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17 year old male CC: Chest pain and palpitations

34 comments

Here's a great case submitted by a faithful reader who wishes to remain anonymous.  Some details have been changed to ensure patient confidentiality.

You are called to the local ER to transfer a 17 year old male to a large metro hospital for evaluation. Your patient  presented to the local ER with chest pain and palpitations following mild exertion. He was alert and oriented, and other than his elevated heart rate, his vitals were within normal limits.  Upon presentation to the ER:

  • O:   Discomfort began during exertion
  • P:   Exertion makes it worse
  • Q:   Dull pain, substernal
  • R:   non-radiating
  • S:   3/10
  • T:   about 20 minutes prior to ER arrival

 

  • S:   Chest pain/palpitations
  • A:   NKDA
  • M:   N/A
  • P:   No previous medical hx
  • L:   Unknown
  • E:   Mild exercise

As far as vitals go, all i can tell you is that they were within "normal limits" with the exception of heart rate. The patient is given trials of adenosine, lidocaine, digoxin, and cardizem, without successful conversion. In fact staff noted that the rhythm seemed to "speed up a bit" after the adenosine. He is put on an Amiodarone drip, which slows the rhythm a bit.  They then elected to cardiovert, and after three attempts he converted to a sinus rhythm.  Here is one of the rhythm strips and a 12 lead they acquired:

At the time you make contact, the patient has no complaints and is still in sinus rhythm. You apply your cardiac monitor and acquire your own rhythm strip and 12 lead:

 

Your trip to the metro hospital is uneventful, and he remained stable in your care.

 

What do you think is going on with this patient?

What is your interpretation of the ECGs?

Is there anything further you want to do for this patient?

 

 

Posted by on January 26, 2012 • Filed under: ems-health-safety, ems-topics, patient-management, training-development • Tagged: , , , , ,

64 year old female CC: Trouble Breathing – Conclusion

13 comments

Lots of great comments and it was good to see the depth of discussion on the appropriate treatment and transport for this patient!

This is the conclusion to 64 year old female CC: Trouble Breathing.

When we left off our crew was attending to an elderly female patient in respiratory extremis. Pulmonary edema was present and their initial 12-Lead was concerning.

Many readers correctly noted the normal sinus rhythm, a 1° AV Block, and a wide QRS. Other readers pointed out the apparent Left Bundle Branch Block due to a negative QS complex in V1. Only a few readers picked up on the abnormal presentation of the LBBB: lead I has an rS complex and there is right axis deviation! Right axis deviation is a very uncommon finding in LBBB [1].

Just as it is important to know what a normal 12-Lead looks like, we also need to know what our abnormal 12-Leads should normally look like. In the case of LBBB, we expect V1 to be negative and leads I/V6 to have broad, monomorphic R-waves.

We also expect the T-waves to be discordant with the dominant deflection of the QRS. A picture is worth a thousand words in this case:

In our case we have three troubling findings:

  1. An rS complex in Lead I with Right Axis Deviation, which is very uncommon in LBBB.
  2. Concordant ST-segments in leads V5 and V6.
  3. Excessive ST-segement elevation in leads V2 through V4.

Many readers stated that a Left Bundle Branch Block is a STEMI mimic and precludes an activation of a STEMI alert until an old 12-Lead is used in comparison. However, criteria exists to diagnose a STEMI in the face of a LBBB or Paced rhythm.

Additionally, this patient's 12-Lead does not show a normal LBBB, but rather a non-specific intraventricular conduction defect or IVCD. Dr. Garcia would encourage, "considering the company it keeps," [2] which includes acute myocardial infarction!

Sgarbossa's criteria (and its modifications) for diagnosing STEMI in the face of LBBB or a Paced Rhythm has been covered in depth before so we'll only cover the positive criteria found on our 12-Lead:

  1. Is there ST-segment elevation ≥1 mm that is concordant with the QRS complex? Yes.

  2. Is there ST-segment depression ≥1 mm in leads V1, V2, or V3? No.
     
  3. Is there ST-segment elevation ≥5 mm, or ≥20% the depth of the S-wave, that is discordant with the QRS complex? Yes.

With 2 of the 3 criteria met (only 1 is required), we can be very confident that we're looking at a STEMI. Additionally, any concordant ST-elevation present should always suggest a STEMI.

The paramedic in this case recognized the concordant ST-elevation and the abnormal LBBB, called in a STEMI alert, and transported the patient to the PCI capable center. The patient improved significantly on the non-rebreather and CPAP was not necessary. Prior to arrival a second 12-Lead ECG was acquired:

Enroute the patient proved to be difficult for IV access, and received external jugular access in the ED. Labs were drawn while they waited for the cath lab team to arrive.

In the cath lab a 100% occlusion of the LAD was found and corrected with stenting.

For QA purposes an old ECG was retrieved after the call to compare to the field ECG:

Given this prior ECG, the new LBBB alone would likely cause a STEMI activation. However, in the absence of our more definitive changes this is a very weak criteria for activation [3].

Even without the prior ECG, we have an abnormal LBBB (most likely IVCD due to a peri-infarction block) with concordant ST-elevation and a patient presenting with signs of actue left sided heart failure: all of which point to an acute myocardial infarction!

This case highlights the importance of knowing what abnormal should normally look like and understanding that not every patient fits the protocol. We hope you enjoyed this case as much as we did, so be sure to continue the discussion below.

  1. Childers R, et al. Left bundle branch block and right axis deviation: a report of 36 cases. J Electrocardiol, 2000; 33 Suppl:93-102. [PubMed]
  2. The Art of Interpretation Series. http://www.12leadecg.com/
  3. Jain S, et al. Utility of left bundle branch block as a diagnostic criterion for acute myocardial infarction. Am J Cardiol, 2011; 107(8):1111-6. [PubMed]
Posted by on January 24, 2012 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , , , , , , ,

64 year old female CC: Trouble Breathing

46 comments

Thanks go to Michael Herbert for this great case! As always, some details have been changed to protect patient privacy.

It's late into your shift when the tones go off for breathing problems at a local extended care facility. Enroute you're advised it is a 64 year old female with a "low O2 sat," and to, "use the main entrance."

As you arrive a staff member is waiting for you at the door and directs you to a familiar room. The patient, a larger woman well known to your unit, is noticably anxious and struggling to breathe even on a nasal cannula.

The staff informs you she's not been feeling well all day, and only recently developed shortness of breath. Your partner places the patient on a non-rebreather at 15 L/min and grabs a quick set of vitals.

A quick look at the patient reveales pale skin, circumoral cyanosis, pink frothy sputum, and a respiratory rate in excess of 30. She has a long cardiac history, and is often transported by your service. Your partner relays her vitals:

  • Pulse: 120 bpm, weak radials
  • B/P: 110/74
  • SaO2: 78% on 2 L/min via NC
  • Resps: 36, shallow
  • BGL: 224 mg/dL

Auscultation of her lungs reveals rales in all fields.

Your partner asks if you'd like to put her on the monitor and you reply, "let's get moving and get it in the truck."

Once in the back of the truck you begin attaching the monitor, while your partner prepares CPAP. Her oxygen saturations have improved to 89% and her pulse and respirations have decreased noticably on the non-rebreather.

The rhythm strip is obscured due to patient movement, however, the 12-Lead prints out without issue.

You're 20 minutes from a PCI capable center and 5 minutes from a community hospital where the patient's physician often has her transported.

What does this 12-Lead ECG show?

What interventions does this patient need?

Do you need anymore information to make the appropriate treatment and transport decision?

Posted by on January 20, 2012 • Filed under: ems-topics, patient-management • Tagged: , , , , , ,

Why we need health care reform

10 comments

Image credit: whitehouse.gov

I went to the emergency department with a kidney stone yesterday.

Here's the estimate I was provided at discharge.

  • ER Level 4: $4,631.94 
  • Insurance contractual discount: -$4,154.03
  • Adjusted estimated charges: $477.91
  • Estimated insurance responsibility: -$257.33
  • Patient co-pay: $125.00
  • Patient applied co-insurance: $95.58
  • Estimated patient responsibility: $220.58

So, I paid $220.58 on my way out the door (on a credit card). I imagine I'll also be receiving bills from the ED physician and radiologist.

What really amazes me about this estimate is the fact that $4,154.03 (almost 90% of the bill) was written off because of the contract between the hospital and Blue Cross.

Keep in mind that doesn't mean Blue Cross paid this amount. It just goes into oblivion. But it was a made-up number in the first place. No reasonable person believes that $4,631.94 is an appropriate amount of money for a visit to the emergency department.

Now imagine that I didn't have insurance. What would my bill have been? $4,631.94.

So, all you folks out there that buy into the propaganda that we don't need health care reform, be glad you have insurance. The system is stacked against the most vulnerable.

Posted by on January 18, 2012 • Filed under: patient-management • Tagged: ,

Behind the scenes video from the Code STEMI web series

1 comment

Some excellent behind the scenes video has been posted at the Code STEMI web series.

Click HERE

Mayme Lou Roettig RN, MSN and Chris Granger, MD from Duke University (RACE program North Carolina) explain how first responders are a critical part of the early management of acute STEMI. “Things are shifting more and more into paramedics playing the key role in providing the initiation of these time-dependent processes for improving care.”

Click HERE.

Michael Hibbard, M.D. talks about the importance of technology in maximizing the benefit of the prehospital 12-lead ECG. Many patients have baseline abnormalities such as bundle branch blocks, conduction defects, or persistent ST-elevation from previous heart attacks. “It’s a lot easier to determine going from normal to abnormal than to determine abnormal to more abnormal.”

Click HERE.

Jodi Doering, R.N. from Mission: Lifeline South Dakota shares what it's like helping build regional systems of care in a rural state. "This is such a once in a lifetime opportunity which is why I'm in this role. I live in a rural environment. I live 40 miles from the nearest Critical Access Hospital and about 120 miles from the nearest PCI facility. This is me. This is my family. We need to have not only plan A but plan B and plan C in South Dakota."

Click HERE.

STEMI survivor Forrest “Mick” Stanton encourages a neighbor to get his chest discomfort checked out and saves his life. "They were calling for the air ambulance and took him to the heart hospital in Sioux Falls. He got home 2-3 days ago. A triple bypass he had. His main artery — his widow maker artery — was so closed up they said there was probably no more than a hair's width — the width of a hair — left in that." 

Click HERE.

Arthur Reba, M.D. F.A.C.C. talks about the problem of patient delay in seeking treatment for acute myocardial infarction and the importance of considering total ischemic time. "We know why people delay but how do we get this message out? Public education campaigns have not been very effective…We need a very innovative way." 

Click HERE.

Lt. Stuart Debrowsky and Lt. Steve Worden talk about Dearborn Fire Department, what it's like to walk in your father's footsteps, and their commitment to being good at both EMS and fire suppression. "Nobody here got hired saying, 'You're a great paramedic don't worry about that fire stuff' or 'you're big enough to carry the truck around the block don't worry about that medical stuff'. From day one when you put that patch on your shoulder you're expected to have a high standard in both fields." 

Click HERE.

National Director for AHA Mission: Lifeline Chris Bjerke, R.N., B.S.N. talks about the American Heart Association and evidence-based care for acute STEMI. "Not all patients can go directly for primary PCI to open up that blood vessel which is what they really need. So for those patients that are located where they can't get to primary PCI within that recommended timeframe — which just went from 90 minutes to 120 minutes — what we want our facilities to do is look at those patients and determine if they would be eligible to receive fibrinolytics." 

Click HERE.

Interventional cardiologist Tim Henry talks about the state-wide STEMI system in Minnesota. "What we've shown with this program is by having a standardized protocols and individualized transfer plans for that community and that hospital, you can effectively transfer patients up to distances of 210 miles away with outcomes that are identical for those patients who present to that PCI hospital itself."

 

*** SPECIAL ANNOUNCEMENT ***

The premier episode of the Code STEMI web series

will debut at EMS Today 2012!

Posted by on January 10, 2012 • Filed under: ems-topics, patient-management • Tagged:

The politics of transporting a patient in a fire engine

14 comments

Image credit: WJLA-TV News 7

The EMS blogosphere, Facebook fan pages, and internet forums are buzzing with discussion (and criticism) of the firefighters who transported a pediatric asthma patient in a fire engine rather than wait for the ambulance.

Apparently a 5 year old girl named Christina Luckett was having a severe asthma attack to the point where volunteer firefighters (at least one of whom was paramedic trained) started chest compressions and mechanical ventilations. I wasn't there but I have my doubts as to whether or not the patient was truly pulseless but that's besides the point.

The ETA of the transport ambulance was reported to be 5-minutes. The hospital was 2.8 miles away down a highway. Rather than wait for the ambulance to arrive, they placed the child in the back of a fire engine and transported the patient to the hospital, continuing care en route.

She lived. 

Fantastic, right? Well, not exactly. Plenty of folks are second-guessing the actions of these firefighters. Scott Kier called it 100% absolutely wrong. None other than Thom Dick commented on JEMS Connect: "Really, 5 minutes? I congratulate the crew and the Good Lord for their outcome. But I generally wish first responders would just do their own jobs well. This makes me think of the prospect of a transport medic fiddling with a pump panel, over an engineer's shoulder. There's no ME in TEAM."

That seems a bit harsh to me. I considered the example of the transport medic fiddling with a pump panel over an engineer's shoulder for about 24 hours and ultimatley reached the conclusion that the parallel doesn't work. This would be more like a paramedic in a third service agency who also happened to be a firefighter arriving at the scene of a structure fire on an ambulance and making a rescue prior to the arrival of the first-due engine. 

If that happened I would hope that no one from fire department wouldn't say, "You know, I thank the Good Lord for this rescue but I honestly wish the transport medic would leave the firefighting to the real firefighters." Ummm…. you mean the ones who weren't there? Yeah, those ones. You're right, Mr. Dick. There's no "me" in team.

That means we can all be happy when a teammate scores a goal.

The Social Medic (David Konig) gets it. "Rules can be wrong. That’s a possibility few people take into consideration, but an important possibility we always have to look at. Especially when we are leaders looking at the actions of our crews, which is why it was refreshing to see the leadership of Prince George County recognize the efforts of their crews with commendations instead of condemnations."

What's important is that Christina Luckett is alive.

See also:

Firefighters honored for saving girl's life

Firefighters ignore the rules, save girl

5-year-old Md. girl thanks firefighters who saved her life

5-year-old thanks Md. firefighters for breaking rules

Feel free to leave a comment below. If you include a URL in the comment it will revert to moderated status which will cause a delay.

Posted by on January 5, 2012 • Filed under: ems-topics • Tagged: , ,

Discussion for 90 year old male cc: chest pain

8 comments

I hope you all had happy holidays!

Here is the discussion for 90 year old male cc: chest pain.  You may wish to go back and review the case.

So, let's get into the case!  There are the usual questions we need to answer as we try to determine the rhythm.  Is the rhythm wide or narrow? Regular or irregular? Is there atrial activity?

It is also important to note that there were a couple confounding factors.  The data quality was not great, which is never helpful. The crew tried to get a better tracing, and this was the best they could get.  As a side note, refer back to this post where Tom Bouthillet outlines his approach to achieving a high level of data quality in his tracings. Sometimes, there is nothing we can do to improve the data quality on a particular patient.  But it is important to make excellent data quality a priority.

Another factor in this case was that a couple of leads, notably V2, looked unusual and narrow, and could throw off someone's interpretation.

So, back to our initial 12 lead:

It is a wide complex tachycardia, at a rate of about 150, which appears at first blush to be regular.  Our differentials include:

  • VT
  • Sinus tach with aberrancy
  • SVT with aberrancy

As far as the wide complexes go, there are no real signs of atrial activity, although as some pointed out, in lead V2, there appears to be something resembling an atrial wave preceding a narrow QRS.  Let's talk about that piece, because many of you put a lot of stock in V2 looking narrow.

We should remember that when considering whether the rhythm is narrow or wide, we look at the widest complex we can find and use that for our measurement, not the narrowest. Why? Because from time to time, part of the QRS in a particular lead may be isolectric, and make the QRS appear narrow when in fact it is not.  Consider the following:

If we draw a line connecting the beginning of the QRS complexes in these leads, we can see that what appears to be a narrow QRS and possible P wave in lead V2 is actually part of the wide QRS as measured against the other leads! If you use this method on lead III, you will also find that what appeared to some as an inverted P wave, is actually part of the QRS as well. This is precisely why we use the widest complex to determine QRS duration and not a narrow one.

What was also confounding was that the rhythm did not look regular, but regularly irregular. If you look closely at the 12 lead and the rhythm strip, you will see that there are two alternating cycle lengths, a short R-R followed by a longer R-R at 340 ms and 380 ms respectively.  Thanks to Christopher Watford for the following graphic illustration:

While the default for a regular WCT is to assume VT unless proven otherwise, I have to admit that this ECG left me feeling uncertain, because of the irregularity. We have to be extremely concerned about an irregularly irregular WCT, such as A-Fib with WPW, but this rhythm is not irregularly irregular so that is off the table.

Because this ECG seemed somewhat unusual to me, I took the liberty of asking Stephen Smith, M.D., of Dr. Smith's ECG Blog to take a look at it.  He also ran it by his associate, renowned ECG Master K. Wang, M.D. for analysis:

From Dr. Smith:

"I believe this to be VT.  Much VT does not have concordance, and aVR has a wide, monophasic initial R-wave".

Although as yet unvalidated, Dr. Smith prefers Sasaki's criteria for VT, and you can find a great post on his blog that deals with Sasaki's criteria here.  As to the alternating cycle lengths, he had this to say: 

"If there were some consistent variation in the QRS morphology, I would say that there is something else going on.  But there is no such consistent difference between QRSs after 340 ms vs 380 ms…So I would just have to say that it is VT with grouped beating, although I admit that is strange."

From Dr. K. Wang:

"I agree it is VT. As you know, if either of the initial or the last part of the QRS is isoelectric in a given lead, the QRS can be narrower than what it actually is in that lead (it can never be wider than what it actually is).  Judging from the other leads taken simultaneously, that is what happened.  Also look at lead III. There seems to be a negative P wave in front of each narrow QRS, but again, judging from other leads taken simultaneously, what appears to be a negative P wave is already within the wide QRS of other leads and it is part of the QRS, not a P wave. That is what i think."

My sincere thanks to these two ECG greats for their contributions to this case.  

One more caveat with regards to using criteria for VT which you have heard early and often on this site:  While it is ok to use the criteria to rule in VT, the failure of the criteria to rule in VT does not rule out VT!!!  VT can look like almost anything, so don't fall into the trap thinking that if it doesn't meet "criteria", or a certain morphology, it can't be VT.  It most certainly can.

Now that we have settled on VT, how do we treat this patient? Where will we transport him? Well, if you believe that the VT is the primary problem, and that the patient does not need PCI, it certainly seems reasonable to go to the closest facility ten minutes away rather than the PCI facility.  

As for the patient, he is alert and oriented, has a pressure of 130/90, but has substernal "chest pressure".  Is this patient stable? Do we treat with antiarrhythmics? Cardiovert? Or do nothing?

While you can say that under ACLS guidelines, the chest pressure makes this patient unstable, However, I do think there is a difference between "chest pressure" and "crushing chest pain."  From the presentation the patient was ambulatory, in "no obvious distress", apparently tolerating the VT.  I think it would be fair to say the patient is stable enough to not need immediate cardioversion in the field.

If we decide the patient does not need to be immediately cardioverted, antiarrhythmics become the other choice.  His pressure is good, and the risk of giving amiodarone or another antiarrhythmic is that we cause the very hypotension and instability that we are trying to avoid.  I think it is reasonable prepare for deterioration, but at the same time monitor closely and hold off on treatments that could be detrimental to the patient until ED arrival.

To me, this is another case that illustrates the difference between decisions we learn in class and decisions we have to make in real life.  Patients do not read our text books or attend ACLS.  They present in that grey-not-so-sure zone where their stability is delicately balanced against what we do and what we decide not to do.

In this case, the crew was unable to gain IV access. They applied the pads as a precautionary measure, and transported the patient to the ED without further incident. After arrival at the ED, IV access was secured.  The patient was treated with a trial of antiarrhythmics, then successfully cardioverted.

Thoughts and comments?

Posted by on January 3, 2012 • Filed under: ems-health-safety, ems-topics, patient-management, Training, training-development • Tagged: , , , , , ,