like I said, when morphological criteria are used to "rule in" VT, it's not a problem. It's when you take the next step and decide that failure to "rule in" VT effectively "rules out" VT that you can make a fatal error. There is no algorithm that can safety classify a wide complex tachycardia as SVT with aberrancy.
> 
> Tom



I thought we were done looking for bunny ears...


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## redcrossemt (Jan 8, 2010)

dave3189 said:


> I was wondering if I can pick the brains of some of you experienced folks out there with a question I have been researching but can't seem to find.  I am a recently certified Basic and I dont recall this being addressed in my course.  Question is, when you are able to get someone back to a rythem from cardiac arrest (VT/VF) with CPR & defib, what is the typical presentation?  I'm guessing the LOC doesn't change much initially but vitals do?  Any help with this is much appreciated!  Thanks all!



Start a new thread for *really* off-topic things, please and thanks!


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## Medic744 (Jan 8, 2010)

Yesterday, caught a possible MI.


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## dave3189 (Jan 8, 2010)

Does that mean I'm not getting my question answered?


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## kittaypie (Jan 8, 2010)

dave3189 said:


> Does that mean I'm not getting my question answered?



start a new thread.


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## Akulahawk (Jan 8, 2010)

redcrossemt said:


> Cool... Poor man's 12-lead right there! Just a lot of moving stickers and acquiring to do...


More like 9-lead because you won't get AVR/AVL/AVF leads. 12-3=9 

But yeah, lots of stickers and acquiring... and the MCL's only approximate the V leads.


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## TomB (Jan 9, 2010)

fma08 said:


> I thought we were done looking for bunny ears...



Who's "we"? 

I don't look for bunny ears to recognize RBBB, and I don't use "turn signals". Rather, I look for a supraventricular rhythm with a QRS duration > 120 ms, a terminal R-wave in lead V1, and a slurred S-wave in lead I.

On the other hand, when it comes to comparing R-waves to see which one is taller (R or R-prime) then it can be useful to think in terms of "bunny ears" especially if you're trying to teach the concept to someone who's a visual learner.

Having said that, I'm not a big fan of using morphology to differentiate between VT and SVT with aberrancy. It's a poorly understood skill that has done more harm than good, IMO.

Tom


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## redcrossemt (Jan 9, 2010)

Just ran a call that highlights the importance of 12-lead!

40-something y/o female with sharp substernal chest pain radiating to left arm. Patient denied SOB/DIB. Only hx is high cholesterol and anxiety. She does (did, hopefully) smoke a pack a day. Per EMT first responders, pain was 10/10, with a pulse of 44, and a BP of 90/palp before we arrived. They were concerned, and said that she looked "really sick".

When we arrived, the patient seemed weak, but was A&Ox4, c/o same pain but now 2/10. Vitals = pulse of 72, BP of 130/90, good skin color, and generally looking okay. Initial 12-lead showed a sinus rhythm at 72 with occasional PACs. There was no ST-segment elevation, but T-waves were noted to be inverted in II, III, and aVF.

Patient got oxygen, aspirin, as well as sublingual nitroglycerin, and transport was initiated to a local ER with a cath lab. Transport took only a few minutes and there were no changes in the patient's condition or in my repeat 12-lead...

...until the hospital driveway, when the patient started to clutch her chest, moaning/screaming that the pain was back and 10/10. Almost instantaneously, huge ST elevation developed on the 3-lead screen of my monitor. The 12-lead was repeated and showed 3mm elevation in leads II and aVF, 4mm elevation in III, and 2mm elevation in V5 and V6. Reciprocal changes (ST depression) were noted in V2 and V3.

The patient was given another SL nitro as we exited the truck. The doctor at the desk was notified that this patient was now a STEMI, and immediately activated the cath lab based on the pre-hospital ECG. Their STEMI protocol was started, including nitro, heparin, integrilin, plavix, etc. immediately. The patient was in the cath lab before I finished my report.

I'm hoping to hear the results of the cath later today. As this was an inferolateral infarct, I suspect there was an LCA occlusion. We will see!


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## ExpatMedic (Jan 9, 2010)

redcrossemt said:


> Just ran a call that highlights the importance of 12-lead!
> 
> 
> 
> I'm hoping to hear the results of the cath later today. As this was an inferolateral infarct, I suspect there was an LCA occlusion. We will see!



Nice, good job!  It's always neat to be able to witness changes real time in the field. Keep us updated.


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## EricCSU (Jan 9, 2010)

Don't know if it has been posted yet, but here is a unique situation where 12 lead makes a difference.  I have had several co-workers who have run a similar call to the one described below.

An patient in cardiac arrest is successfully resuscitated (ROSC).  Along with all of the other supportive measures and rapid transport, a 12 lead is performed.  A ha!  A STEMI is detected!  This patient either goes straight to the cath lab or is stabilized enough in the ER to head up to the cath lab(depending on patient status).  Then the cath lab can fix the problem quickly because EMS has already diagnosed the cause of cardiac arrest.

Eric


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## redcrossemt (Jan 9, 2010)

ExpatMedic said:


> Nice, good job!  It's always neat to be able to witness changes real time in the field. Keep us updated.



Unfortunately they were the bad kind of changes!


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