Tweet about ECG leads to mystery – is this a mimic or the real thing?

One of the best things about EMS 2.0 is the ability to network and learn from EMS professionals all over the World.

Since I’m interested in ECGs and STEMI care I occasionally use the search engine at Twitter to see what folks are talking about when it comes to emergency cardiac care.

During one of those searches I came across this tweet by @in_the_city.

EKG geek? I’m your Huckleberry!

This piqued my curiosity so I answered @in_the_city.

Note: this was from my personal Twitter account @tbouthillet. The EMS 12-Lead blog is also on Twitter @EMS12Lead.

To be honest I was expecting one of the obvious mimics of acute STEMI.

Here’s the story in @in_the_city’s own words (with minor edits).

“EMS is dispatched to an area nursing home that specializes in pediatric patients with special needs and other wards of the state. The patient is a 19 year old ventilator-dependant black male with a chief complaint of a low grade fever 99.8 F taken tympanically.

The patients physician has been consulted and while the patient is responding to Tylenol he wants the patient taken to the ER for rehydration and the probable insertion of a PICC line.

PMH: Cerebral Palsy, Hypertension, Diabetes, Asthma, Respiratory Failure
Allergies: NKDA
Meds: Not recorded

The patient presents as follows:

NonVerbal. GCS=4-2-4 This is normal for this particular patient.

Airway is patent, with a number 6 portex tracheotomy tube in place and connected to the facilities ventilator.

Breathing is being assisted by the ventilator, with the patient taking an occasional spontaneous breath over the programed rate.

Circulation is apparently being maintained, with a normal steady radial pulse and good distal pulses in the feet.

Vitals signs:

BP 110/70
P 72
RR 20
SpO2 100%
EtCO2 35-40
Blood sugar 118

PERRL pupils, clear bilateral breath sounds.

Skin parameters are all normal.

Taking our time we attach the patient to the transport vent with the following settings:

Assist Control Tidal Volume 500 RR 14 FiO2 40% Peep 5.

As per system policy, this patients is considered an ALS patient due to being on a vent so we attach our monitor leads and print a 6 second strip to put with the chart.

At that point, we felt like we were being punked by someone. The elevation was evident to the both of us, in our nonverbal no complaint having vent patient! But neither of us wanted to be less than thorough so we hooked up the 12 lead.

So, since I saw ST elevation, my partner saw ST elevation, and the stupid computer in our Zoll E series saw ST elevation we had no choice but to suspect that our nonverbal complaintless patient was having an inferior wall STEMI.

When we arrived everyone pounced on our patient… at least until my partner showed the physician our 12 lead and she informed us that we had “wasted her time”

She didn’t elaborate. We felt bad. Then found out that benign repolarization effects about 1% the population and is common in young black males. The way to tell the difference (apparently) is that the ST segments, while elevated are scooped.

It really threw me that the repolarization isn’t seen globally, and is localized in those dang inferior leads. But live and learn.”

So what do you think?

I’ll share my thoughts once you’ve had a chance to weigh in.

See also:

Is this a mimic or the real thing? – Discussion

Other great case studies can be found HERE.

31 Comments

  • Ryan says:

    Interesting. I would have called a STEMI on it as well just by the EKG and given history of the patient. It’s too bad that the MD felt uncompelled to explain this. Even though we may be competent in the basics of electrophysiology, there are some odd things that the normal field provider is not going to know. This is one of them.
    Does bring up an interesting point though, how do we treat the unresponsive, or less than responsive patient who may be in a vegetative state with a possible MI? If they can’t do the aspirin/nitro regimen…

    Glad I learned something today. Thanks Tom!

  • nerdpants says:

    Great case. I would’ve been fooled too if lead I (along with AVL) had an inverted T-wave. I’m also still trying to figure out BER….actually, I’m curious about the outcome on this one

  • Mark V says:

    Although it looks like elevation.. I do not see elevation after the J point.

  • ParaMurse says:

    I guess the best way to learn is through experience. I was thinking BER or J-point elevation myself… My recommendation would be, if available, to transmit to a receiving facility or med control post (per system policy) or even just call to talk with a doc and explain the situation if something “just doesn’t fit.” Collaborate with med control to determine an appropriate treatment strategy.

  • Christopher says:

    With the flipped T-wave in aVL this is a hard call. Also, I recall from a previous post that ST-depression in aVR with more global elevation is indicative of pericarditis. I don’t know if I’d call a STEMI, but I would likely call in to the doc’s and let them know what I’ve found.

  • Brandon O says:

    The physician’s two cents almost makes this more difficult, because we’re left trying to guess whether she knows something we don’t, or we might know something she doesn’t. But based on what we have I would not be comfortable ruling out, as Christopher says, inferior STEMI or pericarditis vs. BER. The T-wave inversion in aVL is a particular chin-wrinkler.

  • Troy says:

    I would have been fooled especially with the Q waves developed! I read somewhere that a stemi mimic could also be seen in brain bleed and siezure patients (I believe Ahlerts ECG made easy 3rd ed). Those would be my guesses in this case. Be interested to see if he did a serial 12 lead

  • Brent S. says:

    So, I have had the same thing. Pt was complaining of atypical chest pain, that was non radiating, no n/v, but short of air. Pt had no hx of previous cardiac problems. After doing the 12-lead, ST elevation was noted in the septal leads as I remember. It was only about two milimeters, but it was there none the less. I treated the pt was ASA and nitro per protocal, two lines, and O2. I called ahead for a possible STEMI. Upon arrival, a repeat 12 lead after three nitro and decreased pain, revealed the the ST changes had resolved. HMMMMMM. The Doc told me that it was ,normal variants or lead placement and disregarded the pt leaving me looking and feeling like an Idiot. I have been a medic for about 9 months so im still learning a lot. The doctor offered no explanation as to her reasoning, but the elevation was the scoop as you have on this. 1 hour later the pt was being rushed to the cath lab for a Septal MI. SCORE ONE FOR EMS.

  • Troy says:

    And yes, although I believe BER and pericarditis fit better (especially with the temp) I feel a bit obstinate today. Fight the power!

  • Troy says:

    Brent S.

    Sweet case! Sometimes if you catch the MI early ASA and nitro can relieve the STE, thus the importance of the prehospital 12! Congrats on making the doc eat crow pie. Fight the power! Lol 😀

  • Ben says:

    Had a case of Prinzmetal Angina before I qualified as a Paramedic – strange thing in that pt c/o typical chestpain, ecg shows inferior STEMI with reciprocal changes, aspirin in, then GTN. Pain resolves and ECG returns to sinus rythm with no ST elevation. Thankfully a helpful and friendly cardiologist explained the angina variant at the hospital!

  • Harrison says:

    Sinus rhythm @ 74.

    -Young
    -Male
    -Black
    -J Point elevation
    -Notched J point******giveaway giveaway giveaway of BER
    -High T voltage
    -No Q’s of significance
    -No significant T inversion
    -No significant ST depression
    -Morphology of ST segment points to a STEMI mimic.
    —III almost always has a Q, and is only significant if II and AVF have a significant Q, which is not the case

  • Harrison says:

    Sorry, didnt get all my post in

    Based on the above

    DDx:

    1: BER
    2: Pericarditis (a leap)
    3: HyperK (and a bound)

  • Troy says:

    My question is this though….. if we have STE in inferior leads, inverted T’s in I and aVL, and STD in aVR (which looks at the base of the heart, atria, greater vessels and proximal coronary vessels) I wouldn’t quickly rule out MI. We had a patient in the hospital about a month ago that was 21 with a full MI but also had hyperlipidemia (genetic). So if this kid has cerebral palsy why can’t he have another genetic condition?

  • Troy says:

    Correction…just inverted in aVL

  • Vicki says:

    It’s been a long time since I did this on a daily basis, but the ST-wave is really elevated.
    I keep up w/ what I’ve learned by subscribing to all these pages, b/c I don’t intend to let 3 operations stop me from doing my work in the future.

  • Vicki says:

    BTW I know a lady doctor exactly like the one described in the blog.
    Everybody has no idea why she even chose to be a doctor b/c, at one time, a patient had a seizure in the hospital cafeteria. This doctor stood up and shouted across the room: “Get her out of my sight! I’m eating my lunch.”
    At which point, every doctor in the room came to help the patient, probably in hopes that nobody would confuse them w/ the lady physician who was so offended that anybody would dare have a seizure while she’s eating her lunch in the hospital’s cafeteria.

  • Ahh, the know it all ER docs.

    Remember, there are plenty of paramedics that can read 12-leads better than some ER physicians. Although, this doc was probably correct, the attitude is unnecessary.

    This ECG does show some obvious ST-Elevation in the inferior leads, along with an inverted T-wave in aVL (which is common with an inferior STEMI). The upwardly concave ST-elevation is indicative of BER, but a STEMI CAN STILL HAVE THIS MORPHOLOGY. The big indicators of BER are the notched J-points in lead II, asymmetrical T-waves, and the patient’s presentation. “Consider the company it keeps” (right Tom?). A young patient with a STEMI will probably have the typical symptomatology.

    The 12SL Marquette interpretive algorithm is actually pretty good at ignoring BER, but this pattern does look STEMI-ish. What’s your take Tom?

  • Harrison says:

    Thanks Adam, I had neglected to put STEMI on my DDx list.

    I am more suspecting of BER however and mimics were on my mind. Oh how I wish we could edit posts here.

    What is the “12SL Marquette interpretive algorithm” you are specifying? I have never heard of such a thing before?

  • Bart says:

    Being that we in EMS have no way of proving without a doubt that this pt. Is not having an MI, you did absolutely nothing wrong I would have treated it as an inferior MI just as you did. The Dr. Saying that you wasted her time is just a show of arrogance, I would hope that she could recognize quickly that it is not an MI being that she has much more extensive schooling than we do in cardiology.

  • Brandon O says:

    Harrison, the Marquette is the computerized 12-lead interpretation algorithm built into the Zoll (such as this one), the Lifepaks, and most of the other monitors floating around except the Philip MRx. With a few caveats, it’s generally quite specific (90%+) when it shouts “*** acute MI.” The presence of the flag here is actually a pretty good argument in support of STEMI, or at least the reasonable belief in it.

  • GE Marquette 12SL interpretive algorithm:
    http://www.ecg-professionals.com/ge-marquette-12sl-ecg-analysis-program.html

    The accuracy is very dependent on a CLEAN tracing. Troubleshoot that artifact, and be amazed at how accurate it can be. Tom has stated all this before on this very blog.

    Bart,
    For that matter, we have no way, without a doubt to prove that the patient isn’t experiencing malaria. We go with the odds. Sure, we should be more cautious than those practitioners with conclusive diagnostic tools. However, we can’t over-triage everyone because of what it MIGHT be. I agree with you about the arrogant doc.

  • Troy says:

    Bart,
    I took a patient to an ER once where they were running a full arrest in the other room. The med tray had 2 epi, 2 bicarb, calcium, amiodarone ampules, D50, and atropine. The patient was prenounced but the docs congratulated eachother on the best code they’ve ran yet. The code summary showed that they shocked 8 times. The CCRN/FP-C said the patient never got out of asystole. This was in 2008. Higher trained in cardiology? You tell me

  • defibyou says:

    Troy,
    Wonderful and very honest post. It is amazing what you see sometimes when your standing there watching highly educated Physicians give so many inappropriate meds. Makes you wonder how they graduated Med School. The best answer to you question was given to me by a physician a few years ago as I watched him give Epi to a Symptomatic SVT telling me if he got her pressure up her rate would come down. ” I’m the Dr your the Paramedic. I practice medicine you follow protocol” I thought to myself if this is practicing medicine I want no part of it and walked away. Her rate by the way did slow down. It went from SVT to V-fib, to Asystole.

  • Christopher says:

    What I think is missing is that every profession has it’s bad apples. Whether that be a sorry excuse for a Paramedic or the questionable Doctor. It shouldn’t surprise us, but we shouldn’t allow it to color our judgement of the entire profession.

    My biggest problem is when these situations aren’t used as teachable moments. Nobody learns anything in a dismissive autocracy. I find medics are especially bad with this when dealing with nurses.

    In the long run, that Doctor would rather the Paramedics falsely activate a few BER’s than miss a few STEMI’s.

  • Troy says:

    Christopher,
    I didn’t mean to pull the paragod card. There are some amazingly smart MD’s ( such as Dr. Smith) and part of that is the willingness to take full advantage of a teachable moment. I feel medics are the worst at this as well. If we would all be open for correction then who knows how smart the paramedic field would get!

  • Brandon O says:

    I just think it’s tremendously important to keep an open mind and always assume that I’m the one who’s the idiot. I don’t know how many times I’ve heard something that sounded outlandish to me, only to later discover it reflected a deeper and more nuanced understanding of the issue than I possessed myself. For better or for worse, that’s why we have the clinical hierarchy — because although the medic might know better than the MD, usually, quite frankly, he don’t.

  • Troy says:

    Brandon,
    Plus we don’t have to pay malpractice insurance 😛

  • Brandon O says:

    Well, we don’t make any money either. We all gots our crosses to bear.

  • RM says:

    Extremely suspicious ECG! Here are my thoughts. This doesnt look like BER or hyperkalemia to me. I would expect BER to affect the precordial leads, and certainly not in an anatomical distribution. A prior 12 lead would be nice to possibly rule out aneurysm. The q wave in III looks pathological to me. The absence of reciprocal depression makes it less likely a problem but doesnt rule out stemi. I would imagine BER could obscure std. Right sided leads might be helpful. Dont really see a prolonged PR interval, increased qrs duration or globally peaked t waves of hyperkalemia. And dont see pr segment changes consistent with pericarditis.

    Looking forward to seeing the experts weigh in!

  • CBEMT says:

    Troy- if you’re not carrying you’re own insurance, you really should be.

    As for the “MD” in your story, his name would have been on someone’s desk at the Department of Health the next day if it’d been me.

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