1. Tired of seeing ads? Click here to register today and the ads go away. It's completely FREE, too!
    Dismiss Notice
  2. Can't find what you're looking for? Use the search bar in the upper right corner.
    Dismiss Notice

Debatable 12 lead

Discussion in 'ALS Discussion' started by LACoGurneyjockey, Sep 21, 2018.

  1. LACoGurneyjockey

    LACoGurneyjockey Forum Asst. Chief

    778
    435
    63
    Education:
    Paramedic
    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.
     

    Attached Files:

  2. DesertMedic66

    DesertMedic66 Forum Troll

    9,987
    2,423
    113
    Education:
    Paramedic
    Elevation in I and AVL with recip changes in the inferior leads. I would have called it.
     
    FLMedic311 likes this.
  3. KingCountyMedic

    KingCountyMedic Forum Lieutenant

    127
    18
    18
    poor tracing but looks like LBBB, imitator would not call it
     
  4. CALEMT

    CALEMT The Other Guy/ Paramaybe?

    3,353
    2,277
    113
    Education:
    Paramedic
    Even if it is a LBBB they have concordant ST elevation in V1 and V2. Positive sgarbossa criteria. I would’ve called it.
     
    NPO and VFlutter like this.
  5. photog

    photog Forum Probie

    16
    6
    3
    Education:
    Critical Care EMT-P
    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.
     
    Last edited: Sep 21, 2018
    Gurby likes this.
  6. VFlutter

    VFlutter Flight Nurse

    3,444
    961
    113
    Education:
    EMT
    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.
     
    Gurby likes this.
  7. Gurby

    Gurby Forum Asst. Chief

    744
    514
    93
    Education:
    Paramedic
    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.
     
    Aprz likes this.
  8. LACoGurneyjockey

    LACoGurneyjockey Forum Asst. Chief

    778
    435
    63
    Education:
    Paramedic
    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.
     
  9. photog

    photog Forum Probie

    16
    6
    3
    Education:
    Critical Care EMT-P
    I read my previous post again and natutally I was supposed to write "atrial fibrillation" both times. Oops! o_O
     
  10. KingCountyMedic

    KingCountyMedic Forum Lieutenant

    127
    18
    18
    I'm old I always confuse my RBBB and LBBB. Sounds like you made a good pickup. Did he survive?
     
  11. TXmed

    TXmed Forum Captain

    291
    121
    43
    Education:
    Critical Care EMT-P
    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.
     
    Gurby likes this.
  12. Tigger

    Tigger Dodges Pucks Community Leader

    6,677
    1,856
    113
    Education:
    Paramedic
    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.
     
  13. RocketMedic

    RocketMedic King of the Improbable

    4,072
    1,070
    113
    Education:
    Critical Care EMT-P
    Honestly? Call It for all of the above reasons, but 60/20 +weird heart activity = call an adult and its probably the heart.
     
    Gurby and LACoGurneyjockey like this.
  14. NPO

    NPO Forum Deputy Chief

    1,574
    724
    113
    Education:
    Paramedic
    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.
     
    Gurby likes this.
  15. KingCountyMedic

    KingCountyMedic Forum Lieutenant

    127
    18
    18
    I know, I got them mixed up
     
  16. StCEMT

    StCEMT Forum Deputy Chief

    2,289
    1,238
    113
    Education:
    Paramedic
    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.
     
  17. Peak

    Peak ED/Prehospital Registered Nurse

    230
    107
    43
    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.
     
  18. MSDeltaFlt

    MSDeltaFlt Forum Deputy Chief

    1,401
    26
    48
    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.
     
  19. TomB

    TomB Forum Captain

    393
    82
    28
    Education:
    Paramedic
    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

     
    FLMedic311 and Aprz like this.
  20. Aprz

    Aprz Forum Deputy Chief

    2,400
    304
    83
    Education:
    Paramedic
    The OP for this thread died so I doubt there will be any follow up on this. :(

    https://www.emtlife.com/threads/member-passing.47439/
     
    Gurby likes this.

Share This Page