Feb 2011 EMS 12-Lead column "Run of the Mill" at EMS1.com

The February 2011 EMS 12-Lead column at EMS1.com has been posted.

Run of the Mill

Submit your interpretation and treatment plan for a chance at a T-shirt and bottle opener.

Good luck!


  • Christopher says:

    I go to comment maybe 1 minute after you posted this and its already got 10 on there! MUST HAVE FREE T-SHIRT! 🙂

  • Christopher says:

    I noticed this interesting comment:

    “A classic example of why not to trust the LP interpretation. This is not a junctional rhythm; there are P waves. It is a third degree block” [ed: snipped]

    Potential failing of how rhythm interpretation is taught? Seems like 3AVB is being conflated with the rhythm rather than a pathological condition affecting the underlying atrial and ventricular “rhythms”.

    I remember in school that we didn’t bother with rhythm interp if we saw 1AVB, 2AVB, or 3AVB. We just wrote those down as the rhythm!

  • just another medic says:

    Yes, I was going to comment on EMS1 but they require an account. Oh well.

    I’d call this 3* AVB, junctional escape. Inferior infarct due to II, III, aVF elevation with 1 and aVL depression and T-wave inversion. Probable RVI due to STE III>II and minimal V1 STE. Possible PWMI due to what looks like some depression in V2 (not 100% sure on that one). Thinking proximal RCA.

    ASA as tolerated. We don’t have anything for nausea but I would consider something if we did. 2 IVs, right side/posterior leads as time allowed (low on my list of priorities as it won’t significantly change my treatment). Fluid bolus to keep pressure around 90-100 systolic as long as lungs stay clear. Pacer pads, 2lpm o2, quick trip to cath lab with early activation. Definitely holding off on that nitro!

  • Brandon O says:

    Saw that too Christopher. If you want to chuckle at the computer, I guess you could chuckle at the “no P-waves found” when there’s clearly one right there… just in the wrong area code. But I wouldn’t have been confident on that rhythm without the rhythm strip either!

    Actually, maybe one of you guys could confirm this. When the algorithm interprets the 12-lead, it uses a longer period of data than it actually prints, correct? It’s not merely looking at the ~2.5s of each lead that we see on the recording?

  • Christopher says:

    I can’t speak to exactly how the LP12 algorithm works for rhythm interp, but if *I* were one of the programmers, I would likely take the information accrued from the 10 total seconds (or more) used in the strip 🙂

  • Christopher says:

    Brandon, after reading the 12SL Statement of Validation and Accuracy (March 2007) it appears they use the 10 seconds of acquisition to do the interpretation from. It appears to begin with P-wave detection done asynchronously from QRS interpretation. Then it uses the QRS interpretation coupled with the detected P-waves to see if it missed any P-waves. It is about 65% sensitive for P-waves so says their documentation.

    Interestingly enough it states that the pre-hospital algorithm is modified from the in-hospital to include “pre-STEMI” harbingers like STD.

  • Brandon O says:

    Nice find! I’m flipping through that document now. How cool would it be to work on these algorithms? …

  • Christopher says:

    Other interesting notes from the Comments on the article: the shear number that feel 3AVB only accompanies a wide rhythm (thus this is 2AVB). Goes back to my earlier comment about 3-Lead/12-Lead interpretation education for paramedics/nurses. Perhaps things are a little too rule based. Or are these rules necessary to protect against certain critical misdiagnoses?

    Also pointing out 3AVB but asking for atropine. I’ve seen this done in the ED and in the field, yet I remember getting my butt chewed for suggesting such a treatment during class. I’ve also wondered myself, for say a bad 2AVB, if atropine has utility in the face of an MI. Worried about balancing the workload of the heart and appropriate hemodynamics!

    Also a few pointed out this could be all secondary to a head injury. This case is an interesting mix of the two things we get yelled at the most if we miss/mess up as pre-hospital providers. Definitely colored many of the comments!

    Lots to chew on…

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