EMS1 ECG Challenge: The Court's Verdict
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truetiger
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Anterior MI, spreading to the septal leads.
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I don't see it. Sinus, T inversions in III, borderline STE anteriorly, you may be able to argue v4 as well but it's tough to decide with the wandering baseline.
With his presentation and that 12-lead though he's getting treated as ACS and going to a PCI capable facility. Wouldn't activate on this personally but I'd be pushing to have a physician evaluate him and my serial 12s soon after our arrival.
boerbull
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Shape of the ST segments anterior looks like they are pulling up. Serial ECG in this one is very important. I would not activate PCI, but with a presentation like that I would transport to PCI capable facility.
I wonder if posterior ecg would show something here?
I wonder if posterior ecg would show something here?
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TomB
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Thanks for sharing! You guys will enjoy the solution.
Tom
Tom
limpfurball
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The initial rhythm strip shows Nsr disrupted by two pvc's w/ a compensatory pause. The 12 lead shows Nsr with left axis deviation an a Left anterior hemiblock. Not sure about the STE in the anterior leads, its close but on this one 12 lead I wouldnt call an alert. Im also new at this I can be completly wrong lol
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Hmm, I don't see any glaringly obvious signs of acute injury, but with T wave inversions and borderline ST elevation morphology I'd definitely be going to a PCI capable facility. No cardiac alert for me, but I'd give the doc a heads up on the radio and get him in there quickly to consult.
Treat with ASA, Fentanyl, and consider Nitro depending on the last time the pt. took his Cialis. I'd keep the O2 on for now based on the initial PVCs, but probably turn it down to 2 LPM. I'd also do a right sided 12 lead based on the T inversions in III.
Treat with ASA, Fentanyl, and consider Nitro depending on the last time the pt. took his Cialis. I'd keep the O2 on for now based on the initial PVCs, but probably turn it down to 2 LPM. I'd also do a right sided 12 lead based on the T inversions in III.
Sublime
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Would like to see a posterior view and right sided view as well.
Some depression in inferior leads. Wouldn't call an immediate STEMI but would def. transport to cardiac center.
Some depression in inferior leads. Wouldn't call an immediate STEMI but would def. transport to cardiac center.
The answer still hasn't been posted up.
I am not an ECG expert, I may not be right, but these are the things I am thinking in regard to what you guys have posted.
Truetiger, I think an anterior (septal) MI is developing, but not sure. I don't think it's spreading to the septal leads though. The T-waves being symmetrical in I and V3-V6 make me think it's an anterolateral MI developing.
Limpfurball, I was thinking that it's normal sinus rhythm with premature ventricular contractions, but the compensatory pause is really long in my opinion. On my post on ems1, I called sinus bradycardia with ventricular bigeminy for this reason. I thought the pause looked really odd.
I also don't think it quite makes the criteria for left anterior fascicular/hemiblock. It's technically suppose to be at least -30 degree I thought, and the morphology is qR in I, rS in III (and prossibly in all the inferior leads), and none of my books have said it, but I think it's done by exclusion of other causes of axis deviation like I know in the setting of left ventricular hypertrophy, they don't usually say left anterior fascicular block, at least in the books I've read.
Chaz90 and Sublime, I wouldn't do a right sided or posterior view based on this 12-lead.
For a posterior wall MI, I'd expect at least one or more:
- You'd see ST depression in the anteroseptal leads (V1-V4), it's the reciprocal change to the posterior lead.
- R/S >1 in V1, it would change the Z (transverse) axis the same way other MIs cause the mean QRS vector axis to change in the frontal/coronal plane. The mean vector is going away from the damaged tissue.
- STE in V6, V6 the closest traditional lead to the posterior wall.
I think a lot of people are taught to be suspicious of a right sided infarct if they are having an inferior wall MI. Common things I see with an MI with right ventricular involvement is:
- ST depression in V2, possibly STE in V1 (V1 is on the right side, it would have STE, V2 is on the left side, it would be the reciprocal change).
- STE in lead III is greater than II. If you draw Einthoven's Triangle, III points towards the patient's right side, II points towards the patient's left side (and this is the same for finding the location of any other infarct, the positive electrode is where you'd see STE).
I kinda feel like the point of this 12-lead is to show that even if it says it's normal, it's not normal, but I think that was given when it was posted as a challenge on ems1 and by TomB, lol. I'd kinda like to see him post something that is normal for reals and see if people still look for something. That's what I was kinda worried about looking at this.
I am not an ECG expert, I may not be right, but these are the things I am thinking in regard to what you guys have posted.
Truetiger, I think an anterior (septal) MI is developing, but not sure. I don't think it's spreading to the septal leads though. The T-waves being symmetrical in I and V3-V6 make me think it's an anterolateral MI developing.
Limpfurball, I was thinking that it's normal sinus rhythm with premature ventricular contractions, but the compensatory pause is really long in my opinion. On my post on ems1, I called sinus bradycardia with ventricular bigeminy for this reason. I thought the pause looked really odd.
I also don't think it quite makes the criteria for left anterior fascicular/hemiblock. It's technically suppose to be at least -30 degree I thought, and the morphology is qR in I, rS in III (and prossibly in all the inferior leads), and none of my books have said it, but I think it's done by exclusion of other causes of axis deviation like I know in the setting of left ventricular hypertrophy, they don't usually say left anterior fascicular block, at least in the books I've read.
Chaz90 and Sublime, I wouldn't do a right sided or posterior view based on this 12-lead.
For a posterior wall MI, I'd expect at least one or more:
- You'd see ST depression in the anteroseptal leads (V1-V4), it's the reciprocal change to the posterior lead.
- R/S >1 in V1, it would change the Z (transverse) axis the same way other MIs cause the mean QRS vector axis to change in the frontal/coronal plane. The mean vector is going away from the damaged tissue.
- STE in V6, V6 the closest traditional lead to the posterior wall.
I think a lot of people are taught to be suspicious of a right sided infarct if they are having an inferior wall MI. Common things I see with an MI with right ventricular involvement is:
- ST depression in V2, possibly STE in V1 (V1 is on the right side, it would have STE, V2 is on the left side, it would be the reciprocal change).
- STE in lead III is greater than II. If you draw Einthoven's Triangle, III points towards the patient's right side, II points towards the patient's left side (and this is the same for finding the location of any other infarct, the positive electrode is where you'd see STE).
I kinda feel like the point of this 12-lead is to show that even if it says it's normal, it's not normal, but I think that was given when it was posted as a challenge on ems1 and by TomB, lol. I'd kinda like to see him post something that is normal for reals and see if people still look for something. That's what I was kinda worried about looking at this.
TomB
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"Normal" has been called the hardest diagnosis in electrocardiography! Indeed, in all of medicine! It's hard to say, isn't it?
limpfurball
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I was on the fence with the LAFB, the criteria says a LAD of greater than -45 which this is not but it got me with the qR in Avl, rS in III and delayed deflection in Avl of greater than 0.045, very close call. For it to be a 100% LAFB i would def think a LAD greater than -45 and a qR in Avl and lead I would be necessary along with the other criteria stated.
truetiger
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Do I get a cookie?
Forming Anterior Wall MI, 12Leads every 10 Minutes. You can see Twave inversion in lead 3 I believe it was? Which would be a reciprocal. I would call into the ER and either consult the MD with my findings and both agree on an activation or no activation, or treat as ACS and call in once the 12Lead has become completely diagnostic for MI.