# Need to Vent about a call cool ekg story!



## tah06090 (Jul 27, 2012)

So havent posted in a super long time but had a call last shift i need to vent about and get opinions.

Called for 60 yo pt possible heart attack. U/a male pt c/c substernal chest pressure no radiation. Described as heavy heavy pressure 6/10. Pt stated this has been off and on for the last 3 days. Today pain came back during physical activity and did not subside pt also became dizzy, diaphoretic and nauseous.

Hx 1 prior MI which he states this is similar, Hyperlipidemia, HTN

extensive med list

the initial EKG had T wave inversion lead 2 and avf gave the pt 1 NTG relieved pain to a 2/10 pain returned monitor showed more elevation in lead 2 ran another 12 lead showed big difference st elevation lead 2 3 avf recip in avl i call a STEMI at this point.

addition NTG given brought his ekg back to the initial one relieved the pain. Pain returned and stayed in the last EKG as you can see clear Inferior STEMI.
The DR u/a did not agree with the ekgs i handed her wich are the ones you guys are looking at on here she said she did not see any elevation. When i pointed out the last EKG and were i saw elevation and recip changes she said maybe. So at this point nurse comes out with the ED ekg which is screaming ACUTE MI only at this point shes like hes having a stemi blah blah and had the chopper called. this dr is a traveler but it really ticked me off how did she not see the elevation in my ekgs ugh thanks for listening guys lol

EKG 1- initial
EKG 2- Pain returns
EKG 3- Pain Free NTG
EKG 4- Pain returns stays


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## VFlutter (Jul 27, 2012)

At first glance it does not scream STEMI, almost BER however when you look at the first EKG with the biphasic T wave in lead 3 and the reciprocal changes in AVL and I I would start to consider Inferior ischemia and MI. However pain for 3 days? Maybe angina then finally an MI. The last EKG looks like a possible inferior MI, I would be cautions with the Nitro.


The transient symptoms and ST elevation almost make me consider prinzmetals, vasospasm,  or shifting plaque/thrombi


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## Aidey (Jul 27, 2012)

This sounds like an unstable angina case, not a full AMI. Per our criteria here I could not not have activated the cath lab based on those EKGs. 

Question, where were the inferior limb leads placed?


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## tah06090 (Jul 27, 2012)

as a side note he was flown and had 99% occluded RCA i was catious with NTG after 2 pressure dropped 90/70 that was the other issue with this doc she stated these pts need to be pain free and keep giving NTG regardless needless to say we had a few words exchanged and i walked away some days you can win.


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## NYMedic828 (Jul 27, 2012)

tah06090 said:


> as a side note he was flown and had 99% occluded RCA i was catious with NTG after 2 pressure dropped 90/70 that was the other issue with this doc she stated these pts need to be pain free and keep giving NTG regardless needless to say we had a few words exchanged and i walked away some days you can win.



Completely unconscious does usually = less pain.

Inferior wall MI, should try and move v3 over at some point and check v3R for confirmation.


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## VFlutter (Jul 27, 2012)

Random pharmacology question.  Would you consider using nipride over nitro in an inferior MI due the fact that nipride is more selective to arteries and would still provide after load reduction but not lower your preload as much as nitro would?


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## KellyBracket (Jul 27, 2012)

*Nice ECGs!*

IMHO, #2 and #4 are an inferior wall MI, RCA versus circumflex occlusion is my best guess. Pretty classic.

More fascinating, however, is that I believe you have some really cool findings on ECGs #1 and #3.

It's important to know that the patient was pain-free when you got ECGs #1 and #3. The biphasic T waves in III and aVF in ECG#1 suggest *Wellens Syndrome* to my eyes. Typically this is discussed with regard to anterior MIs, but the principle are the same.

Basically, the biphasic T wave, occurring after an episode of pain has resolved, suggests that previously elevated ST segments are returning to normal - you're catching them right in the middle of the action!

You go on to _prove_ this in ECG #2 and #3, as the ST segments rise, and then collapse as the pain abates, and the biphasic T waves come back once again.

Check out *this case* at Dr. Smith's ECG Blog for another example, from an ER doc who is a heck of a lot better at electrocardiography than me.

Sir, you have a classic set of ECGs that you should be proud of. Keep them for your own study, for teaching students, for showing to your grand kids. Nice catch!

**Missed the update where you said he had an RCA. Perfect!


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## TomB (Jul 28, 2012)

Awesome case! Really cool ECGs. Great job! 

Tom



tah06090 said:


> So havent posted in a super long time but had a call last shift i need to vent about and get opinions.
> 
> Called for 60 yo pt possible heart attack. U/a male pt c/c substernal chest pressure no radiation. Described as heavy heavy pressure 6/10. Pt stated this has been off and on for the last 3 days. Today pain came back during physical activity and did not subside pt also became dizzy, diaphoretic and nauseous.
> 
> ...


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## NYMedic828 (Jul 28, 2012)

KellyBracket said:


> ***Missed the update where you said he had an RCA. Perfect![*



I'll bet the patient didn't think so! :lol:


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## drarnel (Jul 28, 2012)

*re: good looking strips*

I saw your great post from 12Lecg FB page and and was fascinated by the time capture (0, 4, 6 and 12 mnnutes) and was also intrigued by some of the post here.

I am fan of real time chages on telemetry. Lead II alone seems to look like early repolarization changes and maybe this has swayed the eyes of the doc you encountered. Have seen that hundred of times since II is routinely used in telemetry. Howerver lead III tells a different story. The psot of Dr KellyBracket is intriguing (Wellen's T wave in the limb leads). They are indeed biphasic (III , aVF) in strip # 1.  Voltage in avL is low also.

Strip # 2 revealed more to the story. The tales or repol changes are strill tther in the inferior lead but the ST in aVL and V2 is starting to show its true intentions..

Strip # 3 showed the Wellen's T wave look-a-like (biphasic in III and aVF). The voltage in avL is also low. 

Strip # 4 - looks like # 2 but V2 is more concerning.

Looks like the area supplied by the RCA is trying to say something. The RCA must have shouted it in the ecg done in theED. 

Very good looking strips. I wonder if there is/are paper/s on Wellen's T wave look-a-like in the limb leads?


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## Sublime (Jul 28, 2012)

Very interesting case! Thanks for posting, its pretty cool to watch the changes happen in real time on those ekgs. 

Like someone else said I would have went ahead and done a 15-lead to rule out right sided involvement before giving nitro (bob page would be mad if I didn't). 

Otherwise great job on the catch and showing how important serial ekgs are!


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## LearningByMistakes (Jul 29, 2012)

NYMedic828, why would you use V3R? I have ALWAYS been taught (and teach) V4R to confirm. If I remember correctly V4R ST elevation is approx. 88% specific for a R venticular MI. Perhaps you can teach an "old dog" something new.


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## NYMedic828 (Jul 29, 2012)

LearningByMistakes said:


> NYMedic828, why would you use V3R? I have ALWAYS been taught (and teach) V4R to confirm. If I remember correctly V4R ST elevation is approx. 88% specific for a R venticular MI. Perhaps you can teach an "old dog" something new.



idk thats what my class advocated :unsure:

I have always been told you can just do v3R or just v4R, or v3R and v4R to check both.

So my assumption was it really doesnt matter which you use, i just stated v3 in my comment.

Now that I think about it, v4R would be situated more on the right side of the heart than v3R which would mean it is more specific like you said. Never thought about it :wacko:


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## Sublime (Jul 29, 2012)

I was taught to turn V4 into V4R by moving it to the opposite side of the chest in order to check right sided involvement, and move V5 and V6 around to the patients back in order to check posterior involvement. Never heard of moving V3.


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## Christopher (Aug 2, 2012)

Sublime said:


> I was taught to turn V4 into V4R by moving it to the opposite side of the chest in order to check right sided involvement, and move V5 and V6 around to the patients back in order to check posterior involvement. Never heard of moving V3.



One option is to move them all 

The honest answer is ST-E >= 0.5mm V4R is going to have a higher specificity than V3R, but not by much. Interestingly enough, some literature points to V6R having the highest sensitivity and specificity for RVI. (Am J Emerg Med 2005;23:793-799. Br Heart J 1989;61:514-20. Europace 2009;11:1421-1422. Anadolu Kardiyol Derg 2007;7 Suppl 1: 182-5. Am Heart J 1976;91:571-6)

Given the relative variability in V3 placement between two operators, V4 and V4R should be more consistent. Additionally, using V4R allows you to place V8/V9 and labeling all 3 on the same 12-Lead.

I personally move V4-V6 to the right side, then move them to the posterior, if I believe they're indicated.


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## LearningByMistakes (Aug 2, 2012)

Christopher,  you are correct about switching over and getting a full right sided view, when possible. However, the reason I use V4R, is because long ago I was taught (and teach) a “trick” (with a LP-12, not sure if any other monitors can do it).

When I have 3 leads showing on a chest pain pt. and it appears that they have Inferior changes, you can “force” the LP-12 to do a 12 lead, off the limb leads only. If I still have Inferior ST elevations, I then set my V leads normally, with the exception of V4, which I change to V4R, helping me to “rule in or out” possible RV involvement, and then make my decision on the use of NTG.

Perhaps that helps explain. Or perhaps not! LOL!


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## TomB (Aug 3, 2012)

You mean "force" the LP12 to perform a 6-lead ECG? You won't get a 12-lead ECG with limb leads alone (obviously).

Tom



LearningByMistakes said:


> Christopher,  you are correct about switching over and getting a full right sided view, when possible. However, the reason I use V4R, is because long ago I was taught (and teach) a “trick” (with a LP-12, not sure if any other monitors can do it).
> 
> When I have 3 leads showing on a chest pain pt. and it appears that they have Inferior changes, you can “force” the LP-12 to do a 12 lead, off the limb leads only. If I still have Inferior ST elevations, I then set my V leads normally, with the exception of V4, which I change to V4R, helping me to “rule in or out” possible RV involvement, and then make my decision on the use of NTG.
> 
> Perhaps that helps explain. Or perhaps not! LOL!


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## LearningByMistakes (Aug 3, 2012)

Obviously Tom B, yet I should have said that. What’s obvious in your mind isn’t always so obvious to those who are reading. LOL! Thank you for pointing that out.


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