Stemi? or no?

M

mrhunt

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Female in her 50s with acute onset of dizziness, shortness of breath and nausea. Denies chest pain, syncope vomiting or further. Only hx is hypertension and Prior MI 7 years ago. She's cool, pale diaphoretic skin signs, get into back of rig and 4 lead shows run of V-tach with pulses @ 200bpm.

Placed on pads immediately but self converts out before i can sync cardiovert. BP initially 116/72 and declines to 82/60 by er arrival (iv access and fluids already established) Lungs are clear, resp minimally labored at about 20, 12 lead comes back with the following below with acute ***STEMI*** reading.

I interperted as stemi due to Depressions in I and AVL with the noted elevations in II, III, AVF and treat as such.
Er physician stated that this isnt a stemi because there is only "notching" of the ST elevation and said something about "well who knows where her baseline REALLY is" as far as the isoelectric baseline he was refering to.

I know lead II is a bit questionalble (if any) upon further review of elevations but others definately appeared that way to me. Help me to understand where i went wrong.

Either way, its better safe than sorry and better to just do a quick code 3 transport and have it NOT be one than not treat it like that and miss it.....

but just an education moment for me! THanks guys.
stemi.png
 
I don't see a STEMI, but I do see a LBBB. Whether that is new or not is a good question though.

The reason I say it is a LBBB is >0.12 QRS in V1 with .6 R wave in V6.

It does not meet sgarbossa criteria.

The problem is that with witnessed self resolved Vtach, as well as clinical presentation, I would assume cardiac until 100% proven otherwise since ya know how there is more to life than a STEMI. I agree with the code 3 transport as well as the transport to a cardiac facility.
 
Very interesting case.

Lots going on here. First, what’s the rhythm? A rhythm strip would be helpful. Probably Afib RVR with ventricular rates between 100-150. If the patient was unstable, something to keep in mind was cardioverting the patient out of this may be appropriate.

There is also a LBBB morphology. LBBB can cause pseudo-STD/STE. However, QRS width should be the same throughout all complexes irrespective of the lead; it’s the same depolarization and repolarizarion, irrespective of which angle you look at it from. Looking at the second full complex of V4, QRS width appears almost exactly 0.12 s. Measure out 3 little blocks from fifth complex of III, there is still J point elevation beyond what anyone would suspect of normal variant. Ditto STD in aVL. I’m not going to go through each lead but I think this is true ST deviation. Inferior ST changes appear concordant to me.

Qualitatively, this also looks like STE and STD in the setting of LBBB. Just my first reaction looking at it subjectively was that this is not benign LBBB.

Especially in light of the clinical history provided, this is an acute coronary occlusion until proven otherwise. I don’t think you’re wrong here.

edit: disagree that this does not meet Sgarbossa criteria. You have concordant STe inferior, concordant STd in V2.
 
I was under the impression that concordance does not apply to lead 2 and 3. I'll double check, if wrong then meets criteria and I need to brush up!


I was wrong, using original criteria does not apply, but modified for OMI does. Thank you for the correction! Good to know!
 
Computer interpertation was Inferior stemi alert, i believe sinus tach as well since she converted down to 120's / 130's shortly after run of vtach.

Vtach strip was TEXTBOOK and i didnt include because it was so obvious that there was literally no point in attaching the photo.
 
Update, Pt was hyperkalemic (unknown exact level, heard it 3rd person) and flow to a local PCI capable cardiac center within an hour of Bringing her in.

Typically they arent flown unless they have drips that we cant take or its someone highly unstable so im assuming ST elevations may have increased or her Vtac returned.
 
Without a doubt in my mind, this is a STEMI.
 
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I don't like III and aVF.
 
Best to have a Cardiologist on text from your local Cardiac receiving center. Always come in handy for borderline situations like this. Did you ever have a follow up?
 
Dont know outcome once pt was flown to PCI center an hour later. Sorry!
Thanks everyone for your positivity and input on the case!
 
Lead III, AfV elevation with reciprocal in AVL, Inferior MI irritated the **** out of the ventricle resulting in VTACH. In my experience Most inferior MI involves the right ventricle. This is one of the main reasons nitro shouldn't be given to Inferior MI, You will drop your pressure instantly, preload problem, solution is fluids.
Any follow up with the ED, Trop levels, BNP?cath lab. lol or Expired.
 
I agree that is a STEMI. And even if it wasn't your call to activate the cath lab was more than reasonable.
 
looks like it meets scarbosas criteria to me. definitely transmit the strip and make direct continuity with the receiving er md
 
sometimes E.R M.D's get caught up in trying to show how much they know, it's a not seeing the forest for the trees kind of thing, it looks like you got pretty much the same conclusion I and every body here did...always err on the side of what's best for your patient. Don't allow someone else's arrogance to undermine your confidence .....
 
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