# Would you activate the Cath lab or not?



## captaindepth (Jul 10, 2017)

Called to a crowded arena after a public speaking event for a 65y/o male with a "seizure."

When you arrive you find the patient sitting on the ground outside of the building against a wall in the shade. The patient is awake and alert and denies any current complaints (A&O x 4 with a GCS of 15). The patient is there with a social case worker who reported the patient had been standing in the crowded arena for approx 1 hour during the speech. Then upon exiting the arena the pt fell to the ground when he began to "shake." The case worker reported the patient then was able to get back up to his feet shortly after the initial fall and then after walking a few more feet fell and "shook" again. The case worker was unable to report the duration of the shaking but reported the patient had no period of confusion or AMS following the two events. The patient currently stated he "feels fine" and doesn't want to go the hospital.

The patient agreed to further evaluation in the ambulance (due to the crowded scene) and was able to stand and pivot onto the stretcher without assistance. The patient continued to deny any complaints throughout EMS patient contact. After further assessment the patient agreed to transport for further evaluation.

Physical exam findings include: airway patent, no signs of oral trauma/obstruction noted, able to speak in full sentences without difficulty, pupils PEARL (4mm), no head trauma found on exam. The pt had a normal work of breathing with no signs of respiratory distress, LS clear throughout all fields. No abdominal tenderness noted on exam (no urinary or bowel incontinence). No distal neuro deficits noted in the extremities, no trauma noted. Skin was extremely diaphoretic (needed a towel to wipe off the pts chest for 12 lead).

V/S: 96/50, HR 64, RR 20, BGL unremarkable (I don't recall the actual value but we can just call it 100mg/dL), SpO2 95% on room air.

Hx of HTN and Cirrhosis of the liver. 

No drugs or alcohol reported or suspected.

Here are the 12 lead EKGs from the beginning and end of the call. 

Would you be concerned for ACS? How would you treat the patient? Would you activate the cath lab?


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## NomadicMedic (Jul 10, 2017)

Nope on the lab. It looks like BER. Notched j point, scoped ST and tall T. 

I'd treat him how he wanted to be treated. His seizure is worth a work up. Put him in the truck and transport him. Capture serial 12s. If he has chest pain, you can treat that. If you'd get a QI ding for NOT treating as ACS, give him ASA.


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## DesertMedic66 (Jul 10, 2017)

I probably wouldn’t. To me that tracing looks more like BER than a STEMI.

Edit: or exactly what NomadicMedic said.


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## captaindepth (Jul 10, 2017)

My partner and I both noted the BER pattern (especially in the inferior leads + V5/6) but what got me was V3 and V4 (in both 12 leads above). V3 looks like it has 1-2mm ST elevation and lead V4 has 2-3 mm ST elevation, both these leads don't have the BER notch at the end of the QRS complex. Also the inverted T waves in lead AvL and the subtle ST segment depression AvR also was concerning. 

If a BER pattern is noted in one lead group on a 12 lead does that mean it is automatically present in all the other leads as well? 

@NomadicMedic I'm not sold on the "seizures." From the picture we got this seemed more like syncopal events. Now if you picture a 65y/o male with 2 witnessed syncopal events, diaphoretic, and these EKG changes, does that change your mind at all?


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## DesertMedic66 (Jul 10, 2017)

captaindepth said:


> My partner and I both noted the BER pattern (especially in the inferior leads + V5/6) but what got me was V3 and V4 (in both 12 leads above). V3 looks like it has 1-2mm ST elevation and lead V4 has 2-3 mm ST elevation, both these leads don't have the BER notch at the end of the QRS complex. Also the inverted T waves in lead AvL and the subtle ST segment depression AvR also was concerning.
> 
> If a BER pattern is noted in one lead group on a 12 lead does that mean it is automatically present in all the other leads as well?
> 
> @NomadicMedic I'm not sold on the "seizures." From the picture we got this seemed more like syncopal events. Now if you picture a 65y/o male with 2 witnessed syncopal events, diaphoretic, and these EKG changes, does that change your mind at all?


There is also notching in the inferior leads which is seen in BER. Slight depression in AvR is also a normal finding from what I remember.

We also have an elderly man who was standing inside a crowded arena probably in the heat and sun who had episodes that sounds like a syncopal episode/near syncopal episode. The patient is also hypotensive. Patient has a history of HTN, probably on a BB so he isn’t able to compensate very well since his heart rate can’t not increase very well.


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## MonkeyArrow (Jul 10, 2017)

The 12 leads are 20 minutes apart and showing very little morphological changes, which is consistent with a non-ischemic cause of elevation. The rest of the 12 lead looks quite consistent with the BER, especially because all of the leads are concave up and smooth in nature. The 2 mm isn't necessarily concerning anteriorily given by the relatively large R wave amplitude. The only thing that gave me pause was the T wave inversion in avL, which can be early reciprocal change of an inferior infarct. However, given the rest of the 12 lead and the fact that avL has a negative axis, I'm not all too worried. I would call in my finding to the ER but he can take a nice, smooth ride in. In hospital, repeat the 12 lead and get a troponin.


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## NomadicMedic (Jul 10, 2017)

captaindepth said:


> My partner and I both noted the BER pattern (especially in the inferior leads + V5/6) but what got me was V3 and V4 (in both 12 leads above). V3 looks like it has 1-2mm ST elevation and lead V4 has 2-3 mm ST elevation, both these leads don't have the BER notch at the end of the QRS complex. Also the inverted T waves in lead AvL and the subtle ST segment depression AvR also was concerning.
> 
> If a BER pattern is noted in one lead group on a 12 lead does that mean it is automatically present in all the other leads as well?
> 
> @NomadicMedic I'm not sold on the "seizures." From the picture we got this seemed more like syncopal events. Now if you picture a 65y/o male with 2 witnessed syncopal events, diaphoretic, and these EKG changes, does that change your mind at all?



Nope. Still not a STEMI. (And that's what we activate catch labs for) He needs to be seen... just not for the reason you seem to be jumping at.


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## captaindepth (Jul 10, 2017)

So we ended up transporting the patient non emergently, did NOT call a cardiac alert or activate the cath lab, but did treat for ACS. My partner and I had a good discussion with the attending physician in the ED about the event, patient presentation, and the EKG changes we noted. The physician agreed that it did not meet criteria to activate the cath lab but did report they were going to do a full cardiac work up and cardiology was on the way by the time we left. The ED doc also said that if at any point the patient begins to have any ACS associated complaints that they would activate the cath lab.  I have this gut feeling there was an acute cardiac component, the pt looked like a cardiac patient to me. I don't know, I thought it was good call and was worth sharing.


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## jbiedebach (Jul 11, 2017)

It would be interesting to get a follow up from the ED.  I would have transmitted the EKG for sure. If the Pt
was not symptomatic I would have given ASA and let the doc decide. There are medics here with more experience than me and I trust them if they see BER. But is see elevation in 2 or more contiguous leads so prudence demands I call it in.  Treat the pt, not the monitor, but I have no prob asking for help. 


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## StCEMT (Jul 11, 2017)

Agreed on BER, also for Nomads reasons.


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## NomadicMedic (Jul 11, 2017)

jbiedebach said:


> It would be interesting to get a follow up from the ED.  I would have transmitted the EKG for sure. If the Pt
> was not symptomatic I would have given ASA and let the doc decide. There are medics here with more experience than me and I trust them if they see BER. But is see elevation in 2 or more contiguous leads so prudence demands I call it in.  Treat the pt, not the monitor, but I have no prob asking for help.
> 
> 
> Sent from my iPhone using Tapatalk




 Interesting comments. Are you a paramedic? If so, can you call a STEMI alert and activate the catch lab from the field? If not, do you have to transmit 12 leads? Have you ever taken a class on STEMI mimics? Are you aware of the criteria for benign early polarization?  You do see why this is not a STEMI, right?


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## DrParasite (Jul 11, 2017)

I would have probably sent it to the doc just for confirmation (I think the ambulance guys do it for all stemi imposters), but even with the ST elevation, it's curved in the benign way, not the MI way.  I don't think a trip to the cath lab would be warranted.


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## hometownmedic5 (Jul 11, 2017)

No, for two reasons. 1, this isn't a STEMI, and 2, the patient is chest pain free. The cath lab at my primary resource hospital can only intervene with ST elevation and active chest pain. You have neither, so there would be no STEMI alert.

All that being said, when they opened the cath lab two years ago they held a big q&a. One of the topics covered was false activations and it was put forth as official policy that they would rather have a bad alert than miss a real STEMI. So essentially in my system its ok to be wrong, as long as you're wrong on the right side.


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## GMCmedic (Jul 11, 2017)

hometownmedic5 said:


> All that being said, when they opened the cath lab two years ago they held a big q&a. One of the topics covered was false activations and it was put forth as official policy that they would rather have a bad alert than miss a real STEMI. So essentially in my system its ok to be wrong, as long as you're wrong on the right side.



They told us that too. Then they stopped activating on the word of EMS. If you can't or don't transmit, don't expect to go to cath lab around here. 


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## hometownmedic5 (Jul 11, 2017)

We dont have the capacity to transmit, which is irrelevant as the hospital doesn't have the capacity to receive; so they either have to take our word for it or wait until we arrive to do it themselves. The catch lab team at my hospital doesn't seem to mind the minimum overtime they make when the beeper goes off and so far the hospital doesn't seem to mind paying them, so they're still pushing the button on our say so. In talking with the cath lab director last time i had the chance(a few months ago) there aren't enough false activations to cause them concern.


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## GMCmedic (Jul 11, 2017)

hometownmedic5 said:


> We dont have the capacity to transmit, which is irrelevant as the hospital doesn't have the capacity to receive; so they either have to take our word for it or wait until we arrive to do it themselves. The catch lab team at my hospital doesn't seem to mind the minimum overtime they make when the beeper goes off and so far the hospital doesn't seem to mind paying them, so they're still pushing the button on our say so. In talking with the cath lab director last time i had the chance(a few months ago) there aren't enough false activations to cause them concern.


Ive had more false activations from an ED doc and an Urgent care doc on transfers,  in the last 6 months than our service has had in two years. 

But hey, i get paid the same regardless. 

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## jbiedebach (Jul 11, 2017)

I am a medic. And I do know about BER. It is not something we spend a lot of time working on.  The biggest STEMI mimics I see are elevation from bundle branch block.  We do activations all the time for strokes, STEMIs, trauma, etc, but those activations are always subject to override by the hospital.  My protocols say I transmit any STEMI suspect, but the county next door has to transmit *all* 12 leads.

From what I understand from reading the case is that an elderly patient had a syncopal episode/seizure and then had an abnormal EKG.  While the signs and symptoms might not prompt me to think STEMI for sure, I am always going to call in an EKG with elevation is 2 contiguous leads. 


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## DesertMedic66 (Jul 11, 2017)

jbiedebach said:


> I am a medic. And I do know about BER. It is not something we spend a lot of time working on.  The biggest STEMI mimics I see are elevation from bundle branch block.  We do activations all the time for strokes, STEMIs, trauma, etc, but those activations are always subject to override by the hospital.  My protocols say I transmit any STEMI suspect, but the county next door has to transmit *all* 12 leads.
> 
> From what I understand from reading the case is that an elderly patient had a syncopal episode/seizure and then had an abnormal EKG.  While the signs and symptoms might not prompt me to think STEMI for sure, I am always going to call in an EKG with elevation is 2 contiguous leads.
> 
> ...


Please say during this call in you are going to at least mention that the EKG is constant with BER and not just “hey guys I have elevation in leads v3 and v4?”


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## captaindepth (Jul 11, 2017)

We don't transmit our EKGs either and I don't hear too much about false activations coming from field crews.. Here is a copy of our Cardiac Alert protocol (cath lab activation). If you note the inclusion and exclusion criteria they both have associated ACS symptoms as part of the criteria.  So part of the discussion and questions about this call was if the 2 syncopal episodes and diaphoresis count as cardiac related symptoms? Chest pain is the most obvious symptom related to ACS but we also use a "chest pain equivalent" (i.e. epigastric/abdominal pain, dizziness, SOB, back/neck/extremity pain, etc). So even though the patient was complaint free during assessment and transport, would the event and skin signs count as a possible "ACS symptom?" Also here is a good review for BER   https://lifeinthefastlane.com/ecg-library/benign-early-repolarisation/  It is pretty spot on with this case and almost exactly matches up with the strips above (other than the patients age and events leading up to the assessment). 

I am not trying to beat a dead horse here, and have already divulged what was done on the call, but still enjoy the discussion to see where different people lie on this type of call. 

p.s. Still waiting on follow up, I wasn't able to get back to that ED for any updates.


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## NomadicMedic (Jul 12, 2017)

jbiedebach said:


> While the signs and symptoms might not prompt me to think STEMI for sure, I am always going to call in an EKG with elevation is 2 contiguous leads.



Whike I appreciate your honesty (and tenacity) you need to understand that this is wrong. You can certainly call and tell the Doc that you're bringing in a patient with a 12 lead consistent with BER, but calling a STEMI cath lab activation on a mimic is wrong. Almost as wrong as saying "you can't call a STEMI with a LBB".

As a paramedic you are expected to be able to identify STEMI mimics as well as an actual STEMI. Please take a STEMI mimics class on line or one of the traveling classes from Tim Phalen or Bob Page. It'll help.


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## DrParasite (Jul 12, 2017)

jbiedebach said:


> We do activations all the time for strokes, STEMIs, trauma, etc, but those activations are always subject to override by the hospital.


As they should be; they have an MD after their name, and if they feel the need to override you, it's their call.  But I would imagine they would only override you if it was clear that you were wrong


jbiedebach said:


> My protocols say I transmit any STEMI suspect, but the county next door has to transmit *all* 12 leads.


if the hospital wants to transmit all 12 leads, go nuts.  it's a second set of eyes.  I'm hoping they are transmitting (at least the suspected STEMI) it to the cardiology department, and not just to the regular ER.  After all, you want an expert to review them....





jbiedebach said:


> They told us that too. Then they stopped activating on the word of EMS. If you can't or don't transmit, don't expect to go to cath lab around here.


Be wrong too many times, and the hospitals stop trusting your diagnosis (and I can't blame them for that either).   Cry wold too many times and don't be surprised if your warnings get ignored.  But transmitting a questionable 12 lead or calling for a consult should never be frowned upon, especially if you are just looking for confirmation to  your conclusion.

My former NC agency bypasses the ER completely and takes the patient directly to the cath lab (on the EMS stretcher, we could actually watch them do the cath and see their rhythm return to normal).  

When I was up in NJ, we could activate the CATH lab, but still stopped in the ER first, transferred the patient, and they brought them up stairs.

There needs to be a high level of oversight in cath lab activations, and if you are activating incorrectly, than you need to be sent back for retraining.  Someone once told me that a paramedics knowledge of EKGs needs to be on par with a cardiologist, because they could be the first person to identity problems and initiate early intervention.


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## jbiedebach (Jul 12, 2017)

I am always trying to learn and I accept the coaching to learn more about STEMI mimics, good advice.  But I also think it matters what kind of system you work in. I have 6 cath labs in my immediate response area and they are all staffed during the day (3 are staffed 24/7).  So I never "activate the cath" lab. If a patient is symptomatic and they have a suspected STEMI then I call a code STEMI. That means I transmit the EKG, the doc looks at it while en route, a lot of times they meet me at the door (there is one I go to most often, they are also our OLMC). Sometimes we go right to the lab, sometimes they go for bloodwork. If they are non-symptomatic but they have an iffy EKG, then I call it in, transmit it and tell the doc what is going on and we decide together what to do next. Like I said, I see elevation from BBB way more than BER so I have learned to call that out. Part of the reason I am on this forum is to get different points of view, but some of the advice given here doesn't reflect how my system runs- right, wrong or indifferent.


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## hometownmedic5 (Jul 12, 2017)

"calling a code stemi" is functionally synonymous with "activating the Cath lab". There is still action being undertaken on your say so, you just aren't dragging people in from home.


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## DrParasite (Jul 13, 2017)

jbiedebach said:


> I have 6 cath labs in my immediate response area and they are all staffed during the day (3 are staffed 24/7).  So I never "activate the cath" lab.


yes, but if you call a code stemi, doesn't the cardiologist get involved?  either physically going down to the ER to meet you at the door, or at least looking at the 12 lead?   and if you have an emergency cath, they don't push off any prescheduled cath's to get them done, until your emergent one is completed?  and if it's a night time call, do they call people in from home, or from other areas of the hospital (because few people have scheduled caths at 3am) to open and staff the cath lab?

Activating the cath lab (or throwing a monkey wrench into their routine operations) for a STEMI patient when they aren't a STEMI patient is wrong, a waste of resources, and makes you look like a fool who doesn't know his job, which reflects poorly on you, your agency, and EMS as a whole. 

I'm not saying don't call s STEMI if you have a patient having a STEMI, I'm not saying don't speak to the Doc for a second opinion, and if it's questionable, then by all means call it (better to activate for a false positive than not call for a false negative).  But if it's a known STEMI mimic, and you're activating the cath lab for a known mimic, well, your not helping anyone except those hospital personnel that are painting us as idiots who can't be trusted to do anything without a hospital employee verifying that what we are doing is correct.


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## Tigger (Jul 13, 2017)

jbiedebach said:


> I am always trying to learn and I accept the coaching to learn more about STEMI mimics, good advice.  But I also think it matters what kind of system you work in. I have 6 cath labs in my immediate response area and they are all staffed during the day (3 are staffed 24/7).  So I never "activate the cath" lab. If a patient is symptomatic and they have a suspected STEMI then I call a code STEMI. That means I transmit the EKG, the doc looks at it while en route, a lot of times they meet me at the door (there is one I go to most often, they are also our OLMC). Sometimes we go right to the lab, sometimes they go for bloodwork. If they are non-symptomatic but they have an iffy EKG, then I call it in, transmit it and tell the doc what is going on and we decide together what to do next. Like I said, I see elevation from BBB way more than BER so I have learned to call that out. Part of the reason I am on this forum is to get different points of view, but some of the advice given here doesn't reflect how my system runs- right, wrong or indifferent.
> 
> 
> Sent from my iPhone using Tapatalk


So if you can not call a STEMI with a BBB, why can't you do that with the other mimickers? There is no way to defend calling something over the radio a STEMI when it is not. Elevation is not the only criteria.


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