ECG - Opinions needed

Sublime

Sublime

LP, RN
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Heres a little history. Called to a nursing home for 91 y/o female who you find lying on her side in the hallway. Patients son states she got up to walk and became very dizzy and weak and he had to help her to the ground so she did not fall. Patient states she had a steroid shot in her back two weeks ago for pain management and has had chest pain ever since.

She states she feels fine now and is just weak feeling. She does not have chest pain, and hasn't since last night. States the pain was "everywhere" in her chest, but that it got worse last night and felt like "pressure". Did not radiate. It was relieved when she went to bed, and woke up this morning with no pain. Patients only complaint at the moment is nausea and weakness.

History: CHF, Breast Cancer, Hypertension
Vitals: BP 99/69, HR 72, RR 16, SP02 96% on room air

Assessment: breathing normal, non-labored. Pt. skin is warm and dry. Pt. does not appear to be in any acute stress. Lung sounds clear.

Link to ECG:
http://imageshack.us/photo/my-images/840/ecgp.jpg/

Tell me what you think. To me it looks like ST-Depression in inferior leads and ST-Elevation in V1, V2, and AVL. When I asked the nurse what he thought about the ecg he replied "I'm not seeing any st-elevation". Don't think I'll be able to get an update on her but if I do ill report back.
 
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I agree with you. ST-elevation is present and with the ST-depression in the inferior leads it must be explained. Hopefully they were able to compare with an old ECG. Things tend to move slower with old ladies from the nursing home.

Sublime said:
Heres a little history. Called to a nursing home for 91 y/o female who you find lying on her side in the hallway. Patients son states she got up to walk and became very dizzy and weak and he had to help her to the ground so she did not fall. Patient states she had a steroid shot in her back two weeks ago for pain management and has had chest pain ever since.

She states she feels fine now and is just weak feeling. She does not have chest pain, and hasn't since last night. States the pain was "everywhere" in her chest, but that it got worse last night and felt like "pressure". Did not radiate. It was relieved when she went to bed, and woke up this morning with no pain. Patients only complaint at the moment is nausea and weakness.

History: CHF, Breast Cancer, Hypertension
Vitals: BP 99/69, HR 72, RR 16, SP02 96% on room air

Assessment: breathing normal, non-labored. Pt. skin is warm and dry. Pt. does not appear to be in any acute stress. Lung sounds clear.

Link to ECG:
http://imageshack.us/photo/my-images/840/ecgp.jpg/

Tell me what you think. To me it looks like ST-Depression in inferior leads and ST-Elevation in V1, V2, and AVL. When I asked the nurse what he thought about the ecg he replied "I'm not seeing any st-elevation". Don't think I'll be able to get an update on her but if I do ill report back.
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Thanks Tom! Now let me ask, based on her presentation and ECG would you have called STEMI alert or cath lab activation?

I did not call for cath lab activation but did tell them my interpretation of the ECG. Don't know if the facility has had bad experience with medics calling false stemis but the receiving nurse seemed unconcerned. Was a good five to eight mins before they got their own ECG. Will try to get an update but like I said it's unlikely.
 
I would not have called it either. Being 91 y/o that could just be normal for her and yes I agree I would like to see a previous EKG . She is rather all over the board with her description. I would consider pleurisy. I've o2 poc to hospital.
 
Also looks like LAFB
 
Sublime said:
Thanks Tom! Now let me ask, based on her presentation and ECG would you have called STEMI alert or cath lab activation?

I did not call for cath lab activation but did tell them my interpretation of the ECG. Don't know if the facility has had bad experience with medics calling false stemis but the receiving nurse seemed unconcerned. Was a good five to eight mins before they got their own ECG. Will try to get an update but like I said it's unlikely.
Click to expand...

Could be a diagonal occlusion with that constellation of elevation/depression.

I think given her age, comorbidities, and history of present illness it is reasonable to defer a field STEMI activation.

If this was a 50 year old female...
 
From your statement of chest pain/pressure "last night", it reads as though this 91yo little lady is WAY past the deadline for PTCA. I wouldn't call for STEMI unless OLMC said to do so.
 
I'm with Christopher on this one.

A 91 y.o. who fell in the ECF is not exactly a good risk for the cath lab. She could bleed into her head, they could easily laceration her (probably diagonal!) coronary artery, or god knows what.

For what it's worth, the ECG looks legit, and I'm guessing it looked different from the prior. I would probably activate for this, but I would be telling the interventionalist that we needed to talk with the patient and family pretty candidly about the options.
 
I agree with your ST changes. I would not have called an alert, given her age and the time since onset I would bet a paycheck that she would not be getting PCI. I would however relay my findings to the OLMC and start heading to the cardiac receiving center and let the ER and Cardio figure out how to treat it.
 
I agree with your interpretation.

Now let the flaming begin...

I'll play the devil's advocate. I would have activated our STEMI protocol on this, partially because protocol says I have to and partially because I'm not comfortable not calling it with that ECG. They can get grumpy all they want about a false activation but if you don't and they decide to call it a STEMI at the ER you bet you're going to hear it. Now if you continuously have false activations something needs to change.

91 yo female probably not going to the cath lab, like others have said, but with her complaints, history and without being able to compare to a previous 12-lead I'm not comfortable not activating it but I'm also very new at this whole Paramedic thing.
 
NVRob said:
Now if you continuously have false activations something needs to change.
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I'm interested in hearing how various people's cathlab protocols work. Don't you fax the ECG after you've decide it's suspicious for STEMI, and doesn't a physician read it again? Surely if they see NSR and normal STs, etc., they direct you to the ER instead? Or is their no capability to fax the 12-lead ahead?
 
systemet said:
I'm interested in hearing how various people's cathlab protocols work. Don't you fax the ECG after you've decide it's suspicious for STEMI, and doesn't a physician read it again? Surely if they see NSR and normal STs, etc., they direct you to the ER instead? Or is their no capability to fax the 12-lead ahead?
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Our STEMI protocol relies solely on the Paramedic's interpretation of the 12-lead ECG. Certain parameters have to be met but if you can articulate why you activated on a 12-lead that doesn't fit into the perfect little cookie cutter that are protocols you aren't going to be questioned further about it.

We do not transmit 12-leads, we have the capabilities but our Cardiology groups don't see the need according to QA/QI. Generally a Physician will be waiting at or near the door for you and we pass over labs and our 12-leads for them to look at as we are wheeling into the ER.

FWIW we have a low number of false activations and continuously achieve sub 60 minute door-to-PCI times. With us now drawing labs on STEMI activations in the field the goal is <30 minute door-to-PCI times and it isn't uncommon that they meet that goal. I've never done it but apparently crews routinely bypassing the ER and taking the patient straight to the cath-lab on our gurney. With that said I don't get many STEMIs, just wacked cardiac arrests and bad GI bleeds.

I'll see our QA/QI guy tomorrow and ask if he has exact numbers.

System - If you'd like to see our actual ACS/STEMI protocol shoot me a PM and I'd be happy to send it to you. Don't particularly want to post it publically since it'd make it very obvious where I work.
 
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Interesting.

We used to get the initial 12-lead, fax it if we felt it met criteria, and phone consult with either an ER doc or cardiologist. Based on the patients risk factors and cathlab availability, the physician would direct us to do a ER bypass direct to cathlab or push TNK in the truck.

It was strange at first to spend what felt like a long time on scene organising this, (especially the TNK), or to bypass the ER only to wait in the hallway while the cathlab team was setting up.
 
systemet said:
I'm interested in hearing how various people's cathlab protocols work. Don't you fax the ECG after you've decide it's suspicious for STEMI, and doesn't a physician read it again? Surely if they see NSR and normal STs, etc., they direct you to the ER instead? Or is their no capability to fax the 12-lead ahead?
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We call it in based on our findings and the ED doc chooses to activate based on our radio report. I'd say 90% of the time they activate based on our call-in. The times when they don't usually are off-peak and when the story sounds "odd".

Generally speaking we have a wide latitude in what we could activate on, although we'll be held to it if we make a gratuitously bad call. It is non-punitive and presented as con-ed, but that doesn't mean you get to call every LVH with Strain a STEMI and not get a stern talking to.

This freedom has enabled us to activate LBBB STEMI's that don't meet typical criteria and it also lets us call in with, "well the ECG meets criteria, but here's the back story you need to take into account...." for cases like these.
 
systemet said:
I'm interested in hearing how various people's cathlab protocols work. Don't you fax the ECG after you've decide it's suspicious for STEMI, and doesn't a physician read it again? Surely if they see NSR and normal STs, etc., they direct you to the ER instead? Or is their no capability to fax the 12-lead ahead?
Click to expand...

As of right now my service does not have the ability to transmit ECGs to the receiving hospital. This will change by the end of the year or beginning of next year. They are working with the local cath lab facilities so we will be able to transmit ECGs and from there activate the cath lab and be able to go straight there.

Right now if we call a STEMI in we have a "Stemi Kit" for our local facilities that have the hospital gown, iv tubing / hep locks that the hospital uses ect. so that when we get them there they're ready to go.

But till the ability to transmit / fax ecgs becomes available the STEMI activation is based on our interpretation. Generally there will be a doc waiting to look at the ecg and a nurse/tech there right when you come in to get their own ecg.
 
socalmedic said:
I agree with your ST changes. I would not have called an alert, given her age and the time since onset I would bet a paycheck that she would not be getting PCI. I would however relay my findings to the OLMC and start heading to the cardiac receiving center and let the ER and Cardio figure out how to treat it.
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You might be betting ALL of your paychecks if you don't call it and you are wrong.
 
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VirginiaEMT said:
You might be betting ALL of your paychecks if you don't call it and you are wrong.
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Must suck to work in a that would fire you for missing a STEMI.

Also must suck to have a hospital that won't catch and then intervene on a STEMI just because EMS didn't call it in as a STEMI. Definitely not a hospital I'd want to go to...
 
VirginiaEMT said:
You might be betting ALL of your paychecks if you don't call it and you are wrong.
Click to expand...

Only in a poorly functioning system would that be the case for this ECG/Patient. If you work somewhere and don't have the latitude to apply clinical judgement and say, "you know what, this does not need a field activation even though it meets guidelines because of A, B, and C," then you're being asked to provide the same care as a hairless monkey.

When researchers looked at North Carolina's false positives they noticed that a lot of EMS mistakes were related to being a slave to the guidelines and activating every single STEMI regardless of sound clinical judgement. Some patients will simply not be cath lab candidates.

True paramedic systems allow the latitude necessary to use clinical judgement and educate providers when they under- or over-triage. High functioning ones will also provide QA and Con Ed on all STEMI activations and missed STEMI's in a constructive fashion.

This way when you come across a 91 year old with a borderline or even true-positive ECG, you can make the right decision for the patient at the right time.
 
ECG - Opinions Needed - 91yo woman

The ECG is clearly of concern. As per Christopher - could be a 1st diagonal occlusion given ST elevation in lead aVL. In addition - there is some reciprocal ST flattening in leads III, aVF. Lead V2 is definitely of concern with its q and ST elevation.

That said - the history is very difficult to pinpoint - and clearly does NOT sound like the patient's chest pain is new-onset within the past few hours .... so I would NOT activate the cath lab at this time based on what I see.

That said - I'm still concerned about possible acute infarction of uncertain age, possibly quite recent. I'd repeat the ECG very soon (to see if there is any acute evolution) - and I think the cardiologist on call out to be made aware of this patient - as she may need cath soon (albeit this is not an immediate cath lab activation given likely onset beyond a few hours ago ... ).
 
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