# Serial 12 Lead EKG in prehospital setting (How many of you do it?)



## Ecgg (May 28, 2013)

Just curious how many here actually keep the 12 lead electrodes connected for the duration of transport and conduct serial 12 leads? 

Before once I saw a STEMI the precordial leads came off and just monitor remained, usually would get the pads ready and plan for ACLS.

Now I keep all the leads on and usually do another if patient conduction changes, any complaints, response to meds. If all I saw was TWI or depressions and no ST elevations, I do one before wheeling through the doors so I don't get these idiot drivers look from the staff holding hospital EKG showing 2mm elevations. 

A study on this http://www.ncbi.nlm.nih.gov/pubmed/21954895


----------



## abckidsmom (May 28, 2013)

We have a typical transport time of 1 hr. I leave the leads on and get another 12 lead whenever there is a change. 

I had a guy with a STEMI last week that was about 2-3 mm elevation in v1-v4 that was completely resolved on ED arrival because of my treatment. He still went to the cath lab and had his reperfusion there. 

I do not want to be surprised by what the ED admission EKG looks like. Ever. If the 12 lead is a big part of what we have going, at a minimum I get one on scene and one just prior to arrival at the hospital.


----------



## Arovetli (May 28, 2013)

I always did serial ekgs. Generally onscene, enroute (if long enough tx time), and at destination.


----------



## johnrsemt (May 28, 2013)

45min to 3 HR transport time   yes I do them

But when I had short transport times I always tried to do them due to the fact that sometimes what we do changes what the 12 lead shows.
Pre O2, Pre NTG, pre Pain relief    I have also had multiple patients with Severe STEMI's showing normal when I got to the ED due to treatment.

If I didn't have a early 12 lead it can delay their time to the cath lab.      Also I leave the leads on, and anytime the patient states that the pain has increased or changed then I can hit the button and see what changes it shows,  surprising what you may find


----------



## chaz90 (May 28, 2013)

I do them quite frequently. In particular, I make sure I do a couple when the presentation really makes me think MI and I'm just not seeing EKG changes yet. I've seen a series of 12 leads over a 20 minute transport that went from pain but no ST changes to full blown inferior STEMI.


----------



## Handsome Robb (May 28, 2013)

Do them here. Well I do not sure about other medics.

One gets done after every medication that may cause changes or a change in pt complaint (Ntg, ms, metoprolol if applicable). We have short transport times (<20 minutes usually) but I still do them. Give a spray, do something else, in a couple minutes hit the "acquire new 12-lead" button after instructing the pt to hold still for a minute and walla. Generally will try to get them when we are moving slow or stopped but not always possible. 

We have the Philips MRx so I leave it in the live 12-lead view on all cardiac patients. 

Every printout gets labeled, (pre ntg, post ntg 1, post ntg 2, ect...)

Any inferior gets a right sided view as well.


----------



## NomadicMedic (May 28, 2013)

I do it. Usually at least three. One at contact, at least one while en route, and one as I arrive at the ED. They're free...and take no time. 

One is interesting. Two provides a contrast. Three gives you trending. 







*In the words of Dr. Corey Slovis: "One ECG begets another"*


----------



## Summit (May 28, 2013)

Many patients have transient ST elevation that would be missed by a single 12 lead. Patients deserve to have serial or continuous 12 lead monitoring made a high priority.

For further study please review:
"intermittent reperfusion" 
"dynamic ST changes"
http://ajcc.aacnjournals.org/content/11/4/378.full
http://www.ncbi.nlm.nih.gov/pubmed/10688301
http://ajcc.aacnjournals.org/content/11/4/318.full


----------



## Ecgg (May 28, 2013)

DEmedic said:


> One is interesting. Two provides a contrast. Three gives you trending.



I like that, trending is where it's at. If we are prudent trending get's done for all other diagnostic tests yet 12 Lead seems to be that 1 hit wonder.


----------



## epipusher (May 28, 2013)

Yes,always.


----------



## medicsb (May 28, 2013)

If an active CP: one before NTG, one after NTG, one if pt. becomes pain free, and one at arrival.  More 12 leads if there seem to be changes evolving.

Everyone else would vary.


----------



## Handsome Robb (May 28, 2013)

Ecgg said:


> I like that, trending is where it's at. If we are prudent trending get's done for all other diagnostic tests yet 12 Lead seems to be that 1 hit wonder.



Agreed, I've had coworkers here look at me like I have three heads when I come in with  an active STEMI and 3-4 12-leads. My question is why not do them? They're painless, non-invasive and are dynamic. That reason at the end right there makes me wonder why serial 12s aren't the standard.

People in this thread have said it, elevation can resolve with ACS treatment. I'd be interested to see if anyone had ever had an ER cancel a STEMI protocol due to a 12-lead that's "within normal limits" upon arrival to the ED with a patient that's pain free only to have to re-activate later when the elevation returns? I think that would be retry shotty on the hospital's part but stranger things have happened. Whereas if you do serial 12s and show the resolution of the elevation throughout us treatment you can make a much strongest case rather than just "I swear I saw elevation!"


----------



## Arovetli (May 28, 2013)

Continuous *should* be the norm.


----------



## Sublime (May 29, 2013)

DEmedic said:


> *In the words of Dr. Corey Slovis: "One ECG begets another"*



Haha I was literally saying this in my head as I read this thread title. Did you hear this from a recent episode from Dr. Amal Mattu?


----------



## NomadicMedic (May 29, 2013)

No, I went to a presentation on STEMI care that he gave. He's a great speaker. Entertaining and informative.


----------



## Sublime (May 29, 2013)

DEmedic said:


> No, I went to a presentation in STEMI care that he gave. He's a great speaker. Entertaining and informative.



Ah gotcha, Amal Mattu was quoting him and showed his picture in one of his videos not too long ago.


----------



## KellyBracket (May 29, 2013)

Robb said:


> ...
> I'd be interested to see if anyone had ever had an ER cancel a STEMI protocol due to a 12-lead that's "within normal limits" upon arrival to the ED with a patient that's pain free only to have to re-activate later when the elevation returns? ...



Yeah, that ER doc was me - once. Not doing that again!

Spontaneous reperfusion of a STEMI is a good sign, but it hardly means the patient is out of the woods. And despite the impression that NTG or ASA caused the ECG change, the evidence isn't clear what the mechanism is. Nonetheless, it's a very good idea to get multiple ECGs, just like our northern friends have demonstrated!

Edit: Re-read the quote. I actually didn't _cancel_ anything EMS had activated, in my defense, since the ECG resolved in the field. If EMS called again with this situation, I would green-light the lab, mos def.


----------



## RocketMedic (May 29, 2013)

KellyBracket said:


> Yeah, that ER doc was me - once. Not doing that again!
> 
> Spontaneous reperfusion of a STEMI is a good sign, but it hardly means the patient is out of the woods. And despite the impression that NTG or ASA caused the ECG change, the evidence isn't clear what the mechanism is. Nonetheless, it's a very good idea to get multiple ECGs, just like our northern friends have demonstrated!
> 
> Edit: Re-read the quote. I actually didn't _cancel_ anything EMS had activated, in my defense, since the ECG resolved in the field. If EMS called again with this situation, I would green-light the lab, mos def.





I serial 12-lead....everyone I 12-Lead, actually.


----------



## Ecgg (May 30, 2013)

Sublime said:


> Haha I was literally saying this in my head as I read this thread title. Did you hear this from a recent episode from Dr. Amal Mattu?



Link to the episode?


----------



## Handsome Robb (May 30, 2013)

KellyBracket said:


> Yeah, that ER doc was me - once. Not doing that again!
> 
> Spontaneous reperfusion of a STEMI is a good sign, but it hardly means the patient is out of the woods. And despite the impression that NTG or ASA caused the ECG change, the evidence isn't clear what the mechanism is. Nonetheless, it's a very good idea to get multiple ECGs, just like our northern friends have demonstrated!
> 
> Edit: Re-read the quote. I actually didn't _cancel_ anything EMS had activated, in my defense, since the ECG resolved in the field. If EMS called again with this situation, I would green-light the lab, mos def.



Your secret is safe with me haha.

I've never seen elevation resolve but I've heard of crews getting crap because their patient's elevation did and they didn't have serial 12s to prove it.


----------



## Sublime (May 30, 2013)

Ecgg said:


> Link to the episode?



Link to specific episode
http://ekgumem.tumblr.com/post/49173607390/corey-slovis-meets-rodney-dangerfield-10-minutes

Link to home page. Definitely the best thing I've discovered in regards to advancing my EKG knowledge.
http://ekgumem.tumblr.com/


----------



## Ecgg (May 30, 2013)

Sublime said:


> Link to specific episode
> http://ekgumem.tumblr.com/post/49173607390/corey-slovis-meets-rodney-dangerfield-10-minutes
> 
> Link to home page. Definitely the best thing I've discovered in regards to advancing my EKG knowledge.
> http://ekgumem.tumblr.com/



Thanks, that looks promising.

I have one of his books ECG's for the Emergency Physician 1 by Mattu, Amal and Brady, William J. (Sep 29, 2003)

Has some good 12 lead examples with breakdowns. 

The video cases are much better just from a couple that I watched thus far.


----------



## Ecgg (May 30, 2013)

This is slightly off topic, but in case anyone is looking for a good read this book has all the authors mentioned in this thread and covers very pertinent topics related to prehospital care.

Avoiding Common Prehospital Errors [Paperback]
Benjamin J. Lawner DO EMT-P (Author), Corey M. Slovis (Author), Raymond Fowler MD FACEP (Author), Paul Pepe MD MPH MACP FCCM FACE (Author), Amal Mattu (Author)


----------



## Sublime (May 30, 2013)

Ecgg said:


> This is slightly off topic, but in case anyone is looking for a good read this book has all the authors mentioned in this thread and covers very pertinent topics related to prehospital care.
> 
> Avoiding Common Prehospital Errors [Paperback]
> Benjamin J. Lawner DO EMT-P (Author), Corey M. Slovis (Author), Raymond Fowler MD FACEP (Author), Paul Pepe MD MPH MACP FCCM FACE (Author), Amal Mattu (Author)



Will check it out thanks


----------



## Christopher (May 30, 2013)

KellyBracket said:


> Yeah, that ER doc was me - once. Not doing that again!
> 
> Spontaneous reperfusion of a STEMI is a good sign, but it hardly means the patient is out of the woods. And despite the impression that NTG or ASA caused the ECG change, the evidence isn't clear what the mechanism is. Nonetheless, it's a very good idea to get multiple ECGs, just like our northern friends have demonstrated!
> 
> Edit: Re-read the quote. I actually didn't _cancel_ anything EMS had activated, in my defense, since the ECG resolved in the field. If EMS called again with this situation, I would green-light the lab, mos def.



My secret is not showing the ED the resolution ECG...is that wrong?

I obtain serial ECG's on anybody who gets a 12-lead. Typical intervals are q5 minutes when I was on the LP12, but now with the Zoll X-Series I just leave the 12L screen up and print when it looks different.

As this study out of Toronto showed, a single ECG is only going to catch 84% of STEMI patients:

_STEMI was identified on the first prehospital ECG in 275 cases, on the second ECG in 30 cases, and on the third ECG in 20 cases (cumulative percentages of 84.6%, 93.8%, and 100%, respectively). For STEMIs identified on the second or third ECG, 90% were identified within 25 minutes after the first ECG._


----------



## palmer1121 (May 30, 2013)

I always do a minimum of 3.  Initial, 2nd w/ V4r/V8/V9, and one at the hospital.  If treating active chest pain (without ST or T wave changes) I do the inital, 2nd with right and posterior leads, after nitro series, and 1 at hospital.  If treating active STEMI I do: initial, 2nd with right and posterior leads, then I set the LP12 NIBP to q5 and reacquire a 12 lead q5 when it takes a BP while treating with NTG/ASA/Plavix/Heparin/Metoprolol, and at the hospital.  I also label serial 12 leads with prior treatment and pain level.

We have anywhere from a 15 min to 60+ minute transport time.


----------



## the_negro_puppy (May 30, 2013)

Minimum of two. I have caught evolving STEMIs before by doing serial 12 leads


----------



## TheLocalMedic (May 31, 2013)

SHAZAM!  

Wish I had the 12 lead to show off, but here's what I had a few weeks ago!

54 YOM c/o chest pn.  No history, no risk factors, overall seemed pretty fit.  First 12 lead was negative, beautiful sinus rhythm.  Gave aspirin and nitro, loaded up and began transporting.  

Popped an IV in, chest pn was no longer present so I held off the nitro, and took another 12 lead.  Again, beautiful sinus rhythm.  

And then the chest pain came back...

Third 12 lead didn't print out automatically like it should have, but when I took it it read: ***MEETS ST ELEVATION MI CRITERIA*** and showed significant elevation in II, III and aVF.  

Repeated it just to be sure and it showed the same thing.  Code 3 diversion to the STEMI center.

Guy had a 100% occlusion!!!  So leave those leads on and crank out serial 12 leads if it's looking like a possible cardiac event!


----------



## MasterIntubator (Jun 7, 2013)

Yes. First contact, after each treatment, and on arrival of destination


----------

