Debatable 12 lead

LACoGurneyjockey

LACoGurneyjockey

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Transported this elderly male for chest pain, ran into a cardiologist who disagreed with my interpretation of this 12 lead. So I'm looking for some more opinions on it. Any more info that's needed Id be happy to provide.
 

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Elevation in I and AVL with recip changes in the inferior leads. I would have called it.
 
poor tracing but looks like LBBB, imitator would not call it
 
Even if it is a LBBB they have concordant ST elevation in V1 and V2. Positive sgarbossa criteria. I would’ve called it.
 
AF with STE in I and aVL (and V5) with reciprocal inferior depression = high lateral STEMI. The culprit is propably first diagonal branch of LAD, with possible LCX involvement.

V1 and V2 looks like a pseudo brugada pattern to me. Those leads might have been placed too high.

This is not LBBB. Hard to measure QRS duration with this image resolution, though. Some ventricular conduction delay might be included. Irregular rhythm with no visible P waves = atrial flutter. A few PVC's (or VES') can also be seen in the 12-lead, in bigeminic pattern towards the end of the tracing.

I would definitely have activated the cath lab or given the patient Metalyse (+ other thrombolytic drugs as per protocol) if other criteria was met and there were no contraindications.
 
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Morphology is a little perplexing however if patient had ACS symptoms, and no prior 12 leads to compare, it would be a cardiac alert from me.
 
Does the patient know anything about his cardiac history? When did the pain start / how long has it been going on for? Any other recent similar episodes? Vitals?

Looks like a clear RBBB to me... maybe with either an old or developing infarct. I think if the patient doesn't recognize the term "bundle branch block", we have to assume it's new.

Both bundle branches are supplied by the LCA, so if we think he's having an occlusion in some branch of the LAD then maybe this fits the picture I guess.

I definitely call some sort of cardiac alert.
 
No cardiac hx, pain started 30min ago while at rest. BP 60/20, RR 24 and shallow, GCS 15, a fib between 70 and 110.
I called a stemi alert and the cardiologist disagreed. ER doc convinced him to send the pt to Cath where it was discovered he had a complete LAD occlusion and coded.
 
I can see why people are debating over the ECG. If it was just the ECG alone i would probably lean towards not calling it (although it would be close). But given the rest of the patients presentation, CP + hypotension + Tachycardia/Tachypnea, i would definitely call it and would just base it on good judgement IMO.
 
KingCountyMedic said:
poor tracing but looks like LBBB, imitator would not call it
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Right bundle branch blocks are not really considered STEMI mimics. Pronounced ST depression is to be expected in the precordial leads of a RBBB patient, elevation is a concern.
 
Honestly? Call It for all of the above reasons, but 60/20 +weird heart activity = call an adult and its probably the heart.
 
I would activate on this EKG alone. We have so many false positives and false negatives go into the ER, I'd rather this one get activated than not. I hate to play the "pass the buck" card, but in this case, I think it's the best thing. Early activation based on the EKG alone, if for nothing more than to get cardiology to the hospital. Throw in the presentation and I'd be moving quickly to the hospital and let the docs fight it out.
 
Agree on the AF with RBBB and lots of PVC's. Was any of that baseline for him?

I'd call it. You have STE in I-aVL for sure and maybe something with V1 then V2. Lead I looks like it may be a hyperacute T wave then you have symmetric T waves pretty much everywhere. So many things here say pissed off heart. Throw in the complaint and vitals and he would be going to the resus bay with at least 2-3 docs there to hash out details regardless.

Would definitely be trying to get that MAP up, do not like that number.
 
Odd morphology progression and the baseline wander make this EKG difficult to interpret, if you could have gotten a better capture that would have been ideal. I'm not convinced there is a bundle branch block, perhaps a left anterior fasicular block.

A-fib at 70-80, PVC, and probably some AV nodal/bundle beats. LAFB. J point changes are difficult to measure; superficially elevation in aVL, V2. Biphasic ST morphology in several leads. I honestly wouldn't use this as a diagnostic EKG, the quality is too poor for reliable interpretation on its own.

Given this patient's clinical presentation I would have called the cardiac alert. Given a sudden onset of chest pain, tachycardia, and hypotension I think that a quick AP chest and bedside cardiac exam for the exclusion of other chest diagnosis like hemo/pneumo thorax/mediastinum, ensure there is no cardiac effusion/bleed, right heart strain indicative of massive PE, bilateral BPs for high aortic dissection, and so on. That being said unless there is another culprit found quickly this patient needs the cath lab. We send plenty of people to cath lab who end up having no significant findings, the benefit far outweighs the risk.
 
The S wave in lead I appears to be at the same height as the Q wave in the same complex which makes the strip look like an early repolarization pattern and not ST elevation. Which makes aVL only one lead in a row with ST elevation and that is not a STEMI. So I would call this AF with pathologic left axis deviation and PVC's and left bundle branch block. This man is having a cardiac event but not a STEMI from what I can read, though I will admit I am unable to zoom in properly on the strip.
 
I'm not sure what there is to debate here. Bifascicular block and LAD occlusion. I hope that was the cardiologist's opinion (for the patient's sake).

Tom

LACoGurneyjockey said:
Transported this elderly male for chest pain, ran into a cardiologist who disagreed with my interpretation of this 12 lead. So I'm looking for some more opinions on it. Any more info that's needed Id be happy to provide.
Click to expand...
 
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