What are YOU concerned with when doing a 12 lead??

E

EmtTravis

Forum Captain
Messages
410
Reaction score
0
Points
16
Just wanting to see what you deem concern-able when doing a 12 lead. I know what my instructor has told me but I want to see what else everyone looks for.
 
Arrhythmia, ischemia, injury, infarction (especially early recognition of STEMI), conduction disorders (bundle branch blocks), prolonged QT, WPW pattern, Brugada pattern, Osborn waves (hypothermia), electrolyte derangement (especially hyperK), drug overdose (especially TCA), pacemaker capture (or loss of capture), and STEMI mimics in general. It's an incredibly useful diagnostic tool if you know how to use it. Having said that there are a lot of ECGs that are technically abnormal but nonspecific and any ECG is just a snapshot in time. This is where "a little bit of knowledge" can be dangerous if you fail to recognize a subtle STEMI or because you read too deeply into poor R-wave progression (for example). This is less of a problem when the patient is transported (because they'll be evaluated by a physician) but potentially problematic when the patient refuses transport. I've called patient's primary care physicians from the scene to have "old" ECGs pulled from the chart to ask if the LBBB was previously detected but you can't do that at 0300.
 
The basics

Proper placement, proper contact, patient movement, and machine function.

Machine function is largely addressed proactively and through training. Don't yank wires or paper, make sure the machine is checked daily for paper and batteries, make sure there are fresh electrodes, check the tips of the wires which contact the electrodes for corrosion, do periodic checks, report malfunctions.
 
As always, Tom displays a good standard. Like any diagnostic, you're looking for things to guide your treatment. Just recognize that in this case, "treatment" includes not only your meds and interventions, but also -- and especially -- transport destination, priority, and resource activation, including how to respond to a reluctant patient.

So it is less useful when it won't make any difference to your care when added to the clinical picture. It is most useful when it tells you something you never would have known otherwise (especially when this means catching a problem before it becomes clinically apparent, and harmful). In between those extremes is when it helps support or disconfirm a diagnosis you already had in mind.

Warning signs such as Wellens or de Winter waves are a good one to throw in there.
 
EmtTravis said:
Just wanting to see what you deem concern-able when doing a 12 lead. I know what my instructor has told me but I want to see what else everyone looks for.
Click to expand...

TomB said:
Arrhythmia, ischemia, injury, infarction (especially early recognition of STEMI), conduction disorders (bundle branch blocks), prolonged QT, WPW pattern, Brugada pattern, Osborn waves (hypothermia), electrolyte derangement (especially hyperK), drug overdose (especially TCA), pacemaker capture (or loss of capture), and STEMI mimics in general. It's an incredibly useful diagnostic tool if you know how to use it. Having said that there are a lot of ECGs that are technically abnormal but nonspecific and any ECG is just a snapshot in time. This is where "a little bit of knowledge" can be dangerous if you fail to recognize a subtle STEMI or because you read too deeply into poor R-wave progression (for example). This is less of a problem when the patient is transported (because they'll be evaluated by a physician) but potentially problematic when the patient refuses transport. I've called patient's primary care physicians from the scene to have "old" ECGs pulled from the chart to ask if the LBBB was previously detected but you can't do that at 0300.
Click to expand...

Pretty much what Tom said with particular interest on, not just ST elevation/reciprocal depression (to see exactly where the infarct is), but also to determine how many blocks the pt has: AVB, hemi-blocks, BBB. Some pts have all three. Those are the pts you need to be careful giving NTG for ischemic CP due to them being probed to bottom BP quickly, not just because of Rt side AMI.

In my part of the country it is very common.
 
Hoping that I don't find something a cardiologist would have a hard time identifying.....don't laugh, I've seen it once. Took two cardiologists to identify it. I forget exactly what it was called but basically it was SVT but it was flipping the complexes back and forth around the baseline like torsades.
 
All great information. I do know how to recognize BBB's and pathological Q waves and STEMI'S and a few other things but my instructor has told us that all we really need to be concerned with are STEMI'S and basically how many blocks the patients has. I know how to tell hyper/hypokolemia and hyper/hypocalcemia *sp* but he said we really aren't concerned with those things since we can do nothing for them. So should I be concerned with more then STEMI"S and BBB's? Just want to make sure I know exactly what I need to constantly look for.
 
EmtTravis said:
All great information. I do know how to recognize BBB's and pathological Q waves and STEMI'S and a few other things but my instructor has told us that all we really need to be concerned with are STEMI'S and basically how many blocks the patients has. I know how to tell hyper/hypokolemia and hyper/hypocalcemia *sp* but he said we really aren't concerned with those things since we can do nothing for them. So should I be concerned with more then STEMI"S and BBB's? Just want to make sure I know exactly what I need to constantly look for.
Click to expand...

Hyperkalemia is really the electrolyte imbalance you should be most concerned with; it can kill your patient and you absolutely can treat it. The particular cocktail may vary according to your protocol but the greatest benefit is from calcium.

Identifying MI is certainly the central reason for the 12-lead, but doing that job effectively involves recognizing a wide spectrum of things we've mentioned, including subtler signs and stuff that looks like MI but ain't.
 
Reversed lead masked by artifact and dysrythmia.

Don't laugh, especially in hurried enroute strips.
 
I too, have seen a rhythm that drives the cardiologists nuts; 4 medics, 3 ED docs (including medical director) and Head of Cardiology for large hospital system. Cardiologist walked in looked for about 10 seconds; and stated "I can't believe none of you can figure this out" when asked what it was, he took my run sheet; and wrote "This patients heart Rhythm is FUBAR (except he actually wrote it out)". When I stated that what he wrote would get me in trouble; he printed and signed his name behind it; and said now what can they do to you?

He never would say what he thought was wrong with patient; but he went to Cath lab.
 
usafmedic45 said:
Hoping that I don't find something a cardiologist would have a hard time identifying.....don't laugh, I've seen it once. Took two cardiologists to identify it. I forget exactly what it was called but basically it was SVT but it was flipping the complexes back and forth around the baseline like torsades.
Click to expand...

What the flip would cause that? Some re-entry atrial tach with a bundle branch and multiple accessory pathways around the av?

That is just something that comes to mind....
 
When in doubt and confused...

...declare "WPW!" and withdraw. ;)
 
lightsandsirens5 said:
What the flip would cause that? Some re-entry atrial tach with a bundle branch and multiple accessory pathways around the av?

That is just something that comes to mind....
Click to expand...

It's been so long ago (about eleven years) that I don't recall precisely although I do remember that it was a re-entrant tachycardia but beyond that it's really fuzzy. I do know that what triggered the episode though was an absolutely unhealthily large dose of caffeine. The patient was one of my coworkers. :rolleyes:
 
Anything that doesn't look like this:


Nsr.jpg
 
No one's brought up S1Q3T3 in pulmonary embolism yet...
 
You must log in or register to reply here.
Back
Top