ecg question

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emt_irl

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hey guys, thought id run this by you for a second opnion.

treated a patient for some un related leg trauma today and besides dealing with that i done a full set of vitals.
25 y/o male
vitals where:
p:77
resps: 14
bp:124/84
bgl: 4.7 mmo/l
pupils: perrl size 5
a&ox3

ran an ecg on him also as and i picked up this in lead: II
before you look, this was non sympthomatic, patient felt fine with a regular stong pulse. lead placement was correct also.

what would cause the inverted qrs complex? ive never seen a rythm like this before, its appeared sinus in orgin except the qrs.

30xbcyh.jpg


28qwvx0.jpg

(disregard the bed no. its just an automatic setting which we have to select a number for)
2wqfvhw.jpg



sorry for image quality i dont have a scanner so had to take a picture with my dlsr. the patient allowed me take a second trace after i had packed away the bp cuff and all other equipment just for future reference.

i want to build on my knowlegde on ecg's and rythms, im starting to do alot of self directed study and reading
 
Lead placement will do that sometimes, or if you have a lead reversed. Of course, the zebras are that your patient had situs inversus or that his K+ was jacked up from muscle injury. I'm going with one of the first two though.
 
lead placement was on the chest, and electrodes were in correct position. i always double check.
is situs inversus all that common?
now that you mention it the patient had a work related injury effecting his entire left side focused around his shoulder going down along his mid axillary line
 
We should avoid trying to diagnose on a single lead rhythm strip, other than the obvious life-threatening rhythms.

Downward facing QRSs in lead II may be a simple case of the patient having pathological left axis, or it may be as a result of a prior inferior wall MI.
 
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emt_irl said:
is situs inversus all that common?
Click to expand...

No,it comes in 3 variants and is extremely rare.

I have only seen 3 in my entire career, and one was in a cadaver lab.

Supposedly by the numbers it is 1:100,000 but I think that is not accurate.
 
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A single lead tells us little beyond rate and rhythm

Inverted QRS in lead II could be because of axis deviation, ischaemic conduction changes and reversed leads.

Remember that William Eitoven guy and his triangle, check if the black and red leads have been reversed.
 
In an asymptomatic person I've always been informed that its a normal variant. Some people have an electrophysiology that display's with inverted QRS complexes.
 
Scott33 said:
We should avoid trying to diagnose on a single lead rhythm strip, other than the obvious life-threatening rhythms.

Downward facing QRSs in lead II may be a simple case of the patient having pathological left axis, or it may be as a result of a prior inferior wall MI.
Click to expand...

Yep, simply a pathological left axis deviation.

Just a little tip to everyone trying to make a detailed diagnosis: use lead II only to identify obvious rhythms, e.g. V-fib, V-tach, etc. Try getting at least a 12-lead EKG before trying to study the detailed electrical activity. It's pointless otherwise.
 
yea could have been any thing causing that, lead 2 is good for any obvious arrhythmia, 12 lead would have been better to answer your question
 
Also, why were you doing an ECG on a 25 year old with a leg injury? If he didn't have any symptoms you should be doing one because:

1: Waste of time
2: Wast of electrodes
3: Your chances of finding something meaningless that you worry about is much more than your chances of finding cardiac pathology in a 25 year old.
 
zmedic said:
Also, why were you doing an ECG on a 25 year old with a leg injury? If he didn't have any symptoms you should be doing one because:

1: Waste of time
2: Wast of electrodes
3: Your chances of finding something meaningless that you worry about is much more than your chances of finding cardiac pathology in a 25 year old.
Click to expand...

Same
 
zmedic said:
Also, why were you doing an ECG on a 25 year old with a leg injury? If he didn't have any symptoms you should be doing one because:

1: Waste of time
2: Wast of electrodes
3: Your chances of finding something meaningless that you worry about is much more than your chances of finding cardiac pathology in a 25 year old.
Click to expand...

In one of my systems (the MUCH better and more progressive of the two) actually has quite an extensive inclusion criteria for running a 12-lead. Not out of fear of missing something or expecting to spot some abnormal variant, but just to have exposure to as many 12leads as possible. Our medics run on average 3 12leads a shift (3 different pts). They are extremely comfortable and efficient running them, get exposure to all different kinds of presentations, and they are some of the best medics I know at reading 12leads (much more in depth than just ST elevation). And we've actually caught two STEMIs in the last two years that had very atypical presentations that wouldn't have normally warranted a 12lead.

1) It should not take more than 90 seconds (being generous) to apply the leads and have a strip printing. 90seconds on scene isn't quite what I would consider a waste of time. And if it is absolutely critical to "load and go" with this stable, yet time critical pt, you can always do it en route. If it does take longer than that, maybe you should be running as many as you can so you can be more efficient with it...
2) Electrodes are cheap.
3) Not too terribly bad if your 25yo (or 23yo) patient is suffering from coronary artery spasms 2/2 cocaine use (this pt actually went to the cath lab)
 
I'm going to hazard a guess that the 20 something year old suffering from coronary artery spasms secondary to cocaine use was not complaining of a traumatic leg injury.

Rule 10 of The House of God: If you don't take a temperature, you can't find a fever.
 
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thanks for the advice.

rule of thumb here though if you get a trip in the ambulance you get the full works, i suppose i wasnt going to sit there staring in an awkward silence for the 10 min trip to the ED.

no access to a 12 lead here, its not an emt skill.
just thought if fire a quick picture up to see if there was any ovbious "oh would you look at that" answers.
 
Aidey said:
I'm going to hazard a guess that the 20 something year old suffering from coronary artery spasms secondary to cocaine use was not complaining of a traumatic leg injury.
Click to expand...

My post was not so much directed at this:

zmedic said:
Also, why were you doing an ECG on a 25 year old with a leg injury?
Click to expand...

As it was this:

zmedic said:
If he didn't have any symptoms you shouldn't be doing one
Click to expand...
 
emt_irl said:
thanks for the advice.

rule of thumb here though if you get a trip in the ambulance you get the full works, i suppose i wasnt going to sit there staring in an awkward silence for the 10 min trip to the ED.

no access to a 12 lead here, its not an emt skill.
just thought if fire a quick picture up to see if there was any ovbious "oh would you look at that" answers.
Click to expand...


Here is an idea... taaaaaaaaallllllllllkkkkkk to your patient instead of performing needless things. The patient must have thought it was a little awkward to be put on a cardiac monitor when he is 25 with a leg injury! I am guessing per your protocols you are suppose to do a full APPROPRIATE work up!

Happy
 
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HappyParamedicRN said:
Here is an idea... taaaaaaaaallllllllllkkkkkk to your patient instead of performing needless things. The patient must have thought it was a little awkward to be put on a cardiac monitor when he is 25 with a leg injury! I am guessing per your protocols you are suppose to do a full APPROPRIATE work up!

Happy
Click to expand...

Did it hurt the patient? No. Could it have hurt the patient? No. I'm guessing that they did talk to their patient. How much time was lost applying the monitor? 90 seconds? Have you, as a Paramedic/RN, never done something out of a gut feeling? What made that action appropriate?
 
One thing that rides my neck is the amount of people that are pretty much saying 'well, this patient shouldn't have been placed on a monitor. No indications for such.' Yeah, it may have been useless, but did it cause any harm? Please folks, can we narrow it back down to the OP's original post?
 
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