Activated HEMS for LBBB: Made the right call?

[medicsb]

Considering the NNC (number needed to cath, I just made that up) in order to get a "new or suspected new LBBB" with an actual occlusion is big...way big, even with clinical signs supporting it; I think in the absence of primary ST-changes you should not make this call.

I agree with this.

To the OP, do NOT let the outcome justify the transport decision, though your bosses may now be pleased. Think to yourself how you'd feel if he didn't get cathed - lets say he got discharged after a 23 hour observation. What then?

The appropriateness of your decision should be based on the information that you knew at the time, which many of us have argued was not sufficient to support a flight. However, based on your description of the ECG, it does sound like there may have been signs of MI according to Sgarbossa's Criteria, which should cause you to seek out a copy and look it over closely. If it did meet Sgarbossa's criteria, make note of it, and keep an eye out for it in the future, and be happy that you accidentally made the right decision.

Anyhow, it really does sound like you did an overall good job. You identified someone who looked sick, you did an appropriate work-up, and initiated the right treatment, mostly (only because I would argue that flying was a type of treatment). Live and learn.

 

[TomB]

You were perfectly correct to assume an AMI and get this guy to a cath lab ASAP, given the clinical presentation and the non-reassuring EKG finding. A presumably new LBBB in the presence of convincing clinical s/s of an MI, is always an AMI until proven otherwise.

It's definitely not my intent to be argumentative, and medicsb's last comment nails it IMHO, but consider this. I agree that LBBB with s/s of ACS is AMI until proven otherwise, but the issue at hand is whether or not it's STEMI until proven otherwise. That's an important distinction because there's no evidence that immediate cath for NSTEMI/LBBB confers a benefit. Almost 50% of patients with LBBB in the Larson study had no clear culprit artery.

Once again, this isn't about whether or not the treating paramedic in this case made a good call or a bad call. It sounds like s/he did the best s/he could in a tough situation for which he was not adequately trained and where there was insufficient protocols, policies, procedures, and supervision.

Welcome to rural EMS you might say, and perhaps you'd be right. But that's the real issue. Not the actions of one individual.

 

[grub]

STEMI or ?

American heart standards say that :

Signs and symptoms of a STEMI include:

•Chest pain or discomfort
•Shortness of breath
•Dizziness or light-headedness
•Nausea or vomiting
•Diaphoresis (sweatiness) unexplained by ambient temperature
•Palpitations (uncomfortable awareness of the heart beat)
•Anxiety or a feeling of impending doom

If you get any or all of these symptoms as a guideline and an ST elevation in two (2) contiguous leads, reciprocal changes.. then the criterai for EMS observed STEMI has been met in the field.
NOW I say Field and not cath lab.
In the field, Paramedics only have so many tools to go by, 12 lead and experience being the other. The guide lines are there and there will always be false positives in the cath lab.
As I mentioned before, Diabetics will fool you and toss the whole STEMI rules out the window!
Error on the side of caution and train to the best of your abilty with the 12 lead and signs and symptoms are the best path to follow.
NOW, New guidlines show that a new or unknown LBBB is not criteria for a STEMI. This hasn't been diseminated down to all protocols as of yet I'm sure but it has come from extensive studies and there are more to come.

Answering the question of if this Pt. should have gone by helicopter? The pt was very symptomatic 12 lead or not! Prior Hx. that was significant and although poor information on the 12 lead, it bring you back to treat your pt. If this was my pt., i'd want him in a cardiac facility to cover my bases.

Reading a 12 lead and studying your MI pt. is an art. Paramedic could train for another 6 months alone on just cardiac. Like I mentioned in other posts, 12 lead is under taught in EMS and area's that are using telemetry, have stopped 12 lead training all together : ( Sad but true.

Sorry for the long post .........

 

[Christopher]

Not to nitpick but...

American heart standards say that :

Signs and symptoms of a STEMI include:

•Chest pain or discomfort
•Shortness of breath
•Dizziness or light-headedness
•Nausea or vomiting
•Diaphoresis (sweatiness) unexplained by ambient temperature
•Palpitations (uncomfortable awareness of the heart beat)
•Anxiety or a feeling of impending doom

Those are s/s of ACS, not just STEMI (e.g. all squares are rectangles, but not all rectangles are squares). By definition, STEMI requires an ECG.

If you get any or all of these symptoms as a guideline and an ST elevation in two (2) contiguous leads, reciprocal changes.. then the criteria for EMS observed STEMI has been met in the field.

Reciprocal changes are not required for activation in most systems. Anterior Wall STEMI's frequently do not have reciprocal changes. The converse of this is Inferior Wall STEMI's always have reciprocal changes (where "always" is like 6 9's of sensitivity). High lateral STEMI's rarely have 2 contiguous leads of elevation, yet are no less a STEMI.

 

[Brandon O]

This is exactly how I see it. ^^^^

You were perfectly correct to assume an AMI and get this guy to a cath lab ASAP, given the clinical presentation and the non-reassuring EKG finding. A presumably new LBBB in the presence of convincing clinical s/s of an MI, is always an AMI until proven otherwise.

With that said, let me backpedal a bit and reemphasize that the optimal approach to managing such patients should be to develop your ability to interpret the ECG until you DO know how to "read through" a left bundle.

We should have a plan for when things fail, but our real priority should be to avoid failure altogether next time around.

 

[Summit]

(where "always" is like 6 9's of sensitivity)

I haven't heard this one?

 

[Christopher]

I haven't heard this one?

Sorry, this is a Dr. Smith thing, "inferior STEMI virtually always has reciprocal ST-depression in aVL". If ST-depression in aVL (or T-wave changes) is not present, "you should think of something else, like early repolarization or pericarditis".

Reference: Bischof J. Thompson RP. Tikkanen J. Porthan K. Huikuri H. Salomaa V. Smith SW. ST-segment depression in lead aVL differentiates benign ST elevation from inferior Acute STEMI. ACEP Research Forum 2012. Annals of Emergency Medicine 60(4 Suppl):S8-S9; October 2012.

 

[medic109]

Not a lot of what sounds like real rural experience (40+years inner city/suburban) but why not utilize some on-line medical control, also I'm personally not a big put them in a loud scary bird and scare the :censored::censored::censored::censored: out of them as an aggressive stress stress advocate. And for the record the DANAMI study supports the safety and efficacy of early 1/2 lytic then transport further for PCI. And another opinion what's a four month old Medic with limited responses doing as a sole ALS responder who doesn't access some higher or more experienced back-up