ECG Gurus (and everyone else)

[Smash]

Ok, have a look at the attached image. I'm sorry it's a little small, but I'm a bit of a r'tard with images.

Now I don't want to get into a deep and meaningful conversation, I just have one simple question:

If this ECG belonged to a middle aged male with symptoms consistent with ischemic chest pain, would you activate the cath lab on seeing this ECG. In other words, would you call this a STEMI, and if so or if not, why?

 

[NYMedic828]

Ok, have a look at the attached image. I'm sorry it's a little small, but I'm a bit of a r'tard with images.

Now I don't want to get into a deep and meaningful conversation, I just have one simple question:

If this ECG belonged to a middle aged male with symptoms consistent with ischemic chest pain, would you activate the cath lab on seeing this ECG. In other words, would you call this a STEMI, and if so or if not, why?

Guess il be the first.

I'm sure you have some sneaky reason for posting this that I am not going to recognize but I would say yes, it looks like a infero-lateral wall MI.

I,V3,V4 look to be alright but its a small picture.

If it isn't a STEMI for some reason (is it the patients baseline somehow?) I wouldn't have a choice in the matter here in NYC regardless because the monitor would still read >>>ACUTE MI<<< and at that point I have to transmit to the doctor regardless of what I think.

 

[the_negro_puppy]

I would interpret it the same infero-lateral. Call for ICP backup who may start heparin/plavix and maybe thrombolise depending on their interpretation and the time of day etc.

If a big fan of if in doubt treat it as the worst. Id rather have a cardiologist laugh at me than under treat someone

 

[stallion]

Interesting looking ECG + first post...here we go

There's obvious ST elevation, but I'm going to be different and head down the pericarditis route.

Rationale....more U shaped and widespread ST elevation and maybe ( ? ) PR depression in the inferior leads. Can't really justify too much more without other assessment findings. Granted, I would still treat as ACS (including pre-notifying the hospital) unless I could comfortably tick off the pericarditis boxes.

 

[STXmedic]

I'd be a little hesitant to call a heart alert on this one. Yeah, there's obvious ST elevation, but something seems off on it that I can't quite put my finger on. Those are some pretty narly T waves though. It also looks like there may be some J point notching (if not, I'm claiming small ECG ). Some form of early repol maybe? Yup, punt to the doctor via transmitting

 

[Handsome Robb]

I'd have to call a pre-alert per protocol but I'm with poetic on this one, diffuse elevation pretty much throughout makes me think BER or something of the sort.

Not saying a 40 year old cant have an MI and I would treat per ACS but there are plenty of other options that are just as, if not more plausible than an MI.

 

[MSDeltaFlt]

Regardless of age, this person is having a STEMI and having multi-vessel disease: inferior and lateral. LAD is blocked off.

 

[Pavehawk]

If he was asymptomatic I would lean towards BER, but since he is having chest pain and the J notching appears concave (strip is pretty small for my old eyes) I would treat him as an MI and call a STEMI. Better to call it and be wrong then to not call it and be wrong.

In the system here we could also call a Cardiac Alert which would not get the STEMI team called in but would, at least, have the ED team ready to hop on him on arrival. This might be an option depending on the clinical picture he is presenting with, time of day, and where we are.

 

[Aidey]

Is V4 actually V4R? Because there is an R written next to it.

 

[STXmedic]

Lol I forgot we were assuming this guy was having cardiac s/s. I still would be hesitant to call a heart alert and let the doctor make that call. Would still run him as a P1 chest pain.

 

[Scott33]

Looks like pericarditis.

Not seeing much in the way of reciprocal changes or pathological q-waves but I do see almost global (smiley face) ST Elevation. No changes in axis, rate - WNL, no AV blocks (for such an apparently large MI) Possible depressed P-R segment in leads II and III, which also points towards pericarditis.

Fortunately, MIs are dynamic so for those of us who believe in taking more than 1 BP, a second or third 12-lead may yield more info.

 

[Arovetli]

AMI/Pericarditis. Could be one, the other, or both. Differentiating is going to require more than just that tracing.

 

[Brandon O]

Small screen here. LVH likely, hyperk very possible, *early* MI (hyperacute T) possible, simple BER or peicarditis doubtful. Likely a combo. Serial ECGs.

 

[TomB]

Ok, have a look at the attached image. I'm sorry it's a little small, but I'm a bit of a r'tard with images.

Now I don't want to get into a deep and meaningful conversation, I just have one simple question:

If this ECG belonged to a middle aged male with symptoms consistent with ischemic chest pain, would you activate the cath lab on seeing this ECG. In other words, would you call this a STEMI, and if so or if not, why?

This would be a reasonable cath lab activation (assuming signs and symptoms of ACS). I say that because the T-wave is inverted in lead aVL. Since you're asking I'm assuming this was a "false positive" cath lab activation. I've seen something similar before.

See this case for an example (it is not identical but it also shows an inverted T-wave in lead aVL): http://ems12lead.com/2011/03/is-this-a-mimic-or-the-real-thing-discussion/

Your ECG also shows notched J-points in the inferior leads. I'll be interested to find out the answer to this one! I'm guessing pericarditis. Any way you slice it a fascinating ECG!

Tom

 

[Smash]

Thanks everyone. I'm afraid I can't give you an answer to this one. It was sent out by a manager in a rather strident and borderline abusive email as an example of inappropriate cath lab activation that is "making us look bad"

I felt that this was a bit unjustified, as I would have activated the cath lab on the basis of the elevation in II, III and aVF especially with the T-Wave inversion in aVL.

Personally I would rather "look bad" by having a few false positives to my name than miss a bunch of STEMIs

I appreciate that it is always difficult to make and accurate assessment without some clinical correlation, so thanks everyone for your replies.

 

[bigbaldguy]

Since when is EMS about looking good?

 

[Brandon O]

Thanks everyone. I'm afraid I can't give you an answer to this one. It was sent out by a manager in a rather strident and borderline abusive email as an example of inappropriate cath lab activation that is "making us look bad"

I felt that this was a bit unjustified, as I would have activated the cath lab on the basis of the elevation in II, III and aVF especially with the T-Wave inversion in aVL.

Unquestionably an appropriate activation. The concern for false positives shouldn't lead to slicing this thin to the line no matter which side it lands on.

Now that I view a larger screen I see the PR depression; I'm more willing to buy pericarditis. However, the T waves, especially in V4-V6 need to be explained; they are far too large and tented, even for LVH -- and there's inappropriate concordance in that case anyway. (A rhythm strip would be nice since there's some clear variability, however.) The large R waves do go strongly against STEMI, but those T waves could be early hyperacutes, and the aVL inversion is always a disturbing sign. Overall morphologically and with these intervals I do think hyperkalemia is a real possibility, but there's almost certainly a few concomitant issues here.

 

[Arovetli]

Some false activation is to be expected and is indicative of a healthy system, not a broken one.

http://www.ncbi.nlm.nih.gov/pubmed/22133467
http://www.ncbi.nlm.nih.gov/pubmed/18165668
http://www.ncbi.nlm.nih.gov/pubmed/22284976

 

[Smash]

Thanks for those articles Arovetli, I might just email them to the manager in question.

 

[TomB]

This is the best kind of false positive! A really good STEMI mimic. It wasn't a false activation based on poor data quality, a confounded computerized interpretive algorithm, a simple LBBB, paced rhythm, obvious BER, or typical strain pattern from LVH. It has a pseudo-reciprocal change! It seems to me the manager (I'm assuming you meant EMS manager and not cath lab manager) who sent out the "strident and borderline abusive email" isn't skilled enough in ECG interpretation to realize that this a very suspicious ECG for a chest pain patient! Perhaps this manager should share his or her vast wisdom with the paramedics so they would understand how easily it could have been classified as "other-than-STEMI".