# 12lead NSR? or a story in the details



## Outbac1 (Jan 29, 2012)

It was semi quiet in the ER yesterday. One of the ERPs and I were talking and she produces this 12 lead. "Here " she says to my partner and I. "Read this and tell me what you think". 
 The story with it a crew got a call for a seizure. 45m, somewhat large and obese, who woke up on the floor and didn't know how he got there. He had R shoulder pain and a low b/p 86/40, hr 80's - 90's. Mildly sob. Since he could basicaly walk, talk and chew gum the crew took him to the ER.
 In the ER further hx and 12 lead were obtained. Had substernal c/p for past 5 days, hx of HTN, non compliance with his HTN meds. Shoulder found to be dislocated. 
 She said this 12lead is classic for his condition. Do you see what she saw? What is his condition?


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## Aidey (Jan 29, 2012)

Was his condition being the invisible man?


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## Handsome Robb (Jan 29, 2012)

Picture didn't work boss.


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## epipusher (Jan 29, 2012)

i am confused:wacko:


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## Outbac1 (Jan 30, 2012)

There are three things on the ecg that are not normal. She tells me that this is in fact a common question for ERPs on their exams. This and his presentation led her to radiology which confirmed his condition. He is now being successfully treated. 
 I found the three things but couldn't put it together with his presentation. I rescanned it at a higher resolution. Hopefully this will help. 
 I like it when Drs take time out to show me things that you rarely see.


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## Aidey (Jan 30, 2012)

Still no picture. Via the website there is nothing. In tapatalk it shows an attachment, but it is blank and you can't click on it.


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## technocardy (Jan 30, 2012)

Outbac1 said:
			
		

> There are three things on the ecg that are not normal.



Outbac1, there is still no picture available to us. Can you please try to re upload the picture? Does this site accept imgur links?


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## mycrofft (Jan 30, 2012)

Without the picture:
Some ekg software is verklempt at detecting some arrythmias. My MD"s said "Sinus tachycardia with occasional PVC's". The one across the hall (newer and different brand) said "Atrial Fib". Cardiologist confirmed machine "B". So if the machine _says_ SNS but it looks wrong, follow your training.

Does this undermine your faith in AED's a little?


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## Outbac1 (Jan 31, 2012)

I think I have it fixed. The album it was in was marked private not public. The pic is there when I click on the thread when I'm not logged in. 
 I'm sorry. :sad:


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## DesertMedic66 (Jan 31, 2012)

Outbac1 said:


> I think I have it fixed. The album it was in was marked private not public. The pic is there when I click on the thread when I'm not logged in.
> I'm sorry. :sad:



It's working for me. But I don't really know anything about EKGs yet so I can't say anything lol.


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## STXmedic (Jan 31, 2012)

I've got nothing =/ I'm going to blame it on the inability to effectively measure time  What I see:

P waves with normal PRI, normal rate, and no evidence of atrial enlargement

QRS normal duration, no Q waves present, normal axis, amplitude, and R wave progression

ST segment not elevated/depressed. Appears to be normal QTc. T waves with correct morphology*

*The only thing that appears remotely abnormal to me is the inverted T in III...

Please enlighten


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## VFlutter (Jan 31, 2012)

I am just learning 12 leads but possible LVH?? The amplitude is not that bad.


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## triemal04 (Jan 31, 2012)

PoeticInjustice said:


> *The only thing that appears remotely abnormal to me is the inverted T in III...
> 
> Please enlighten


Follow through with that.  It's not completely classic for this condition; missing one thing (assuming I'm seeing what the ER doc saw) but it's pretty damn close.  

What would cause t-wave inversion *in lead 3 only* and 2 other things that are there that you missed (they're a bit subtle)...


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## Maine iac (Jan 31, 2012)

Looks pretty normal to me... Possibly the Ts are starting to get a little large in V2,V3, which might be a little K+ issue or early repol, but I feel that with this EKG I might be trying to find something that isn't there.

It would be great if I could open it in a new window and zoom in...

Is the P wave changing in II (at the bottom of the page)??? Super hard to tell because I can't zoom in, but if it was I'd say wondering pacemaker.


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## triemal04 (Jan 31, 2012)

The history also points to this condition...


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## Medic87 (Jan 31, 2012)

looks like s1q3t3 possible PE  but I am not sure 100%


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## systemet (Feb 1, 2012)

The only problem is this particular set of ECG changes occurs in a lot of conditions, not just the one condition it's particularly well known for.  It's a very nonspecific finding.


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## Scott33 (Feb 1, 2012)

Medic87 said:


> looks like s1q3t3 possible PE  but I am not sure 100%



Yes, but it is very subtle.

Here is a more obvious one I had a few months back

Click thumb




However, the subsequent CT was negative for PE. S1Q3T3 is a poor predictor of PEs occurring in only around 20% of cases.


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## Outbac1 (Feb 1, 2012)

Medic87 said:


> looks like s1q3t3 possible PE  but I am not sure 100%



And the winner is Medic87. 
Even though the pt wasn't very sob or tachycardic she picked up on these subtle changes on what many would say was a normal 12 lead. Radiology confirmed a fairly large PE and the pt is being treated for it with a good prognosis. 
 I enjoy either learning new things or being reminded of things I knew and have since forgotten. 

Some articles on it. They explain it better than I.

http://www.amc.edu/amr/archives/200408/EKG1_ans.html

http://medicine.ucsf.edu/education/resed/Chiefs_cover_sheets/ecg_pe.pdf

http://ems12lead.com/tag/s1q3t3/


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## Sublime (Feb 19, 2012)

Thanks for posting that, I feel like I learned at one point how to find a PE w/ a 12-lead but have totally forgot. Will remember this now..


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## systemet (Feb 19, 2012)

Sublime said:


> Thanks for posting that, I feel like I learned at one point how to find a PE w/ a 12-lead but have totally forgot. Will remember this now..



Just to reiterate an earlier point --- even if you see the sign, it by no means guarantees that the patient is having a PE.  It can be present in many other conditions.


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