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Cam Pollock and John Friederich from Physio-Control put on a demonstration for us at Fire-Rescue Med 2012 to show how the LUCAS Chest Compression System can be incorporated into a "pic crew" concept for CPR and resuscitation. As you will see the application of the LUCAS device need not cause a significant delay in chest comrpessions.
This is an outstanding video that shows clips of an actual resuscitation and features a sudden cardiac arrest survivor.
It's important to collect data so we can measure our progress and prove that we are saving lives, but as we build these systems of care we must always remember that these are our mothers, fathers, sisters, brothers, sons and daughters.
Click HERE
Excellent job by AMR and Portland Fire Department!
Here's a case submitted by a faithful reader who wishes to remain anonymous. He has submitted several cases before and they are always excellent so thank you, Mr. Anonymous!
EMS is called to the residence of a 69 year old female who is complaining of sudden onset of shortness of breath and weakness.
The patient is seen in the emergency department of a local community hospital where she is found to have slight J-point elevation in the anterior leads.
(The vital signs and results of the physical exam are not available.)
Approximately 2 hours later there is a slight change in ST-segment morphology and new T-wave inversion in lead aVL. A cardiologist is consulted via telemedicine at the tertiary care center and the decision is made to transfer the patient.
Concurrently with this decision the patient is given 3 doses of SL NTG with complete resolution of her symptoms.
The transport ambulance arrives and records the following 12-lead ECG.
Several more are recorded en route. Here's the ECG captured on arrival at the PCI-hospital.
Do you think this patient is having a STEMI? Why or why not?
Click HERE to check it out!
Kudos to the HeartRescue Project for developing this "Save a Life" Simulator!
This should go a long way toward preparing lay bystanders for the "shocking" reality of encountering a sudden cardiac arrest in the community. I think this is an excellent tool to leverage through social media so be sure to share with friends and family!
My only criticism is that there are no post-shock compressions.
I was just watching the "podmedic" Jamie Davis interview Physio-Control's VP of Marketing Cam Pollock and noticed another video of Jamie interviewing Ted Setla from Setla Films and First Responders Network about the Code STEMI Web Series.
You can watch the first two episodes of the Code STEMI Web Series and all the behind the scenes footage at CodeSTEMI.tv.
Episode 1: Rural STEMI sytem of care – Sioux Falls, SD
Episode 2: Understanding STEMI from the ground, up – RACE Program, NC
Click HERE!
In this episode Tom Bouthillet sits down with Christopher Granger, M.D., Mayme Lou Roettig, R.N and James Jollis, M.D. from the RACE Program in North Carolina. In the course of our "unplugged" session some incredible insights are developed from one of the highest functioning STEMI systems in the United States!
See also:
Episode 1 of the Code STEMI Web Series – Sioux Falls, South Dakota
On behalf of Team EMS 12-Lead (Tom Bouthillet, David Baumrind and Christopher Watford) I am pleased to officially acknowledge that the EMS 12-Lead blog won Judges' Choice for 2012 EMS Blog of the Year.
This contest was hosted by EMS1, FireRescue1 and FireCritic.com and sponsored by the American Military University.
The total list of nominees can be found here. Lots of good reading can be found here!
Congratulations to Insomniac Medic who took home the Readers' Choice award.
The winning Fire blogs were STATter911 and Backstep Firefighter.
Here are the submission criteria that were used to select the winners.
"Our judges will choose ten finalists from the first round of nominations. The finalists will then be eligible for a ‘Judge’s Choice’ prize as well as a ‘Reader’s Choice’ prize.
Judges will choose these finalists based on the following criteria:
For the second part of the contest, readers will then be able to vote in our poll for their favorite blog, which will provide us with a ‘Reader’s Choice’ winner. The ‘Judge’s Choice’ winner will be ascertained by judges then considering the following criteria:
The judges were:
I'd say we didn't bribe them but I haven't checked with David and Christopher yet.
It's been a good year for the EMS 12-Lead blog and we'd like to thank all of our friends, colleagues, followers, fellow bloggers and podcasters, and everyone else who helps to make the EMS blogosphere (EMS 2.0) a dynamic environment where learning can be interesting and "cool" again.
We'll do our best to continue innovating, sharing awesome cases, hosting interesting guests, expanding into new media and challenging you in engaging and participatory ways!
Check out our archives here.
This is the conclusion to 88 year old male CC: Chest pain. You may wish to go back and review the history and clinical presentation.
First, let's look at the rhythm strip.
This shows an undetermined regular rhythm at a rate of about 60 with demand ventricular pacing.
This is an oversimplification but as long as the intrinsic rhythm has an R-R interval of 1000 ms or less (blue arrows for reference) the pacemaker will inhibit itself because it's not needed.
Then we see the first 12-lead ECG.
Lead V1 is often a good place to see atrial activity. Now we can see flutter waves which explains why there is no atrial pacing (assuming this is a dual chambered pacemaker). You will note that the "wide" QRS complexes in the 12-lead ECG are exactly 1000 ms apart and are functioning in an apparent demand capacity which means these complexes are almost certainly paced.
As at least one person mentioned in the comments a typical paced rhythm with the pacing lead in the apex of the right ventricle will show LBBB morphology (this ECG shows RBBB morphology) so this is a bit unusual. However, in this modern day and age of mutlisite pacing none of these rules are set in stone.
I will say, however, that when I first saw this 12-lead ECG the T-waves in the right precordial leads (V1-V3) looked unusually large to me even though they are appropriately discordant with the QRS complex.
Now let's look at the next 12-lead ECG.
Interestingly, the intrinsic rhythm does not look particularly concerning in the right precordial leads (V1-V3). However, I do see a problem! To demonstrate I'm going to place leads V5 and V6 from 12-Lead 1 and 12-Lead 2 side-by-side.
This is a subtle finding but note the loss of upward concavity in the ST-segments between 12-Lead 1 and 12-Lead 2. In other words, there is a "straightening" of the ST-segment (it's not curved upward anymore) and that's bad!
Now let's look at the final 12-lead ECG.
This ECG appears to show acute lateral STEMI. Would it be better to have seen a previous 12-lead ECG with paced rhythm in the left precordial leads (V4-V6)? Absolutely! But clearly there is excessive discordance in leads V5 and V6 and the T-waves look hyperacute.
Here is the ECG that was taken in the emergency department.
These changes were not appreciated by the paramedics, the ED physician or the cardiologist.
Labs:
@ 2245
@ 0535
CT was negative for PE or aneurysm.
It was also noted in the chart that the patient had a history of AF and MVP S/P repair (could this explain the RBBB morphology with the paced rhythm?).
This was ultimately diagnosed as an acute coronary syndrome but not a STEMI. The case was handled medically (did not go to the lab) and the patient was discharged home.
Was it a missed STEMI? I can't say conclusively due to the abnormal lab values but I'm curious to hear what Stephen Smith, M.D. has to say!
EMS is called to a 88 year old male with a chief complaint of chest discomfort.
On arrival the patient meets EMS at the front door. His skin is slightly pale and moist. He appears anxious.
Paramedics lead the man to a chair and the assessment begins.
Vital signs are assessed.
Breath sounds: Clear in the apexes, diminished in the bases.
No JVD or pitting edema.
The patient is placed on the cardiac monitor.
A 12-lead ECG is obtained.
The patient is placed on oxygen via NC @ 4 LPM and is removed to the back of the ambulance. An IV is initiated and the patient is given 0.4 mg NTG spray SL.
The pain subsides to 3/10.
En route an additional 12-lead ECGs is obtained.
And one more just prior to arrival.
Do you see anything here to be concerned about?
Photo credit: Kelly Arashin
"Team EMS-12 Lead" (Christopher Watford, Tom Bouthillet and David Baumrind) at the EMS 10 Awards
It's been an amazing week at EMS Today 2012! As you probably already know (if you've been following our Facebook page) I won an EMS 10 Award on Wednesday night.
I was nominated by our good friend David Hiltz from the American Heart Association (a previous EMS 10 Award honoree and well known for his work with HeartSafe Communites) and co-nominated by Associate Editors Christopher Watford and David Baumrind.
This is a tremendous honor but I'm very congizant that I couldn't do it without such awesome friends and mentors! The EMS 12-Lead blog and podcast would not be what it is without Christopher and David.
Photo credit: Chris Montera
"Podmedic" Jamie Davis, Tom Bouthillet and Ted Setla discuss the Code STEMI Web Series on the MedicCast
This week was also marked by the release of Episode 1 of the Code STEMI Web Series at First Responders Network! I've seen the first episode a couple of times but being there at the premier was really amazing!
Special thanks to Ted Setla and Chris Eldridge from First Responders Network and Erik Denny from Physio-Control (our indispensable partner on the road) for making this possible! I'm delighted to have been a part of it!
Episode 1 was very well received! In fact, a couple of top-notch EMS systems are very interested in having us come out to feature their STEMI systems and the locations sound amazing! So keep your fingers crossed. We'd love to continue this series!
If you haven't watched the first episode yet, what are you waiting for? CLICK HERE!
Photo credit: Dave Konig
Premier of the Code STEMI Web Series at the Physio-Control Learning Center
Kelly and I are having a wonderful time. We're seeing lots of old friends and making some new ones, too! EMS 2.0 has been called an idea and it's been called a movement. More than anything else we've come to realize it's about friendship and it's about relationships.
It may have started online but it's accomplishing some amazing things in the real world!
Heading to EMS Today 2012? Then we have an announcement for you!
Episode 1 of the Code STEMI Web Series will released at EMS Today 2012 in Baltimore! This is the rural episode that features the emerging system of care in South Dakota and the work of AHA Mission: Lifeline. It includes EMTs, paramedics, nurses, physicians, administrators and STEMI survivor Forrest "Mick" Stanton.
Jodi Doering, RN – Director of Mission: Lifeline South Dakota
The screenings will take place at the Physio-Control booth (#2907).
If you're not going to make EMS Today 2012 don't worry! The episode will also be released at CodeSTEMI.tv at First Responders Network!
Complete a product tour at the Physio-Control booth and you will receive as a special gift web-access to an exclusive version of the 12-Lead ECG Challenge app by Tom Bouthillet and Limmer Creative including 10 new cases and a 12-lead ECG quiz!
You may recall my previous post about the Heart Attack Grill when Blair River, the 572 pound spokesman for the Heart Attack Grill died at the age of 29 from sudden cardiac arrest.
Well, they're in the news again for all the wrong reasons.
Image credit: Fox 5 News
Click HERE for video.
Once again, owner "Doctor" Jon Basso is full of shit.
"The gentleman could barely talk…He was sweating, suffering. Anyone with an ounce of compassion would've felt for him…I actually felt horrible for the gentleman because the tourists were taking photos of him as if it were some type of stunt. Even with our own morbid sense of humor, we would never pull a stunt like that."
If you believe that one I've got some swamp land in Florida you might be interested in. He's loving this publicity.
Don't get me wrong. I like naughty nurses as much as the next guy.
Photo credit: Outhouse Rag
Maybe even more!
But the Heart Attack Grill makes light of the death and suffering associated with cardiovascular disease.
Don't encourage them by visiting their establishment.
See also:
Image credit: whitehouse.gov
I went to the emergency department with a kidney stone yesterday.
Here's the estimate I was provided at discharge.
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.
Some excellent behind the scenes video has been posted for the Code STEMI Web Series (my special project with First Responders Network).
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
made its debut at EMS Today 2012 in Baltimore!
Click HERE to watch Episode 1
See also:
Ted and Tom discuss the Code STEMI Web Series on the MedicCast from EMS Today 2012 (Video)
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.
Thanks to Ivan Rokos, M.D. for pointing out an important change in the 2011 ACCF/AHA/SCAI Guidelines for Percutaneous Coronary Intervention.
Photo credit: Code STEMI Web Series at First Responders Network
For years now many have complained about the AHA's official recommendation that primary PCI for acute STEMI be accomplished within 90 minutes of first medical contact (which can be a Critical Access Hospital 1 or 2 hours away from a PCI hospital or a volunteer BLS EMS system in the rural setting).
There are two main reasons the 90-minute standard for rural patients is problematic.
You could argue that it's time to change the recommendation from 90-minutes to 60-minutes for walk-in patients at PCI hopsitals (which I agree with). But even so, for many patients the mortality benefit of primary PCI over fibrinolytic therapy persists well past 90-minutes.
It's also important to remember that many patients have contraindications to fibrinolytic therapy, meet high-risk criteria (pulmonary edema, hypotension, tachycardia) that make primary PCI necessary, and that up to 30% of patients who receive fibrinolytic therapy will have "failed fibrinolysis" (their symptoms and ST-elevation will not resolve after being given clot-busing drugs indicating that they have not been reperfused).
In other words, all hospitals need (in the words of Jodi Doering, R.N.) "a Plan A, a Plan B and a Plan C." This is far too important to leave to chance. There is mounting evidence that transfer PCI takes too long and that rural hospitals are not achieving door-in to door-out (DIDO) times of less than 30-minutes so there is plenty of room for improvement and my intent here is not to blame the guidelines for preventable delays.
Having said that it's simply not possible for some patients who would benefit from primary PCI to have their infarct-related artery opened up on the cath table within 90-minutes of first medical contact (which, let's face it, is not even being measured in the vast majority of STEMI "systems" — the word "systems" in scare quotes because if it's not measured it's not a system.)
Which brings me to the 2011 ACCF/AHA/SCAI Guidelines for Percutaneous Coronary Intervention (free full text).
5.2.2.2. Primary PCI of the Infarct Artery: Recommendations
Class I
Primary PCI should be performed in patients within 12 hours of onset of STEMI. (Level of Evidence: A)
Primary PCI should be performed in patients with STEMI presenting to a hospital with PCI capability within 90 minutes of first medical contact as a systems goal. (Level of Evidence: B)
Primary PCI should be performed in patients with STEMI presenting to a hospital without PCI capability within 120 minutes of first medical contact as a systems goal. (Level of Evidence: B)
Primary PCI should be performed in patients with STEMI who develop severe heart failure or cardiogenic shock and are suitable candidates for revascularization as soon as possible, irrespective of time delay. (Level of Evidence: B)
Primary PCI should be performed as soon as possible in patients with STEMI and contraindications to fibrinolytic therapy with ischemic symptoms for less than 12 hours. (Level of Evidence: B)
Class IIa
Primary PCI is reasonable in patients with STEMI if there is clinical and/or electrocardiographic evidence of ongoing ischemia between 12 and 24 hours after symptom onset. (Level of Evidence: B)
Class IIb
Primary PCI might be considered in asymptomatic patients with STEMI and higher risk presenting between 12 and 24 hours after symptom onset. (Level of Evidence: C)
Class III: HARM
PCI should not be performed in a noninfarct artery at the time of primary PCI in patients with STEMI without hemodynamic compromise. (Level of Evidence: B)
The following statement accompanies the change in guidelines:
"Several reports have shown excellent outcomes for patients with STEMI undergoing interhospital transfer where first medical contact–to-door balloon time modestly exceeded the systematic goal of <90 minutes. In these reports, the referring hospital and the receiving hospital established a transfer protocol that minimized transfer delays, and outcomes were similar to those of direct-admission patients. On the basis of these results, the PCI and STEMI guideline writing committees have modified the first medical contact–to-device time goal from 90 minutes to 120 minutes for interhospital transfer patients, while emphasizing that systems should continue to strive for times ≤90 minutes. Hospitals that cannot meet these criteria should use fibrinolytic therapy as their primary reperfusion strategy."
This is an important change that every state, Critical Access Hopsital and rural EMS system should make note of and take steps to act upon.
The lives of our rural STEMI patients may depend upon it!
See also:
Cross-posted from the Follow the Crew blog at CodeSTEMI.tv.
We had a wonderful time in Dearborn. I was welcomed as a brother at Dearborn Fire Department and got to learn about an awesome fire-based EMS system which made me happy. In addition, we met some motivated and passionate caregivers at Oakwood Hospital.
They are doing some awesome things in Dearborn and it's clear they're doing a great job treating STEMI patients. However, there's one area that created some cognitive dissonance for me and it's data sharing (or lack thereof) between the hospital and the EMS system.
One of the first questions I asked when we arrived at Oakwood was whether or not they had a multi-disciplinary STEMI meeting. "Absolutely!" we were told. Every Wednesday morning and all the stakeholders were present from emergency medicine, nursing, cardiology and administration.
"What about EMS?" Blank stare.
Finally I was told, "We have an EMS liaison." Unfortunately, it soon became clear that it wasn't enough. The bottom line is that the EMS Chief does not have a seat at the adult table in this hospital. That doesn't mean it isn't a great hospital.
I dragged my feet before writing this blog post because I don't want to cause any offense or ruffle any feathers. However, we are the First Responders Network. We tell stories from the point of view of EMS. The bottom line is that everyone we met at Oakwood talked about their extraordinary door-to-balloon times (less than 60 minutes and even less than 40 minutes) but we still haven't seen it on paper in context.
The door-to-balloon times at Hilton Head Hospital hang on the wall of the emergency department (warts and all).
As Carl Sagan said, "Extraordinary claims require extraordinary evidence." Another quote from Thom Dick comes to mind. "Your agency is not the best in the nation. It's not the best in the state, either. In fact, it's probably not very good at all, unless you can prove it." We're not doing a commercial for Oakwood Hospital we're telling the story of their system which includes EMS and their interaction with EMS.
Every EMS system has room for improvement and my own EMS system is far from perfect. We have our own politics and our own struggles. In some areas Dearborn Fire Department and Oakwood Hospital are better than we are. Having said that, when it comes to quality and process improvement I'm a bit of a skeptic, and justifiably so. I'll spare you the details but I still don't know the actual "call received" time in my own EMS system.
The bottom line is, you might be the best EMS system or the best hospital on Earth.
Don't tell me. Show me.
This is the conclusion to 90 year old male CC: "Possible stroke". You might want to go back and familiarize yourself with the details of the case. Let's take another look at the 12-lead ECG.
Now with the computerized interpretive algorithm.
On Facebook I had asked whether or not this ECG showed signs of ischemia.
This ECG shows ST-depression in the lateral leads (I, aVL, V5 and V6) and modest ST-elevation in the right precordial leads (V1-V3). That's because it shows a strain pattern or secondary repolarization abormality due to left ventricular hypertrophy.
According to at least one study this is the most common cause of ST-elevation in chest pain patients. Hence, it is a very important pattern for paramedics to recognize in the field (although it's rare for LVH with strain to fool the GE-Marquette 12SL interpretive algorithm).
How would we know it's a strain pattern?
When we look at any 12-lead ECG we should consider the Six Step Method (or some other standardized approach).
Here we see that the patient is in sinus rhythm with a normal frontal plane axis. The QRS duration is < 120 ms so it's not a bundle branch block or paced rhythm.
At this point we might pick up on ST-depression in the lateral leads but it's too early to call it ischemia. We need to consider other possible causes. Since left ventricular hypertrophy often presents with ST-depression in the lateral leads that is a likely culprit.
Let's add the depth of the S-wave in lead V2 with the height of the R-wave in lead V5 (or V6 — they're both about the same). Is the result equal or greater than 35 mm?
Yes!
You don't need calipers for this because it doesn't have to be perfect. 35 mm is 7 large blocks so eye-ball it. The S-wave in lead V2 is at least 4 large blocks deep (it's actually more than 5 but this is the "fast and dirty" method) and the R-wave in lead V6 is at least 3 large blocks in amplitude. That's greater than 35 mm so you've met the criteria.
There are other criteria for LVH but this is the most important for ruling out STEMI mimics because LVH is usually an anterior STEMI mimic so the most important issue here is the depth of the S-waves in the right precordial leads (V1-V3). With a "strain pattern" the deeper the S-waves the more pronounced the secondary ST-T abnormality in the opposite direction.
Conversely, the taller the R-waves, the more pronounced the ST-depression and T-wave inversion. A lot of people talk about the shape of the ST-segments and T-waves in the presence of LVH, how it should be asymmetrical and upwardly or downwardly concave. That's ususally true but it's not always the case.
In this case the "strain pattern" is fairly modest. The ST-elevation in V1-V3 is not particularly impressive. Other times the result can be quite profound.
If you're still not clear on what a "strain pattern" is with LVH, take a look at the precordial leads. The QRS complex starts out negative in lead V1 and ends up positive in lead V6. The transition lead is lead V4 (which is equiphastic). As the QRS complex transitions from negative to positive, the T-wave transitions from positive to negative.
That's what we call a "widened QRS/T angle" which means that there is more than 100 degrees difference between the QRS axis and the T-wave axis. Let's take a look at the computerized measurements. The QRS axis is 16 degrees and the T-wave axis is 148 degrees.
To be much simpler about it, with a strain pattern positive QRS complexes have negative T-waves and negative QRS complexes have upright T-waves. (You should not include isoelectric or equiphasic QRS complexes in this analysis).
The general appearance of this 12-lead ECG is one of T-wave discordance. That's a finding that should almost always make you pause and consider that you're dealing with a secondary ST-T abnormality — in other words a STEMI mimic.
This patient received a fairly extensive workup for his near-syncope including a CT scan and nothing was found. He was discharged from the emergency department.
You can find previous posts about left ventricular hypertrophy here.
See also:
The Code STEMI Web Series comes to First Responders Network!
I just got back from South Dakota and principal photography for the 2nd episde of the Code STEMI web TV series is complete! What an awesome time!
We attended the 2nd Annual South Dakota STEMI Summit, visited the two major health systems in South Dakota, interviewed EMTs, paramedics, nurses and physicians, met a STEMI survivor and took in the hospitality!
The platform for the Code STEMI web series is here. The "follow our crew" blog is here. You can find our Flickr feed with lots of "behind the scenes" images here.
Special thanks to Setla Films, Mission: Lifeline South Dakota, Avera McKennan hospital, Sanford USD Medical Center, Prairie Lakes Healthcare Sysem, Watertown Fire Department, and our sponsor Physio-Control!
Next stop: Dearborn, Michigan!
*** UPDATE ***
Behind the scenes footage from AHA Scientific Sessions 2011 in Orlando: Mayme Lou Roettig, RN, MSN and Chris Granger, MD (Duke University and North Carolina's RACE program) talk about the critical role EMS plays in the early treatment and triage of acute STEMI patients here.
“Things are shifting more and more into paramedics playing the key role in providing the initiation of these time-dependent processes for improving care.”
EMS responds to a 90 year old male with a "possible stroke".
On arrival the patient is found sitting on the toilet (lid down). His spouse states that he had walked outside to retrieve the newpaper when he lost his balance and skinned his knee. She helped him inside and sat him down on the toilet in the bathroom when his eyes rolled back in his head and he started "shaking all over".
At the time of evaluation he is conscious, alert and oriented to person, place and time. He remembers falling while retrieving the newspaper but denies losing consciousness in the bathroom.
His skin is pale and diaphoretic.
He denies chest pain or shortness of breath.
Past medical history: Mild cognitive impairment, HTN, dyslipidemia
Medications: Metropolol, donepezil (Aricept), lovastatin (Mevacor)
Vital signs are assessed.
Breath sounds clear bilaterally.
Neuro exam: No facial droop, equal smile, clear speech. Slight pass pointing on the right side.
The cardiac monitor is attached which shows sinus rhythm, borderline sinus tachycardia.
A 12-lead ECG is captured.
What is your impression of this ECG?
See also:
EMS 12-Lead podcast – Episode #6 – Code STEMI Web Series (Special Episode)
Podcast: Play in new window | Download
As you probably already know if you've been following EMS 12-Lead or First Responders Network on Twitter or Facebook, we're working on a new web series called Code STEMI.
We just got back from AHA Scientific Sessions 2011 in Orlando which was our first location. We met some incredibly passionate people and had some amazing experiences!
Ted Setla, Jamie Davis and I discussed it on a special episode of the EMS 12-Lead podcast.
Ted Setla
Executive Producer of the Code STEMI Web series
Setla Films
First Responders Network
Jamie Davis
Executive Producer of the EMS 12-Lead podcast
MedicCast
ProMed Network
The first teaser for the series has also been released at the First Responders Network.
Click HERE to watch.
Chris "the Dridge" Eldridge, Ted Setla and Tom Bouthillet
at AHA Scientific Sessions 2011
Believe it or not I've only used an AED once in my entire career and I wasn't even on duty! It was over 10 years ago on a commercial jet airliner. It was a nice little AED complete with an ECG screen (it's nice to see what you're shocking) made by Philips. Afterwards I did an internet search and my best guess at the time was that the AED on the plane was the HeartStart FR2 or FR2+.
Even though I had never used this particular AED before it was remarkably similar to the Laerdal AED Trainer. The device worked flawlessly and led to a positive outcome. Fast forward to 2011 and Philips has announced the HeartStart FR3, a device that Philips promises to make life-saving faster, easier and better.
Features of the device:
See demo video here. The Philips product page on JEMS is here. Connect on Facebook here.
Tom Bouthillet and ems12lead.com have no conflict of interest with Philips Healthcare although we have noticed an ad for this product running occasionally on our blog which means we receive some modest ad revenue if you click on it. So feel free!
EMS 12-Lead podcast – Episode #5 – Product Review from EMS World Expo 2011 (Part 2)
Podcast: Play in new window | Download
In this episode Tom Bouthillet, David Baumrind, Executive Producer Jamie Davis (MedicCast and ProMed Network) and Rob Theriault (Paramedic Tutor and EMS EduCast) discuss 12-lead ECG interpretation, regional systems of care for acute STEMI, and quality and process improvement for cardiac arrest.
Specifically we discuss Physio-Control's CODE STAT Suite software and ZOLL Medical Corp's CPR Dashboard and See Thru CPR.
Rob Theriault
Paramedic Tutor
EMS EduCast
YouTube Channel (highly recommended)
"Podmedic" Jamie Davis
Executive Producer of the EMS 12-Lead podcast
MedicCast
ProMed Network
See also:
Product Reviews from EMS World Expo 2011 Part 1 – EMS 12-Lead Podcast #4
EMS 12-Lead podcast – Episode #4 – Product Review from EMS World Expo 2011 (Part 1)
Podcast: Play in new window | Download
In this episode Tom Bouthillet and David Baumrind are joined by Executive Producer Jamie Davis (MedicCast and ProMed Network) and Rob Theriault (Paramedic Tutor and EMS EduCast).
We discuss the ReadyLink 12-Lead ECG by Physio-Control , the RescueNet 12-Lead by ZOLL Medical Corp., 12-lead ECG interpretation, regional STEMI care, and ECG transmission in general.
Rob Theriault
Paramedic Tutor
EMS EduCast
YouTube Channel (highly recommended)
"Podmedic" Jamie Davis
Executive Producer of the EMS 12-Lead podcast
MedicCast
ProMed Network
See also:
Previous coverage of the ReadyLink 12-Lead ECG by Physio-Control can be found here, here and here.
Previous coverage of the RescueNet 12-Lead ECG by ZOLL Medical Corp. can be found here.
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