Interesting ECG that got me....

[Handsome Robb]

Ran a call today that I kinda felt like I jumped the gun and misinterpreted the ECG.

Toned out for a P1 Syncope across the street from the Trauma Center, literally could've thrown a rock and busted out of window of the Helicopter on the ground pad from the front yard.

U/A you find a 60 year old hispanic female in obvious, emotional, distress (she looked freaked but honestly did not look sick to me at all, my partner agreed.) with a number of very hyped up, panicked family members running about. She's seated in the front seat of a car, spanish speaking only, son instantly picks her up and carries her to the gurney as fire pulls it out of the back of the ambulance. All of this was interpreted through her daughter, who was pretty good but like I said, she was pretty panicked like the rest of her family.

Per the patient was eating breakfast, stood up to go to the bathroom, became dizzy and "fell down and passed out". She said she "shook for about a minute" afterwords and "her eyes rolled in the back of her head". As far as I could tell she was A&O when we arrived. Daughter said they then walked to the car with her to take her to the hospital when it happened again so they decided to call 911. Per the daughter the patient was complaining of dizziness and 8/10 chest pressure that started with the first syncope but I couldn't really get any more assessment out of her than that about it. No recent illness or any other complaints as far as I could figure from the info I was getting. Daughter kept telling me she had blood draws "this morning" but couldn't tell me why.

Vitals:
160/100
70 Sinus without ectopy, 12 lead is attached below and this is what got me.
90% on RA, 97% on 2 lpm
170 mg/dl CBG

Hx: HTN, NIDDM, CVA 2 years prior with no lasting deficits, hyperlipidemia. THe daughter was very adamant that the patient had no cardiac history whatsoever.

NKDA

Meds: Off the top of my head, labatelol, glyburide, a statin I hadn't seen before and hydrocodone.

What I did:
STEMI protocol activation
Bilateral 20s, tried to draw labs but I was tied up doing things and my partner didn't leave the TQ in place so she couldn't get them to draw.
324 mg aspirin.
NTG SL x2 pain down to 5/10, no EG changes pre/post NTG, no notable changes in her HR or BP.
Quick trip across the street where the STEMI protocol was cancelled pretty quickly.

The 12 lead really got me on this patient. It looked like LVH to begin with but my interpretation was: Sinus without ectopy 2 mm elevation in V1-V3, T wave inversion and 1 mm ST depression in aVL and I.

I try to always fold the monitor interpretation over and not look at it until after I've done it myself and I had decided to activate our STEMI protocol before I read the monitor interp, which had interpreted it as ***Acute MI***.

Now knowing what I know about ECGs there wasn't reciprocal changes in this 12-lead and there was an LVH pattern present, a great STEMI imitator. I'll admit I got tunnel visioned on the STE in the anteri then then T wave inversion and ST depression in the high lateral leads. I felt like an *** bringing in a false positive but at the same time the cardiologist even said, "I'd rather have you call it and be wrong than not call it when you should have. I've got no problem with how you handled this call".

After my giant rant, did I jump the gun activating our STEMI protocol on this patient? I'll admit, I didn't have a long DDx list (MI, AAA/Dissecting TAA, Tamponade as my zebra).

I'm all ears for everyone's thoughts, I wont tell you the Dx yet but I will tell you it was a false activation of the cath lab.

 

[Handsome Robb]

Here's the 12 Lead

 

[VFlutter]

I see bi-atrial hypertrophy, LVH, lateral ischemia, and possible LV aneurysm. I personally would not activate a STEMI alert based off the EKG.

But I am on my phone after a few beers so take it with a grain of salt lol

I am sure the EKG gurus will chime in soon.

 

[Handsome Robb]

I see bi-atrial hypertrophy, LVH, lateral ischemia, and possible LV aneurysm. I personally would not activate a STEMI alert based off the EKG.

But I am on my phone after a few beers so take it with a grain of salt lol

I am sure the EKG gurus will chime in soon.

Hindsight is 20/20 but I should've taken more time reading it. The atmosphere, the language barrier and having our HR director riding as a third with me definitely had me a little more wound up than usual. Made me mad, I always pride myself in staying really calm on scene no matter what's going on. We're always our own toughest critics though, right?

 

[truetiger]

Bi-atrial hypertrophy? Where do you see that?

 

[truetiger]

I think you did fine playing it safe, no one will ever come after you for playing it safe. If it was me personally, I would of transmitted the ekg and discussed it with the physician as to if he wanted to activate or not.

 

[VFlutter]

Bi-atrial hypertrophy? Where do you see that?

It looked like there was the typical biphasic P wave morphology in some of the leads but looking again it'a probably normal.

 

[truetiger]

Right atrial hypertrophy is typically diagnosed in II or V1 with an amplitude greater than 1.5mm.

 

[Handsome Robb]

I think you did fine playing it safe, no one will ever come after you for playing it safe. If it was me personally, I would of transmitted the ekg and discussed it with the physician as to if he wanted to activate or not.

I get a lot of sick patients and a lot of weird calls, STEMIs aren't one of them though. Only had one as a Medic (this was only my second cath lab activation) and a few real severe ones as an Intermediate.

Unfortunately we cannot transmit ECGs. Well, I'm sure the MRx is capable but we don't have the system in place at the ERs to receive them and I'd honestly have no idea how to do it.

Like I said, we were across the street from the ER. We used the disco lights since it's a busy street that's virtually impossible to cross without the help of a traffic signal or wee-woos, but our transport time was <60 seconds, even if we could transmit I don't think I would have just because of the time factor. If I was still on nights it'd make sense, I guess, since the cath team isn't on campus but during the day they're all there so it's not as big of an ordeal to activate them as far as having to wake people up and get them driving towards the ER.

 

[Handsome Robb]

and possible LV aneurysm.

I will tell you they were pretty worried about a TAA, I know, not the same but they also threw out an LV aneurysm as well. Her bedside ECHO wasn't anything like "holy smokes we need to go now" but they didn't seem happy with it either.

I got to watch the screen while they did it but I will admit I didn't have much of a clue as to what I was looking at and what was "normal" vs "not normal". Although watching it and listening to them talk was pretty neat.

 

[Veneficus]

U/A you find a 60 year old hispanic female in obvious, emotional, distress (she looked freaked but honestly did not look sick to me at all, my partner agreed.) with a number of very hyped up, panicked family members running about.

I think the term you are looking for is "staticus hispanicus" or "hispanic panic."

Ok, jokes aside, learning tip: Some cultures are very vocal about pain. It always seems out of proportion to what it is. Best to treat them like the cultures who do not verbalize pain and consider something serious until proven otherwise.

Also, they usually respond better to benzos than opioids, but if your protocol allows, a little of both go a long way.

All of this was interpreted through her daughter, who was pretty good but like I said, she was pretty panicked like the rest of her family. .

Welcome to my world.

Already read the Dx so I will not go there.

 

[Clare]

I see lateral ischaemia and some sort of hyperthrophy although I am a bit rusty on hyperthrophy

Oh and cut you fingernails dear

 

[katgrl2003]

Oh and cut you fingernails dear

Hahahaha!

On the serious side, we had a medic unit near us have almost the exact same thing. He activated the cath lab, and the docs in the er said it was LVH. 12 lead looked pretty similar to yours.

 

[Clare]

Hahahaha!

On the serious side, we had a medic unit near us have almost the exact same thing. He activated the cath lab, and the docs in the er said it was LVH. 12 lead looked pretty similar to yours.

I'm not one of these girly girly types but um yeah, I noticed ....

You bring up another good point; you should always give early notification to the hospital to advise them of ? STEMI and if they open (or free up) a PCI suite unnecessarily then that is fine, I'd rather have them free one up and not need it than not do it and need it.

Since last year Emergency Medical Technician (BLS) can acquire a 12 lead ECG so in their RT call they can now advise of the automatic interpretation; generally for STEMI so if you get the rare situation where two EMT are transporting a ? STEMI they something a bit more objective to get the PCI suite opened up rather than "we think cos he has chest pain ...."

While I do not believe in relying upon automatic interpretation for BLS AO's its a good idea.

 

[Sublime]

Looks like LVH with a strain pattern to me. Personally wouldn't have activated on that.


Language barriers definitely complicate things and hispanics also tend to be over dramatic (not being racist, just stating what I've noticed). So I can see why this wasnt an easy call.

Interested to hear diagnosis.

 

[blindsideflank]

we have been told by our medical director that when you get a ***MI it is 98% accurate. (that was the statistic we were given). There has been a push to always transmit these and have a quick discussion even if you are pretty sure its nothing.
we dont find everything and i dont have too much pride to admit that i can miss things

 

[Aprz]

For the size of those complexes, the STE is minimal.

From what I've read, the shape of the ST-segment and reciprocal changes have been getting more and more recognition, however, T-waves symmetry is massively under appreciated. The T-waves in this 12-lead is asymmetrical, which is a good thing.

 

[Brandon O]

I will tell you they were pretty worried about a TAA, I know, not the same but they also threw out an LV aneurysm as well. Her bedside ECHO wasn't anything like "holy smokes we need to go now" but they didn't seem happy with it either.

Just to clarify, when people talk about "left ventricular aneurysm" in regards to the ECG, typically what they mean is not necessarily a literal aneurysm (which may or may not be present) but rather persistent changes after an old STEMI. It's characterized by deep QS waves, mostly in the anterior leads, without particularly hyperacute T waves or very much elevation. Usually it's a benign finding, although they can be pretty good mimics.

 

[Christopher]

Here's the 12 Lead...

I've got nothing really huge to add, other than it looks pretty typical for LVH with Strain.

"It's got a lot of ink," is one of the gut checks that works Ok when differentiating LVH from other processes.

Keep in mind MI's most often attenuate voltages. By that I mean in the non-ACS ECG any time you have high depolarization voltages you should expect proportionally high repolarization voltages (e.g. ST-e/big T-waves). So when you differentiate LVH from AWMI you need to be looking for a loss of expected R-wave amplitude and proportionally larger ST/T-wave changes.

It is interesting that the MRx said ACUTE MI though. Perhaps a reasonable over-activation of the system.

 

[Christopher]

I see...lateral ischemia...

I am sure the EKG gurus will chime in soon.

My one suggestion would be to drop the usage of "<Focal Area> Ischemia" as this term is not actually correct. Subendocardial ischemia causes diffuse ST-depression rather than focal changes. I was a sinner once too, but Dr. Smith has helped me see the light with this one.

Any time you see localized ST-depression your first thought must be "reciprocal change".

In this case the ST-depression is an expected finding with the LVH pattern.