# Interesting ECG that got me....



## Handsome Robb (Mar 8, 2013)

Ran a call today that I kinda felt like I jumped the gun and misinterpreted the ECG.

Toned out for a P1 Syncope across the street from the Trauma Center, literally could've thrown a rock and busted out of window of the Helicopter on the ground pad from the front yard. 

U/A you find a 60 year old hispanic female in obvious, emotional, distress (she looked freaked but honestly did not look sick to me at all, my partner agreed.) with a number of very hyped up, panicked family members running about. She's seated in the front seat of a car, spanish speaking only, son instantly picks her up and carries her to the gurney as fire pulls it out of the back of the ambulance. All of this was interpreted through her daughter, who was pretty good but like I said, she was pretty panicked like the rest of her family. 

Per the patient was eating breakfast, stood up to go to the bathroom, became dizzy and "fell down and passed out". She said she "shook for about a minute" afterwords and "her eyes rolled in the back of her head". As far as I could tell she was A&O when we arrived. Daughter said they then walked to the car with her to take her to the hospital when it happened again so they decided to call 911. Per the daughter the patient was complaining of dizziness and 8/10 chest pressure that started with the first syncope but I couldn't really get any more assessment out of her than that about it. No recent illness or any other complaints as far as I could figure from the info I was getting.  Daughter kept telling me she had blood draws "this morning" but couldn't tell me why. 

Vitals:
160/100
70 Sinus without ectopy, 12 lead is attached below and this is what got me. 
90% on RA, 97% on 2 lpm
170 mg/dl CBG

Hx: HTN, NIDDM, CVA 2 years prior with no lasting deficits, hyperlipidemia. THe daughter was very adamant that the patient had no cardiac history whatsoever. 

NKDA

Meds: Off the top of my head, labatelol, glyburide, a statin I hadn't seen before and hydrocodone. 

What I did:
STEMI protocol activation
Bilateral 20s, tried to draw labs but I was tied up doing things and my partner didn't leave the TQ in place so she couldn't get them to draw.
324 mg aspirin. 
NTG SL x2 pain down to 5/10, no EG changes pre/post NTG, no notable changes in her HR or BP. 
Quick trip across the street where the STEMI protocol was cancelled pretty quickly. 

The 12 lead really got me on this patient. It looked like LVH to begin with but my interpretation was: Sinus without ectopy 2 mm elevation in V1-V3, T wave inversion and 1 mm ST depression in aVL and I. 

I try to always fold the monitor interpretation over and not look at it until after I've done it myself and I had decided to activate our STEMI protocol before I read the monitor interp, which had interpreted it as ***Acute MI***.

Now knowing what I know about ECGs there wasn't reciprocal changes in this 12-lead and there was an LVH pattern present, a great STEMI imitator. I'll admit I got tunnel visioned on the STE in the anteri then then T wave inversion and ST depression in the high lateral leads. I felt like an *** bringing in a false positive but at the same time the cardiologist even said, "I'd rather have you call it and be wrong than not call it when you should have. I've got no problem with how you handled this call".

After my giant rant, did I jump the gun activating our STEMI protocol on this patient? I'll admit, I didn't have a long DDx list (MI, AAA/Dissecting TAA, Tamponade as my zebra). 

I'm all ears for everyone's thoughts, I wont tell you the Dx yet but I will tell you it was a false activation of the cath lab.


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## Handsome Robb (Mar 8, 2013)

Here's the 12 Lead


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## VFlutter (Mar 8, 2013)

I see bi-atrial hypertrophy, LVH, lateral ischemia, and possible LV aneurysm. I personally would not activate a STEMI alert based off the EKG. 

But I am on my phone after a few beers so take it with a grain of salt lol 

I am sure the EKG gurus will chime in soon.


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## Handsome Robb (Mar 8, 2013)

Chase said:


> I see bi-atrial hypertrophy, LVH, lateral ischemia, and possible LV aneurysm. I personally would not activate a STEMI alert based off the EKG.
> 
> But I am on my phone after a few beers so take it with a grain of salt lol
> 
> I am sure the EKG gurus will chime in soon.



Hindsight is 20/20 but I should've taken more time reading it. The atmosphere, the language barrier and having our HR director riding as a third with me definitely had me a little more wound up than usual. Made me mad, I always pride myself in staying really calm on scene no matter what's going on. We're always our own toughest critics though, right?


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## truetiger (Mar 8, 2013)

Bi-atrial hypertrophy? Where do you see that?


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## truetiger (Mar 8, 2013)

I think you did fine playing it safe, no one will ever come after you for playing it safe. If it was me personally, I would of transmitted the ekg and discussed it with the physician as to if he wanted to activate or not.


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## VFlutter (Mar 8, 2013)

truetiger said:


> Bi-atrial hypertrophy? Where do you see that?



It looked like there was the typical biphasic P wave morphology in some of the leads but looking again it'a probably normal.


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## truetiger (Mar 8, 2013)

Right atrial hypertrophy is typically diagnosed in II or V1 with an amplitude greater than 1.5mm.


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## Handsome Robb (Mar 8, 2013)

truetiger said:


> I think you did fine playing it safe, no one will ever come after you for playing it safe. If it was me personally, I would of transmitted the ekg and discussed it with the physician as to if he wanted to activate or not.



I get a lot of sick patients and a lot of weird calls, STEMIs aren't one of them though. Only had one as a Medic (this was only my second cath lab activation) and a few real severe ones as an Intermediate. 

Unfortunately we cannot transmit ECGs. Well, I'm sure the MRx is capable but we don't have the system in place at the ERs to receive them and I'd honestly have no idea how to do it. 

Like I said, we were across the street from the ER. We used the disco lights since it's a busy street that's virtually impossible to cross without the help of a traffic signal or wee-woos, but our transport time was <60 seconds, even if we could transmit I don't think I would have just because of the time factor. If I was still on nights it'd make sense, I guess, since the cath team isn't on campus but during the day they're all there so it's not as big of an ordeal to activate them as far as having to wake people up and get them driving towards the ER.


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## Handsome Robb (Mar 8, 2013)

Chase said:


> and possible LV aneurysm.



I will tell you they were pretty worried about a TAA, I know, not the same but they also threw out an LV aneurysm as well. Her bedside ECHO wasn't anything like "holy smokes we need to go now" but they didn't seem happy with it either. 

I got to watch the screen while they did it but I will admit I didn't have much of a clue as to what I was looking at and what was "normal" vs "not normal". Although watching it and listening to them talk was pretty neat.


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## Veneficus (Mar 8, 2013)

Robb said:


> U/A you find a 60 year old hispanic female in obvious, emotional, distress (she looked freaked but honestly did not look sick to me at all, my partner agreed.) with a number of very hyped up, panicked family members running about.



I think the term you are looking for is "staticus hispanicus" or "hispanic panic." 

Ok, jokes aside, learning tip: Some cultures are very vocal about pain. It always seems out of proportion to what it is. Best to treat them like the cultures who do not verbalize pain and consider something serious until proven otherwise.

Also, they usually respond better to benzos than opioids, but if your protocol allows, a little of both go a long way.



Robb said:


> All of this was interpreted through her daughter, who was pretty good but like I said, she was pretty panicked like the rest of her family. .



Welcome to my world.

Already read the Dx so I will not go there.


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## Clare (Mar 8, 2013)

I see lateral ischaemia and some sort of hyperthrophy although I am a bit rusty on hyperthrophy 

Oh and cut you fingernails dear


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## katgrl2003 (Mar 8, 2013)

Clare said:


> Oh and cut you fingernails dear



Hahahaha!

On the serious side, we had a medic unit near us have almost the exact same thing. He activated the cath lab, and the docs in the er said it was LVH. 12 lead looked pretty similar to yours.


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## Clare (Mar 8, 2013)

katgrl2003 said:


> Hahahaha!
> 
> On the serious side, we had a medic unit near us have almost the exact same thing. He activated the cath lab, and the docs in the er said it was LVH. 12 lead looked pretty similar to yours.



I'm not one of these girly girly types but um yeah, I noticed .... 

You bring up another good point; you should always give early notification to the hospital to advise them of ? STEMI and if they open (or free up) a PCI suite unnecessarily then that is fine, I'd rather have them free one up and not need it than not do it and need it.

Since last year Emergency Medical Technician (BLS) can acquire a 12 lead ECG so in their RT call they can now advise of the automatic interpretation; generally for STEMI so if you get the rare situation where two EMT are transporting a ? STEMI they something a bit more objective to get the PCI suite opened up rather than "we think cos he has chest pain ...."

While I do not believe in relying upon automatic interpretation for BLS AO's its a good idea.


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## Sublime (Mar 8, 2013)

Looks like LVH with a strain pattern to me. Personally wouldn't have activated on that. 


Language barriers definitely complicate things and hispanics also tend to be over dramatic (not being racist, just stating what I've noticed). So I can see why this wasnt an easy call.

Interested to hear diagnosis.


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## blindsideflank (Mar 8, 2013)

we have been told by our medical director that when you get a ***MI it is 98% accurate. (that was the statistic we were given). There has been a push to always transmit these and have a quick discussion even if you are pretty sure its nothing.
we dont find everything and i dont have too much pride to admit that i can miss things


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## Aprz (Mar 8, 2013)

For the size of those complexes, the STE is minimal.

From what I've read, the shape of the ST-segment and reciprocal changes have been getting more and more recognition, however, T-waves symmetry is massively under appreciated. The T-waves in this 12-lead is asymmetrical, which is a good thing.


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## Brandon O (Mar 8, 2013)

Robb said:


> I will tell you they were pretty worried about a TAA, I know, not the same but they also threw out an LV aneurysm as well. Her bedside ECHO wasn't anything like "holy smokes we need to go now" but they didn't seem happy with it either.



Just to clarify, when people talk about "left ventricular aneurysm" in regards to the ECG, typically what they mean is not necessarily a literal aneurysm (which may or may not be present) but rather persistent changes after an old STEMI. It's characterized by deep QS waves, mostly in the anterior leads, without particularly hyperacute T waves or very much elevation. Usually it's a benign finding, although they can be pretty good mimics.


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## Christopher (Mar 8, 2013)

Robb said:


> Here's the 12 Lead...



I've got nothing really huge to add, other than it looks pretty typical for LVH with Strain.

"It's got a lot of ink," is one of the gut checks that works Ok when differentiating LVH from other processes.

Keep in mind MI's most often attenuate voltages. By that I mean in the non-ACS ECG any time you have *high depolarization* voltages you should expect proportionally *high repolarization* voltages (e.g. ST-e/big T-waves). So when you differentiate LVH from AWMI you need to be looking for a _loss of expected R-wave amplitude_ and proportionally larger ST/T-wave changes.

It is interesting that the MRx said ACUTE MI though. Perhaps a reasonable over-activation of the system.


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## Christopher (Mar 8, 2013)

Chase said:


> I see...lateral ischemia...
> 
> I am sure the EKG gurus will chime in soon.



My one suggestion would be to drop the usage of "<Focal Area> Ischemia" as this term is not actually correct. Subendocardial ischemia causes diffuse ST-depression rather than focal changes. I was a sinner once too, but Dr. Smith has helped me see the light with this one.

Any time you see localized ST-depression your first thought must be "reciprocal change".

In this case the ST-depression is an expected finding with the LVH pattern.


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## Christopher (Mar 8, 2013)

truetiger said:


> I think you did fine playing it safe, no one will ever come after you for playing it safe. If it was me personally, I would of transmitted the ekg and discussed it with the physician as to if he wanted to activate or not.



We've got a pretty liberal activation policy in my area, but excessive false positives will get you in trouble and probably should. Our area does not consider LBBB w/o primary changes or LVH to be reasonable activations. Systems with paramedic activation need to make sure they're not just activating to cover their butt. (_nb: this comment is not directed at this ECG in particular_)

Borderline cases are best called in as, "we've got X and Y, which any other day of the week we'd call a STEMI, but because of Z we don't meet criteria. We think this guy needs to an ACS workup ASAP upon arrival, we'll advise if his ECG trends to meeting criteria."


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## FLdoc2011 (Mar 8, 2013)

Veneficus said:


> I think the term you are looking for is "staticus hispanicus" or "hispanic panic."



Had the exact same thought/joke in my mind...


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## KellyBracket (Mar 8, 2013)

Robb said:


> Ran a call today that I kinda felt like I jumped the gun and misinterpreted the ECG....
> 
> Quick trip *across the street* where the STEMI protocol was cancelled pretty quickly.



If you were truly "across the street," then you rock.

It seems that all too often we hear the explanation "we were right around the corner," when EMS shows up with some syncopal octogenarian, but no ECG. I'm starting to think that the population density within a one-block radius of our ED approaches that of Hong Kong! 

On another note - this is a fairly common STEMI mimic, but it routinely gets called as *** ACUTE MI *** by the computer. Although people claim that the computer is very specific for STEMI, I am dubious. *Christopher*, I'm sure you have some equipment-specific insights!


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## Brandon O (Mar 8, 2013)

KellyBracket said:


> If you were truly "across the street," then you rock.
> 
> It seems that all too often we hear the explanation "we were right around the corner," when EMS shows up with some syncopal octogenarian, but no ECG.



To me, one step outside the ED door is a vast distance from one step inside, as far as certain time-to-care issues and decisions are concerned. It's like entering Narnia.



> On another note - this is a fairly common STEMI mimic, but it routinely gets called as *** ACUTE MI *** by the computer. Although people claim that the computer is very specific for STEMI, I am dubious. *Christopher*, I'm sure you have some equipment-specific insights!



The Marquette algorithm was highly specific. All of the newer algorithms, and the Philips algorithm too, seem to be less so (presumably in the pursuit of greater sensitivity). We must adjust.


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## systemet (Mar 8, 2013)

Robb said:


> I try to always fold the monitor interpretation over and not look at it until after I've done it myself and I had decided to activate our STEMI protocol before I read the monitor interp, which had interpreted it as ***Acute MI***.
> 
> (snip...)
> 
> After my giant rant, did I jump the gun activating our STEMI protocol on this patient? I'll admit, I didn't have a long DDx list (MI, AAA/Dissecting TAA, Tamponade as my zebra).



As someone else said, I think it's really hard to ignore the monitor when it spits out "ACUTE MI SUSPECTED", and you want to bias any errors in the favour of the patient.  Better to upset the cathlab than miss the MI.

That being said, I think there's been a lot of good discussion about ST proportionality and T wave symmetry.  The downsloping ST depression in the lateral leads looks very LV strain'y.

For what it's worth, I got myself caught calling a STEMI on a RBBB c/ RAD / RVH the other day.  I think these type I / false positive errors are much better for the patient than a type II / false negative.  We're all human.


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## KellyBracket (Mar 8, 2013)

Brandon Oto said:


> The Marquette algorithm was highly specific. All of the newer algorithms, and the Philips algorithm too, seem to be less so (presumably in the pursuit of greater sensitivity). We must adjust.



Wish we had some numbers to back up that impression, as I obviously agree!


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## Summit (Mar 8, 2013)

I learned in this thread. So where to read more on some of the proportionality discussion? A particular 12 lead book you all recommend?


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## mycrofft (Mar 8, 2013)

*Speak to me not of algorithms...*

The machine in the north exam rm said I had occasional PVC. The one on the south said atrial fib. Updated software maybe. Guess which was right?
==========
I'm encouraged to hear no one got distracted by the seizureform activity after falling out.  Seen that in lots of vaso-vagals post immunization with NO cardiac issues. 
=========
OP quote:
"STEMI protocol activation
Bilateral 20s, *tried to draw labs* but I was tied up doing things and my partner didn't leave the TQ in place so she couldn't get them to draw.
324 mg aspirin. 
NTG SL x2 pain down to 5/10, no EG changes pre/post NTG, no notable changes in her HR or BP. 
Quick trip across the street where the STEMI protocol was cancelled pretty quickly. "

Drawing labs when you are a couple hundred feet away from a hospital? I'm assuming you are throwing that in to make us think about what would be occurring if you were fifty miles out as well.


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## Christopher (Mar 8, 2013)

mycrofft said:


> Drawing labs when you are a couple hundred feet away from a hospital? I'm assuming you are throwing that in to make us think about what would be occurring if you were fifty miles out as well.



We draw them because when we activate a STEMI we go right to the cath suite and hand off our labs on the way. Only reason for the hospital to draw them is if we have to pit stop in the ED or if we couldn't get access and they do it in the cath suite.


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## Christopher (Mar 8, 2013)

KellyBracket said:


> On another note - this is a fairly common STEMI mimic, but it routinely gets called as *** ACUTE MI *** by the computer. Although people claim that the computer is very specific for STEMI, I am dubious. *Christopher*, I'm sure you have some equipment-specific insights!



I don't have the DXL guide handy, but my guess is it went something like this:

Gender and age make STJ measurements in V1-V2 back to "isoelectric is normal"
Broad QS complexes in V1-V3 recognized as Anteroseptal Infarct
In the absence of >1.5mm STE in V1, I believe you'd have seen "age undetermined" rather than >>> ACUTE MI <<<
LVH disabling AWMI detection probably occurs with r-waves present
I didn't think Marquette called LVH STEMI quite that often, and I know the Inovise on our Zoll X-Series (when it's not complaining about data quality) avoids STEMI w/ LVH, but I can't say definitively whether the DXL or Glasgow make an "early out".

I've seen Marquette get an inferior STEMI w/ LVH correct before, so I dunno. I think you can teach Paramedics how to weed out cases which fool the monitor and it would be best to leave the sensitivity a bit higher on the devices and improve the specificities on the people.


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## truetiger (Mar 8, 2013)

Is it just me or does the Zoll X series just take terrible 12 leads? More often than not it will take forever to pick up a signal in 12 lead mode. Always seems like I'm waiting on a lead or two. Most of the 12 leads seem to be substandard quality as compared with our last Zoll monitor or the Lifepak 12.


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## Christopher (Mar 8, 2013)

Summit said:


> I learned in this thread. So where to read more on some of the proportionality discussion? A particular 12 lead book you all recommend?



It is pretty simple really, just perhaps not put to you in this way:

The amplitudes of the electricity in the heart as seen on the ECG are roughly proportional to the myocardium involved. (and what electrode pair you're using)

This is why the P-waves of the atria are small and the R-waves of the ventricles are large.

Taking this one step further, if you get an enlarged atria or ventricle you get an increased amplitude in their corresponding complexes.

This applies to more than just the amplitudes of _depolarization_.

If you think about it, if X amount of myocardium depolarizes, X amount is going to repolarize. So, if the amplitude of depolarization is large, the amplitude of repolarization will be large as well.

What separates repolarization from depolarization is _how_ it occurs. Depolarization follows a wavefront and moves rather quickly. This is why you mostly get sharp upstrokes and downstrokes in your QRS complexes.

Whereas repolarization occurs on an individual basis and isn't homogenous. This is why your T-waves are broad and asymmetric.

So back to proportionality.

If we expect big depolarizations to have big repolarizations, certain features of repolarization are bound to be exaggerated. In this case, the ST-elevation found in LVH or LBBB will look exaggerated. Both of these are processes which alter depolarization, thus we _expect_ to see this exaggeration.

Simply put, altered depolarization = altered repolarization. Tack onto that a constant multiplier for the amount of myocardium involved and you've got yourself an explanation for proportionality.

So why do we use absolute millimeter criteria?

STEMI's don't care about our criteria, and you can probably guess the primary changes of ACS are a continuous variable rather than a discrete one. Tiny depolarizations will have a tiny primary change during ACS, and aVL is a great example.

But, when they were designing and defining cut-offs for "normal" STJ measurements during the trials of Thrombolytics for MI's they needed to arrive at a measure that was both *Sensitive* and *Specific* for myocardial infarction. Thus you end up with the arbitrary &gt;1mm STE in &ge;2 contiguous leads and later modifications to make it &ge;2mm STE in the right precordials.

I hope that helps with your understanding of proportionality!


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## Brandon O (Mar 8, 2013)

Well, Mr. Watford, that's about the best of proportionality explanation I've heard.


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## Sublime (Mar 9, 2013)

Christopher said:


> It is pretty simple really, just perhaps not put to you in this way:
> 
> The amplitudes of the electricity in the heart as seen on the ECG are roughly proportional to the myocardium involved. (and what electrode pair you're using)
> 
> ...



Yup.. you're awesome.


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## BandageBrigade (Mar 9, 2013)

Robb said:


> Unfortunately we cannot transmit ECGs. Well, I'm sure the MRx is capable but we don't have the system in place at the ERs to receive them



All you need is a blue tooth capable phone and the ER fax number.


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## mycrofft (Mar 9, 2013)

truetiger said:


> Is it just me or does the Zoll X series just take terrible 12 leads? More often than not it will take forever to pick up a signal in 12 lead mode. Always seems like I'm waiting on a lead or two. Most of the 12 leads seem to be substandard quality as compared with our last Zoll monitor or the Lifepak 12.



Have your wiring harness checked or swap it between two same-brand machines which work differently (one is better). A faulty set of wires will cause delay in a lead or two before it goes out entirely. Is it the same leads over and over?


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## mycrofft (Mar 9, 2013)

Christopher said:


> We draw them because when we activate a STEMI we go right to the cath suite and hand off our labs on the way. Only reason for the hospital to draw them is if we have to pit stop in the ED or if we couldn't get access and they do it in the cath suite.



Good deal as long as nothing needing STAT hospital juju happens while trying to draw labs "_ across the street_". Has a strong potential for a Murphy's Law encounter, but good they will work as closely as that!


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## Handsome Robb (Mar 9, 2013)

mycrofft said:


> OP quote:
> "STEMI protocol activation
> Bilateral 20s, *tried to draw labs* but I was tied up doing things and my partner didn't leave the TQ in place so she couldn't get them to draw.
> 324 mg aspirin.
> ...



Yes, we were across the street. I could have thrown a rock threw the window of the helicopter on the ground pad. Well, maybe not but I definitely could come close. Our transport milage was 0.1.

We draw labs on STEMI activations that we take to a certain facility because, like Christopher said in the quote below, we generally meet a cardiologist or ER Doc at the door they look at our 12-leads and then send us on our way to the cath lab or cancel it. We do stop in the ER if the lab isn't ready or they're all being used. 



Christopher said:


> We draw them because when we activate a STEMI we go right to the cath suite and hand off our labs on the way. Only reason for the hospital to draw them is if we have to pit stop in the ED or if we couldn't get access and they do it in the cath suite.



Quoted for my answer above. 



mycrofft said:


> Good deal as long as nothing needing STAT hospital juju happens while trying to draw labs "_ across the street_". Has a strong potential for a Murphy's Law encounter, but good they will work as closely as that!



Agreed, but even being close to the hospital there are still things that need to get done before we get there. While I'm working on getting asa on board, activating the cath lab, getting her on O2 since the protocol gods want it my partner is dropping a line and pulling labs off it, generally a pretty quick task except she may or may not have taken the TQ off so it wouldn't draw and I was busy and didn't have time to help her. 


I've learned a lot from this thread, thank you! I've got some questions but I'm too tired right now from riding all day to comprehend anything complex right now.


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## truetiger (Mar 10, 2013)

mycrofft said:


> Have your wiring harness checked or swap it between two same-brand machines which work differently (one is better). A faulty set of wires will cause delay in a lead or two before it goes out entirely. Is it the same leads over and over?



Not the same leads, and it does it on pretty much all of the Zoll's. They are not even a year old yet.


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## the_negro_puppy (Mar 10, 2013)

02 for STEMI is verboten here unless they are de-saturated


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## Clare (Mar 10, 2013)

the_negro_puppy said:


> 02 for STEMI is verboten here unless they are de-saturated



Same here, oxygen in general is absolutely contraindicated in all patients unless there is an indication for it.  We have had it smashed into us over and over that we must not give oxygen unless there is clinical evidence of hypoxaemia; particularly in those patients with stroke and myocardial ischaemia.

I have almost seen a crew dukeing it out over their positions on giving oxygen; one pro and one against; it was like .... damn guys its just bloody oxygen, chill!


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## Fish (Mar 10, 2013)

I am responding to this thread without reading the other responses so that my interpretation is not biased.


I see LVH, with lateral Ischemia. No STEMI seen here, ACS patient. Treat with a normal chest pain protocol, and show your findings on the ECG to the receiving ER Doc.


Now on to read the other responses to see what others thought


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## Handsome Robb (Mar 11, 2013)

the_negro_puppy said:


> 02 for STEMI is verboten here unless they are de-saturated





Clare said:


> Same here, oxygen in general is absolutely contraindicated in all patients unless there is an indication for it.  We have had it smashed into us over and over that we must not give oxygen unless there is clinical evidence of hypoxaemia; particularly in those patients with stroke and myocardial ischaemia.
> 
> I have almost seen a crew dukeing it out over their positions on giving oxygen; one pro and one against; it was like .... damn guys its just bloody oxygen, chill!



I agree that not everyone needs oxygen. The two patients I've activated on, this one and one that was a very obvious inferior MI both were brought in on a nasal cannula by yours truly. 

Unfortunately, even if they're at 100% I still have to give o2, the way our protocol is written. Most all say "Assess oxygenation and administer O2 as needed". Our ACS and Stroke protocol both say "Assess oxygenation and administer O2", takes the option of withholding it away from us. 

With that said, this thread is about ECG interp, so no more O2 arguments por favor 

Had another pair of borderline ones today. 92 year old with nonspecific chest pain and SOB with rhales bilaterally. LBBB on the 12 and both her and her son were very adamant she had a "perfect EKG" last week. I called a doc and we deferred the activation due to her age and the fact that neither of us thought it was a STEMI. 

Second one was a syncopal with weakness as a primary complaint, 84 year old female denied any Hx, allergies or medications...take that for what it's worth... V1 and 2 had 1.5mm STE, no reciprocal changes though, she also had a "perfect" ECG not too long ago per her, her son and her daughter. Had been seeing a cardiologist because of new pedal edema She adamantly AMAd and went POV. 

These borderline 12-leads are making my head spin.


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## Christopher (Mar 11, 2013)

Robb said:


> Had another pair of borderline ones today. 92 year old with nonspecific chest pain and SOB with rhales bilaterally. LBBB on the 12 and both her and her son were very adamant she had a "perfect EKG" last week. I called a doc and we deferred the activation due to her age and the fact that neither of us thought it was a STEMI.



New or suspected new LBBB is not a STEMI equivalent. So no need to fret over activation. LBBB _with primary changes_ is, however, a STEMI equivalent.



Robb said:


> Second one was a syncopal with weakness as a primary complaint, 84 year old female denied any Hx, allergies or medications...take that for what it's worth... V1 and 2 had 1.5mm STE, no reciprocal changes though, she also had a "perfect" ECG not too long ago per her, her son and her daughter. Had been seeing a cardiologist because of new pedal edema She adamantly AMAd and went POV.



V1 and V2 can have ST-elevation normally, at 84yo it is less likely to be normal, but what you're describing might be Left Ventricular Aneurysm (LVA).



Robb said:


> These borderline 12-leads are making my head spin.



Highly functioning systems haven't replaced us with machines because there is such a large gray area in ECG interpretation.


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