Scenario: would you call this 12-lead?

[Burritomedic1127]

Don't know the exact QRS duration but I'm saying incomplete LBBB, which would naturally make the morphology of the "depressions" in the high lateral leads the op mentioned earlier.

If it truly were depressions (which this is not) in the high lateral leads, you would see reciprocal changes in the inferior leads (II, III, aVF). Usually these (inferior STEMI) have more parasympathetic tone and would have slower heart rate, the rate on the original 12 is around 90-100ish

 

[Brandon O]

Reciprocal changes are absolutely just as localized as primary ischemic changes.

For anybody still worried about these ST/T changes, here's an absolutely, completely normal LVH ECG that'll really alarm you (courtesy LITFL):

 

[Underoath87]

So Brandon, considering what you're showing us, what would we need to see in someone with LVH or LBB to actually suspect a STEMI? An actual "tombstone" shaped S-T/T wave?

 

[Brandon O]

Use Sgarbossa (the principles, not the numbers)! Concordant changes (same direction as the QRS) are bad. So are discordant changes that are too big compared to the QRS.

Dr. Smith at Hennepin has come up with a modification that helps compare the proportionality with the very large waves of LVH. Basically, if your elevation/depression is more than about 1/4 to 1/5 (he keeps tinkering with the formula) the size of the QRS, that's too much, even if it's discordant as it should be. Get a sense for what "normal LVH" (or normal LBBB, or any of these mimics) looks like so you can recognize 1) that it's different from STEMI, and 2) what it looks like when there's a STEMI on top of that.

Here's a true STEMI in the setting of LVH:

 

[Brandon O]

The morphology of the ST elevation and other clues can also be helpful, but this is one of the most universally valuable tools to understand. Notice the numerous ST changes in the same direction (not opposite) the last deflection of the QRS complex. And notice, for instance, aVL, where the ST segment is depressed, which is discordant to the QRS... but it's nearly as deep as the QRS is tall, which is far too much (disproportionate).

Compare against the precordial leads in my PREVIOUS strip, where there is over 5mm of ST elevation, but it's discordant to the QRS, and if you could measure that huge S wave the amount of ST elevation (while objectively large) would only equal a fraction of it, relatively speaking. That's all normal.

 

[Underoath87]

Thanks! I'll reread all that when I'm fully sober and rested...

 

[medic6676]

I'm going to throw in here the AMA RMA point here, seeing as everyone is talking about the 12 lead, which I see elevations in V1-V2, and would def consider that a septal STEMI.

That being said I read a recent article in JEMS in regards to refusals. It spoke about how you need to be sure that the patient is fully competent in self and mind to refuse any further care. It then went on to explain that this goes beyond "acceptable vitals" and the patient is CAOx3, and that if the patient doesn't fully comprehend the fact that they may likely be choosing to die, the legally you as a provider have the right to deny a refusal, and seek ways to transport the patient against their wishes.

In this case, based on the 12 lead, I would be concerned for the patients future safety, and would clarify that they could likely die if they do not seek immediate care. If they still refuse but don't seem aware, or just don't seem to care, you can always contact MedCon for assistance. Sometimes getting a doctor on the phone to convince a patient that they should be in the ER does the trick, and if it doesn't and the MD agrees with you, they can give orders to detain the patient, whether through PD assistance or some other legal method as deemed by agreed upon local laws and protocols.

1800-MEDCON is my favorite number when on duty. I don't always call them, but I definitely an not afraid to call. They are always available to aid you in any way possible, even if you just want to bounce ideas off of them.

 

[captaindepth]

So i was just rereading through the thread and I'm curious, What are we using to confirm LVH in the original 12 lead? The Sgarbossa criteria has been very helpful and makes a lot more sense but Im still not quite sold on the LVH.

 

[Brandon O]

So i was just rereading through the thread and I'm curious, What are we using to confirm LVH in the original 12 lead? The Sgarbossa criteria has been very helpful and makes a lot more sense but Im still not quite sold on the LVH.

That's my point. It doesn't matter. At least not for the question of STEMI. (If you're into cardiology you can worry about diagnosing LVH.)

 

[captaindepth]

But both those elevations and depressions are deflected opposite the QRS and proportionate in size, which is the expected strain pattern for baseline LVH without acute injury.

Here you attribute the elevation and depression to LVH and where the entire discussion turned to the Sgarbossa criteria. Now you are saying it doesn't matter, and totally lost me. . Sorry to be stubborn but I still see an acute event happening with the original OP.

 

[chaz90]

Here you attribute the elevation and depression to LVH and where the entire discussion turned to the Sgarbossa criteria. Now you are saying it doesn't matter, and totally lost me. . Sorry to be stubborn but I still see an acute event happening with the original OP.

Proportionally appropriate discordance doesn't only apply to LVH. Whether the original EKG exhibits criteria that allow diagnosis of LVH (which isn't the gold standard anyway) isn't really relevant. The minor ST segment elevation we're noticing is not overly shocking based on the massive preceding negative QRS deflection. The similarly negative ST segment depressions are also appropriately discordant with significant positive QRS deflections.

One of my favorite quotes from several medical blogs from people who know far more about electrocardiography than I: "Novices read ST segment changes as numbers alone; Professionals read the entire EKG."

Sgarbossa criteria are numbers to determine what is appropriate and what isn't most of the time, but the general principle still applies that when you see huge QRS deflections, small and discordant ST changes simply don't matter as much. Look at it, then move on to serial EKGs and continued assessment in light of the patient's condition and clinical signs.

 

[Nova1300]

Guys, we may be missing the forest here.

The EKG is interesting. But this a female patient with years of uncontrolled diabetes and hypertension. Her acute coronary syndrome can be expected to be atypical. And with routine glucose in that range, she should be presumed to have coronary disease.

She is presently hypertensive and has a HR of 106. That is a heart under strain. Granted she may have autonomic dysfunction from her terrible diabetes, but that's not a call to make in the field.

Even the sats are a little worrisome. A lady with no pre-existing lung disease shouldn't have sats in the mid 90's. That is a ventilation perfusion mismatch. Was she morbidly obese?

Not only could this be an NSTEMI, but this is frequently how diastolic heart failure presents.

I do my best to talk this lady into a trip downtown. Maybe not a cath lab alert, but certainly for troponins and an echo. We do this same workup on BS patients all the time. This is a lady who actually deserves it.

 

[chaz90]

@281mustang

To help validate our opinions on this EKG, what was the diagnosis for this patient at the hospital? Did cardiac enzymes show much of anything? Did she get taken for a cath? If not, do you know if she received a cardiology consult or if the ED physician handled it?

 

[Brandon O]

Here you attribute the elevation and depression to LVH and where the entire discussion turned to the Sgarbossa criteria. Now you are saying it doesn't matter, and totally lost me. . Sorry to be stubborn but I still see an acute event happening with the original OP.

chaz said it pretty well already, but here's my best shot:

If you see an ECG like the OP posted, it should instantly send you back like Proust's cookies to thoughts of LVH... a whiff of LBBB... even a dash of early repolarization. Although these are distinct disorders, for the matter at hand, they have the same relevance, because what we're doing is pattern recognition based upon the shapes, widths, and sizes of the QRS-T complexes. And as soon as you start thinking that way -- realizing this strip fits into that family -- you should stop trying to compare ST segments against the isoelectric line and start using the different "baseline" you've learned is normal for those syndromes. Looking for a STEMI will always be one of our top priorities in emergency medicine, and this method is how you do it with an ECG that looks this way.

Whether the patient actually has LVH, LBBB, etc is a totally different question. But who cares? Are you trying to code in a new ICD-9 diagnosis? In some cases those questions are worth asking, in others not. For instance, newly diagnosing a patient with LVH has some significance as to their cardiac risk. Diagnosing them with benign early repolarization does not. In both cases, however, this is not a very important task for paramedics except as a hobby, because it bears very little upon prehospital care. (The old idea that "new or presumed new" LBBB should be a STEMI equivalent has been roundly disproven.)

I understand what you're asking, which is: "How can we know whether to apply a Sgarbossa-type analysis if we don't know whether there truly is [LBBB or whatever]?" My answer is: "The general pattern of secondary changes consistent with these electrical abnormalities is what leads you to apply that approach, not their definite, confirmed diagnosis."

Does that make sense? The important dilemma is whether the original ECG here shows a STEMI. Now, it looks a little like it has LBBB morphologies, but I'm not going to add up the boxes to see if it's >.120ms or not, because that's not the question. It also looks a little like LVH, but I'm not going to add up R and S amplitudes to see if they exceed one of the numerous ECG criteria for LVH, because that's not the question either. But irrespective of those distinctions, I DO know that the patterns I'm seeing cause secondary ST/T changes, and after I take those into account, I see no evidence of any ischemic changes superimposed onto that baseline.

Sorry if this isn't very clear. Sometimes I give good explanations. This isn't one of those days.

 

[Handsome Robb]

I'm going to throw in here the AMA RMA point here, seeing as everyone is talking about the 12 lead, which I see elevations in V1-V2, and would def consider that a septal STEMI.

That being said I read a recent article in JEMS in regards to refusals. It spoke about how you need to be sure that the patient is fully competent in self and mind to refuse any further care. It then went on to explain that this goes beyond "acceptable vitals" and the patient is CAOx3, and that if the patient doesn't fully comprehend the fact that they may likely be choosing to die, the legally you as a provider have the right to deny a refusal, and seek ways to transport the patient against their wishes.

In this case, based on the 12 lead, I would be concerned for the patients future safety, and would clarify that they could likely die if they do not seek immediate care. If they still refuse but don't seem aware, or just don't seem to care, you can always contact MedCon for assistance. Sometimes getting a doctor on the phone to convince a patient that they should be in the ER does the trick, and if it doesn't and the MD agrees with you, they can give orders to detain the patient, whether through PD assistance or some other legal method as deemed by agreed upon local laws and protocols.

1800-MEDCON is my favorite number when on duty. I don't always call them, but I definitely an not afraid to call. They are always available to aid you in any way possible, even if you just want to bounce ideas off of them.

A physician cannot order you to transport someone against their will unless they are a danger to themselves or others. With that said, being awake, alert, oriented, not intoxicated and able to reiterate the risks you explain back to them and still refusing transport for a potentially life threatening illness does not equal suicidal intentions/ideations, which is about the only time we can transport someone against their will. People have the right to make decisions about their healthcare, even if they are bad decisions. It is not our place to decide wether patients go to the hospital or not. I've AMAd STEMI and CVA patients. That's not saying I didn't spend an extended period of time on scene reasoning with them and contacting the hospital to have a physician speak with them and explain to them the risks in order to have another person in my corner trying to convince them they need to go but at the end of the day if they are awake, alert, oriented and competent they can refuse care. I'd tread carefully forcing patients to go to the ER against their will and treating them against their will. That is kidnapping, assault and potentially battery if you perform invasive treatments on them during transport.

Even the sats are a little worrisome. A lady with no pre-existing lung disease shouldn't have sats in the mid 90's. That is a ventilation perfusion mismatch.

I live at altitude, I run at 95-96% at my baseline without any pre-existing lung pathologies outside of exercise induced bronchospasm. While I agree with what you're saying a SpO2% in the mid 90s without a history of respiratory disease does not equal a V/Q mismatch.

 

[Nova1300]

Yes, it is correct that in an environment with decreased partial pressure of oxygen, the sats will decrease. And this does not represent a VQ mismatch. So, I guess I stand corrected. If this call took place on a mountaintop, it is possible her hypoxemia is from altitude.

However, in the absence of some confounding factor like altitude or an underlying disorder shifting the oxy-hgb curve, she has mismatch.

Was this fine specimen mountain climbing at the time of her presentation?

 

[medic6676]

A physician cannot order you to transport someone against their will unless they are a danger to themselves or others. With that said, being awake, alert, oriented, not intoxicated and able to reiterate the risks you explain back to them and still refusing transport for a potentially life threatening illness does not equal suicidal intentions/ideations, which is about the only time we can transport someone against their will. People have the right to make decisions about their healthcare, even if they are bad decisions. It is not our place to decide wether patients go to the hospital or not. I've AMAd STEMI and CVA patients. That's not saying I didn't spend an extended period of time on scene reasoning with them and contacting the hospital to have a physician speak with them and explain to them the risks in order to have another person in my corner trying to convince them they need to go but at the end of the day if they are awake, alert, oriented and competent they can refuse care. I'd tread carefully forcing patients to go to the ER against their will and treating them against their will. That is kidnapping, assault and potentially battery if you perform invasive treatments on them during transport.

That was kind of my point, I guess I should have elaborated that there needs to be extenuating circumstances that make an MD agree with you.

 

[281mustang]

@281mustang

To help validate our opinions on this EKG, what was the diagnosis for this patient at the hospital? Did cardiac enzymes show much of anything? Did she get taken for a cath? If not, do you know if she received a cardiology consult or if the ED physician handled it?

No idea if they even drew labs, I don't typically work in that area and this is the only transport I've done at that specific hospital.

The doc's rational was that the deep Q waves were pathological from a previous septal MI which was causing repolarization abnormalities/elevation. Don't know if he got a consult but I doubt it, he didn't seem concerned about the situation whatsoever.

 

[Brandon O]

The doc's rational was that the deep Q waves were pathological from a previous septal MI which was causing repolarization abnormalities/elevation. Don't know if he got a consult but I doubt it, he didn't seem concerned about the situation whatsoever.

This is what we often call "left ventricular aneurysm," or LVA. Bit of a misnomer since there may or may not be any anatomical aneurysm, but it just refers to persistent ST changes from prior MI. The changes look more or less like this, although I might quibble a little since it's debateable whether some of these are truly Q waves. (No question the R progression is pretty abused, though.)

 

[jwk]

Sorry - still trying to get past the BS of 470 which is "low for her".