Imagine you are an emergency physician working in a medium-sized community hospital.
It’s a busy day in the emergency department. You are the only physician on duty.
One of the nurses has called in sick, there is no tech, and the weakest unit secretary is on duty.
All the rooms are full, the waiting room is packed, the ambulance bay is jammed, and there are overflow patients waiting to be admitted.
There is a policy in the emergency department that the emergency physician shall review the 12-lead ECG of chest pain patients within 10 minutes of the patient’s arrival.
You are suturing a large laceration in a patient’s leg when a nurse walks in, holds up an ECG and says, “We have a walk-in chest pain patient in bed 4.”
It’s going to take you another 20 minutes to suture up the patient’s laceration.
What are your orders?
See also:
full set of obs pain score R side ecg, ? treat gtn if bp allows ?analgesia, monitor pt o2 via simple mask. iv access
I would suggest right sided EKG, labs, seems that we might have here some ischemia to lateral & inferior leads.
This is why ED overcrowding is a problem… overworked nurses rotate all the limb leads!
Depending on hospital protocol – , do another ECG in 5 mins, load aspirin, clopidogrel, call the cath team. ST ‘depression’ in V2 is an ST elevation equivalent for a posterior infarction. Interesting that the ST segments are ok in the inferior leads.: large Qs there, TWI. Wonder if this is an old inferior, with a new posterior; but sometimes the ST elevation can persist after an infarct and this may be a plain old NSTEMI. Quick chat to the patient might clear this up.
Good spot Brandon. Didn’t see aVR!
hahahaha brandon !!!!
Right arm lead is on left leg; left leg is on right arm. So that makes lead I an ‘inverse lead III’; lead II an inverse lead II; lead III an inverse lead I. So the downsloping ST depression in lead I and lead II is actually ST elevation in the inferior leads. Makes this a true infero-posterior STEMI. Great case.
Mark, I saw it as more of a clockwise rotation — right arm to left arm, left arm to leg, leg to right arm. But I see that swapping right arm and leg also works, and is simpler (therefore more plausible). I like it your way; nice catch. But I’d like a cleaner ECG to call depression… although since in your model aVL is still “legit,” I believe those inverted T-waves would count as reciprocal changes!
Very neat, very enjoyable case.
“put him in a wheelchair and wheel him into this room. and for god’s sake, would someone teach the unit secretary where to put those damn leads?”
ASA, Oxygen by cannula as need for diff breathing. Repeat EKG now (with the leads on right) and in 5 minutes, Dual IV’s with a bolus, get the closest STEMI ER physician on the phone, and call 911 for the STEMI transfer. Inferior, Posterior MI with First Degree Heart Block.
@Brandon – I thought it was rotation as well, but then the limb leads didn’t ‘calculate’ properly. The only combination that worked was a swap between right arm and left leg.
I agree with burned out medic. I would also give the pt the tv remote and a cup of coffee looks like it’s gonna be a while!
The P Wave is upside down, that is the main clue about lead reversal.