Some questions about a call from last night and EKG

[Hockey]

Dispatched for 84 year old male complaining of difficulty in breathing. Once we arrived, he was laying in bed and didn't appear to be in any distress.

He said he got up to use the bathroom when he became extremely winded.

Lung sounds clear

BP 140/90

HR 88

SPO2 90%

Skin is pink warm dry.

History of 3 stents, with the most recent being in Jan. Minor blockage but "nothing bad" per patients wife.

Recent stress test. Per both patient and wife, doctor didn't say anything was wrong with patients EKG.

No old 12 leads available.

12 lead prior to moving patient

http://imgur.com/jHOMR (sorry don't want to embed due to large size)

Second 12 lead

http://imgur.com/PNSMd

I attempted a 15 lead, but when I had him move a little, he became very winded (plus our wires always seem to be too short to do it as it should) and it was a really tight area so I opted to move him to the stretcher and get going. Didn't get a chance to do a 15 lead and we decided to load and go since we were less than 2 miles from the hospital.

So, dumb question, what is going on in Lead 2? 3 lead showed initially a sinus with PVC.

Besides IV, O2, Monitor was there anything else we could have done for this?

 

[d_miracle36]

Those are some pretty tall r waves in v3. Just looking at it looks like a strain pattern but by definition does not match right ventricular hypertrophy to my knowledge. I dont think there would be much more to do for this patient. One of my differentials would be a pulmonary embolism so i would dive into history a little bit more. I would verify lead placement and just monitor en route with serial ekgs. Is he on beta blockers? I would suspect more tachycardia.

 

[Christopher]

So, dumb question, what is going on in Lead 2? 3 lead showed initially a sinus with PVC.

Well...a common cause of an isoelectric limb lead is the RL (green, common ground) electrode being swapped with an arm lead, usually RA. However, Lead I looks unaffected so I would imagine it is simply a matter of the axis.

Isoelectric in Lead II means the axis is going perpendicular to it, so either along +aVL or -aVL. Since aVL is positive it would be -30 degrees. The calculated axis is -27 degrees, so this checks out assuming the electrodes are all in the right place.

I advocate using the "3am Rule" whenever the ECG looks weird.

#1 look at the patient
#2 look at the electrode placement
#3 If these are good, accept that the ECG is weird

It certainly has the look of a hypertrophy ECG, but more like a cardiomyopathy ECG.

I think you did everything you could, no worries.

 

[Hockey]

Thank you for mentioning it about the PE. He had a PE about 3-4 months ago apparently. Could this be a new PE?

 

[Ecgg]

The bottom of that EKG is cut off what was the frequency response for this EKG? Was it MON 0.5-40Hz or Diag 0.5-150 Hz?

Assuming the leads are in correct anatomical positions and none are misplaced, the R wave progression in precordial leads looks bizarre to me.

But it has the look of strain patterns however those are best seen in V5-V6 and I AvL the lateral leads.

Whats funny, if you want to go by lead II rhythm interpretation that looks like ventricular standstill.
http://www.learnekgs.com/ventricularstandstill.htm

What else can you do?
I would asses for TIMI Risk Score for UA/NSTEMI. ACLS has a good chart you can carry with you. Score the patient and relay the info to the ED attending physician maybe they will get cardiology involved.

http://www.mdcalc.com/timi-risk-score-for-uanstemi/

http://jama.jamanetwork.com/article.aspx?volume=284&issue=7&page=835

With just the info you provided here he probably has 4 points, further assessment might yield even higher score.
20% risk at 14 days of: all-cause mortality, new or recurrent MI, or severe recurrent ischemia requiring urgent revascularization.


How were the heart sounds? Any murmurs? Or abnormal sounds heard?

 

[d_miracle36]

I wouldn't say exclusively it was a pe but I would keep it a possibility. With the sudden onset of soa I would consider it. it can be subtle at times. What other history does he have? Does he have any other problems than the stents?

 

[Brandon O]

Whats funny, if you want to go by lead II rhythm interpretation that looks like ventricular standstill.

Except that correlating against the other leads, those nubbins aren't P-waves, they're the QRS.

 

[Veneficus]

I want to give this some thought, but I would just like to quickly point out.

History of 3 stents, with the most recent being in Jan. Minor blockage but "nothing bad" per patients wife.

What in her opinion would make it bad? There are criteria for placing stents and "just in case" isn't one of them.

 

[Hockey]

I wouldn't say exclusively it was a pe but I would keep it a possibility. With the sudden onset of soa I would consider it. it can be subtle at times. What other history does he have? Does he have any other problems than the stents?

Diabetes that is controlled by diet

I want to give this some thought, but I would just like to quickly point out.




What in her opinion would make it bad? There are criteria for placing stents and "just in case" isn't one of them.

True, but I didn't have much to go off since there was no old EKG's available

 

[Veneficus]

Diabetes that is controlled by diet
True, but I didn't have much to go off since there was no old EKG's available

Eliciting a patient history is not llike trying to solve a mystery.

It is an interrogation and the desired outcome is confession.

 

[jjesusfreak01]

I personally like the idea of a PE. Winded, low SPO2, hx of cardiac occlusion, acute onset, depression in the anterior precordial leads with no reciprocal changes. He needs a quick trip to the hospital, and if he uses the words "pain" and "chest" in the same sentence he gets ASA and maybe some nitro in addition to your prescribed treatment. I suspect he will be a candidate for tPA at the hospital.

 

[FLdoc2011]

TPA no way. He's only maybe a little hypoxic, certainly not hemodynamically unstable. He may get a dose of lovenox in the ED but certainly not tpa from what we know so far.

 

[jwk]

TPA no way. He's only maybe a little hypoxic, certainly not hemodynamically unstable. He may get a dose of lovenox in the ED but certainly not tpa from what we know so far.

Thank you.

 

[usalsfyre]

What in her opinion would make it bad? There are criteria for placing stents and "just in case" isn't one of them.

That was my first thought when I read that. Can't you just see the cards note. "Stent placement was performed due to mechanism..."

 

[MadMedic]

PE was my first thought but with the history provided, I can't say that. Was there any pain with movement? during breathing? Was the PT on any meds? What was he doing when it started? The stent in Jan. would lead me to down the path of PE but i need more info. ASA would have been a thought, not sure about NTG. Fluids/O2 for sure. and then a ton of diesel. The EKG has a few things going on that would have made me check everything and print out continuous strips. Good case, would like to hear about the follow-up.