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On some machines a right axis deviation does not stop at 180 degrees but continues all the way to 270 degrees (in the right superior quadrant or "extreme axis" deviation). Which axis should you pay attention to? Mostly the QRS axis but I also look at the T axis. When there is 100 degrees or more...

When you have a wide QRS (= or > 120 ms) with LBBB morphology in lead V1 (QS or rS complex) you should have a monomorphic R-wave in lead I. In other words, you should have no S-wave at all. Not a little one. Not a prominent one. If you do it's not a LBBB, it's a nonspecific IVCD, the most...

Thanks, ChrorusD! You are correct. Both LBBB and LVH with strain create a widened QRS/T angle (a general pattern of discordance) and this should always make you pause and think about it before declaring something to be a STEMI. Negative concordance in the precordial leads (not referring...

Having paced myself on several occasions it's just plain mean to dial up the mA too quickly. It makes the muscle contractions more violent. They are far more tolerable when you increase the energy gradually. I capture at 110-120 mA with AP pad placement. Interestingly, the energy has to drop...

There's no way you had capture at 30 mA. Post the strips and if I'm wrong I'll pay you $100.00.

As a final thought, using patients with positive biomarkers is a fatal flaw because it groups together STEMI and NSTEMI and we're only looking to identify patients with an occlusive thrombus in an epicardial coronary artery. Smith's modification seems to do quite well at identifying LAD occlusion.

No idea with regard to biventricular pacemakers. They can do some wild things with multi-site pacing. As for discordant ST-elevation the problem with Sgarbossa's criteria is that it did not take into account the depth of the S-wave (rule of proportionality). The Smith modification appears to be...

You can use Sgarbossa's criteria but I would caution against using 5 mm of discordant ST-elevation as an activation criterion. LAD occlusion is a tough one for both LBBB and paced rhythm. At any rate, I agree 100% with the idea of establishing a baseline and looking for changes on serially...

I think there's already lots of eye opening data. Drugs don't work. Early CPR, defibrillation, and expert post-resuscitation care are key, including early identification of STEMI, PCI, therapeutic hypothermia, and CABG or ICD placement if necessary.

It's not like there's a mountain of high quality to support epinephrine, amiodarone, lidocaine, magnesium sulfate, sotalol, procainamide, or any other intervention save high quality chest compressions and defibrillation. If the patient is in refractory VF there's a good chance that a critical...

If the patient is in referactory VF hook up a second defibrillator and give a double shock. By the time you've given two doses of amiodarone you've probably shocked at least 6 times (probably more). The patient doesn't need more drugs. The patient needs more electricity (or better CPR or a...

Who says it requires QS complexes across the precordium?

I agree with AF and LBBB (although I'm tempted to call it nonspecific intraventricular conduction defect due to the negative concordance in the precordial leads). Left axis deviation. It's hard to comment on the amount of ST-elevation due to the scan quality although the chief complaint is not...

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

It sounds like a crock to me. In every ED I've ever worked in (or delivered patients to) a conscious patient will get a 12-lead of their arrhythmia prior to treatment.

Awesome case! Really cool ECGs. Great job! Tom

As long as the low frequency / high pass filter is set to 0.05 Hz you should be good to go as far as accurate ST segments. The high frequency / low pass filter will show more 60 cycle artifact when set to 150 Hz. For that reason all of our 12-lead monitors are set to 0.05 - 40 Hz which is still...

This is one of the most dangerous EMS myths ever created (that VT will have a right superior axis). As Christopher said, a right superior axis can help rule in VT but VT can have an axis in any quadrant. The most important criterion for VT is "wide and fast". This is one area where 12-lead ECG...

I wrote a blog post to help answer this question. http://ems12lead.com/2010/12/why-learn-axis/

Rules like this are made when too many medics in a given EMS system 'get a quick 3-lead' and then either wait until the patient is loaded in the back of the ambulance to get a 12-lead or neglect to get one at all. If you do QI for a STEMI system you run into this problem a lot and paramedics can...