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83 year old male CC: “Cardiac patient in distress” – Conclusion

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This is the conclusion to 83 year old male CC: "Cardiac patient in distress". You may wish to check out the previous post for details about the patient's clinical presentation.

Let's take another look at the 12-lead ECG.

This ECG shows a regular narrow complex tachycardia at a rate of 170.

Could it be sinus tachycardia? One of the "rules of thumb" for the maximum sinus rate is 220 minus age. This patient is 83 years old. 220 – 83 = 137. Granted, this is just a rule of thumb so I'm sure expections exist but 170 is a good distance from 137.

I agree with some commenters that atrial fibrillation can appear regular at very fast heart rates. However, a trained eye can still pick up on some irregularity with rates < 200. You can also use calipers or fold the ECG paper in half and line up the R-waves to verify that the rhythm is regular.

In this case the rhythm is clearly regular which rules out atrial fibrillation but not 2:1 atrial flutter.

In lead V1 we can see atrial complexes (inverted or "retrograde" P-waves) after the QRS complex. We're narrowing in on the mechanism of this tachycardia. If we play the odds there's a good chance this is AV nodal reentrant tachycardia (AVNRT). However, it could still be 2:1 atrial flutter or the less common (but not uncommon) orthodromic AVRT.

You will recall that the paramedics documented "cannon waves" that corresponded to the heart rhythm. Some of you asked, "What are cannon waves?" Cannon waves are pulsations that are visible in the external jugular veins when the right atrium contracts against a closed AV valve. 

Normally atrial systole is an end-diastolic event (the so-called "atrial kick"). When the P-waves follow the QRS complexes the pressure generated by ventricular systole have already forced the AV valves shut. Hence, the atria contract against closed AV valves and back pressure creates a visible "wave" or pulsation that is transmitted back up the superior vena-cava and to the external jugular veins.

Here's an example to give you an idea although this patient's external jugular veins are severely distended and the heart rate is much slower. For the current case study the patient's cannon waves were fast, regular and visible just above the clavicle on the right side.

Does determining the exact mechanism of the tachycardia matter in the field? No, because that's not possible. We don't have an EP lab. However, we can carefully document the arrhythmia before and after treatment on those occasions where the patient is not critically unstable! 

The first thing the treating paramedics did was put this patient in a supine position and place him on oxygen which perked him up a little bit. Remember, BLS before ALS. I am aware of the controversy associated with placing a patient in Trendelenberg. However, I think we can all agree that lying flat is better than sitting or standing when you're hypotensive! 

Vagal maneuvers were attempted (the patient was asked to "bear down" and blow into an empty syringe) with no effect to the tachycardia. An IV was started but unfortunately the only good peripheral access was a 20 G IV in the back of the left hand.

Many (perhaps most) lf you recommended synchronized cardioversion for this patient. I have no quarrel with that. However, I do know that it's easier to say than do when you have a conscious, talking patient in the back of the ambulance. It also helps if you carry the right drugs and don't have to play "mother may I" with online medical control.

In this case paramedics pushed the PRINT button and gave 6 mg of adenosine followed by a 5 ml "flush" of 0.9% NS. It took more than 30 seconds to have an effect (Clinical tip: always follow adenosine with a minimum of a 20 ml flush) but here's what happened. The next four strips are continuous.

With the conversion to sinus rhythm the patient felt much better.

Vital signs were re-assessed.

  • RR: 18
  • Pulse: 100
  • NIBP: 138/81
  • SpO2: 100

A post-conversion 12-lead ECG was captured.

The patient was transported to the hospital in a position of comfort.

No further information is available.

Posted by on October 22, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , , , , ,

EMS World Magazine names ReadyLink 12-Lead ECG as one of the Top Innovations of the Year

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EMS World Magazine has named the ReadyLink 12-Lead ECG by Physio-Control as one of the Top Innovations of the Year. The award was presented at the New York State EMS Symposium – Vital Signs 2011, in Syracuse, NY.

ReadyLink enables basic life support EMS teams to acquire and transmit a patient’s 12-lead ECG to hospitals using Physio-Control’s LIFENET System, a cloud-based data management network for remote physician interpretation and decision support, providing clinicians earlier insight into a chest pain patient’s condition, especially in rural areas with limited access to advanced life support providers.

Physio-Control's Frank Piraino at Vital Signs 2011 

Previous coverage:

Physio-Control to launch ReadyLink 12-Lead ECG — new device will tie rural areas into regional systems of care

ReadyLink 12-Lead ECG by Physio-Control (Update)

Posted by on October 19, 2011 • Filed under: ems-topics • Tagged: ,

83 year old male CC: “Cardiac patient in distress”

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EMS is dispatched to a "cardiac patient in distress".

On arrival paramedics are led to the bathroom where the patient is found sitting on a foot stool. He is conscious but appears acutely ill. Skin is pale and he is slumped over. He states that he feels weak.

Past medical history: High blood pressure, high cholesterol, valve surgery.

Medications: Numerous but his spouse can't locate them. When the patient is asked for his medication list he states, "Ask my wife."

Vital signs:

  • RR: 18
  • Pulse: Rapid and weak
  • NIBP: 85/53
  • SpO2: 99 on RA

Breath sounds: Clear bilaterally.

Cannon waves are noted at the patient's neck.

The cardiac monitor is attached.

A 12-lead ECG is captured (retrieved here from the LIFENET).

What is your impression of the patient's ECG?

How would you treat this patient?

Posted by on October 16, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , ,

AEDs and Emergency Response Plans in Schools – EMS 12-Lead Podcast Episode #3

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EMS 12-Lead podcast – Episode #3 – Syncope and Sudden Death in Student Athletes Part 3 – AEDs and Emergency Response Plans in Schools

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In this episode Tom Bouthillet, David Baumrind and Christopher Watford and joined by Monica Kleinman, M.D. the Chair of the AHA's Emergency Cardiovascular Care Committee.

Monica Kleinman, M.D.
Chair of the AHA's Emergency Cardiovascular Care Committee
Photo credit: www.childrenshospital.org

See also:

Denver schools begin installing AEDs at every facility

School district rejects life-saving technology

LA teen cheerleader dies of cardiac arrest during football game

Coaches save 12-year-old Frisco girl with defibrillator

Previous podcast featuring Dr. Monica Kleinman:

2010 AHA ECC Guidelines with Monica Kleinman, M.D.

Resuscitation Science:

Effectiveness of Emergency Response Planning for Sudden Cardiac Arrest in United States High Schools With Automated External Defibrillators

Other media:

 

Medical Emergency Response Planning Schools

 

View more presentations from David Hiltz

 

 

Posted by on October 4, 2011 • Filed under: ems-topics, patient-management • Tagged: , ,

RescueNet 12-Lead by ZOLL Medical Corporation at EMS World Expo 2011

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Photo credit: EMSWorld.com

ZOLL Medical Corp has some smart people working on their products and a couple of innovations were standouts at EMS World Expo 2011.

The first is the RescueNet 12-Lead.

For a long time I've been preaching about the importance of making 12-lead ECG transmission simple, cost-effective, and interoperable with existing technologies.

As our good friend Ivan Rokos, M.D. said to heartwire back in April 2009:

"It seems incredible that we can email a photograph around the world, but we haven’t yet found an easy way of transmitting an ECG to a nearby hospital."

The reality is that the technology was always there but industry has had little incentive to make it cost-effective or interoperable. Better to charge subscription fees for ECG transmission and make sure that customers are locked into proprietary software. That way you're more likely to continue using Brand X when it's time for a monitor upgrade. After all, now you're committed to a platform. A solution.

In what seems a huge leap of faith, ZOLL Medical Corporation has unlocked the doors. Here's Amy Smith, ZOLL's Director of Data Integration on the EMS Leadership podcast.

"RescueNet 12-Lead is the first fully web-based 12-lead management system. No proprietary software to install. All we need is an internet connection and a web browser to allow EMS and hospitals quick, rapid access anywhere within the world to their critical 12-lead data…ZOLL is offering this service at no cost to EMS and hospitals as an extension of the care we provide through our defibrillator devices." 

When asked if other monitors could use this platform for ECG transmission:

"Absolutely. ZOLL has architected this with open architecture in mind. We will be making available to all of the defibrillator vendors in this market space our APIs that will give them the opportunity at no cost to them to also transmit their 12-lead data into the system. So where we have STEMI regions that use multiple devices…they have an opportunity to use a single software system to receive and manage those 12-leads regardless of their defibrillator devices." 

I was so impressed with this that I mentioned it to Jon Cloutier (Marketing Manager for EMS) who said, simply, "We listened." 

Yes, Jon. You did! 

I went over to the ZOLL both and watched as Amy transmitted a 12-lead ECG from a ZOLL M-series monitor to the RescueNet 12-Lead with a simple cell phone connection.

I said, "Looks good! Can you forward it to my email?" She said, "Absolutely!" Moments later she had entered my email address into the computer and my Droid X vibrated in my pocket.

The 12-lead was attached as a 98K .pdf document.

Piece of cake! 

You couldn't ask for much more. It's nice to see ZOLL step up to the plate and solve this problem. Clearly ZOLL is looking at regional STEMI systems and seeing customers to be served rather than cows to be milked. That's a huge gesture of good faith on their part and will go a long way toward building trust between ZOLL and their customer base.

Bravo! 

See also:

Amy Smith from ZOLL on RescueNet 12-Lead with EMS Leadership Podcast

Jon Cloutier From Zoll Shares Innovations at EMS Today 2011

Posted by on September 28, 2011 • Filed under: ems-topics, patient-management • Tagged: , , ,

ReadyLink 12-Lead ECG by Physio-Control (update)

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Now that I'm starting to get caught up on my regular duties after my recent trip to EMS World Expo 2011 there are a few products I'd like to highlight from the trip.

The first is Physio-Control's ReadyLink 12-Lead ECG.

You may recall that Physio-Control allowed ems12lead.com the privilege of announcing the launch of this product back at the beginning of August.

One thing I know now (that for whatever reason I didn't understand at the time) is that the ReadyLink 12-Lead ECG has a monitor screen! 

I snapped this photo with my Droid X on the show floor at EMS World Expo 2011.

Apparently the monitor screen is so that basic EMTs can tell if there is wandering baseline, loose lead or muscle tremor artifact. However, to me this is a big deal!

I can imagine the ReadyLink 12-Lead ECG being placed along side AEDs on commercial jet airliners. At any rate, I just wanted to clarify that the ReadyLink 12-Lead ECG has a monitor screen for anyone who, like me, thought it did not.

You will recall that when we announced the product launch we called the the ReadyLink 12-Lead ECG a "game changer" and so it is for rural systems that can now be tied into existing systems of care that are already using the LIFENET.

This is especially important in light of recent evidence that while PCI centers have done an amazing job shortening door-to-ballon times since the advent of the D2B Alliance, there are still significant delays for STEMI patients transferred from non-PCI hospitals.

That shouldn't be a surprise to anyone with a special interest in regional systems of care for acute STEMI.

More than 34% of patients transferred for PCI had a delay in total treatment time (> 120 minutes from presentation at initial hospital). The reasons for the delay included:

  • Awaiting transportation (26%)
  • Emergency department delays (14%)
  • Diagnostic dilemma (9%)
  • Cardiac arrest (6%)

Keep in mind this does not include prehospital time prior to presentation at the initial hospital.

To measure these delays correctly would require that we measure from 9-1-1 call to reperfusion. But let's put that issue aside for the time being.

The point is that 40% of the delays from referring hospitals could be completely eliminated if EMS was capable of identifying acute STEMI in the fiend and bypassing them altogether in the first place.

Even without that there are opportunities for improvement for the transferring hospitals and EMS needs to be a part of that solution (since 50% of acute STEMI patients self-report to non-PCI hospitals).

There is no acceptable reason that an acute STEMI patient should be sitting around waiting for a transport ambulance if the local 9-1-1 system has a unit available.

That's a totally legitimate emergency call and EMS systems that "don't do interfacility transport" need to reconsider their policy for life-threatening emergencies (like acute STEMI) where every minute counts.

Posted by on September 25, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , ,

12-Lead ECG Challenge app now available for Android and Apple iOS

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In a previous review of the ACLS Review app by Limmer Creative I announced that I was working together with Limmer Creative to create a 12-Lead ECG Challenge app.

I'm pleased to announce that the app is now available for Android and Apple iOS! The product made its debut at EMS World Expo 2011 in Las Vegas.

As chance would have it I was there for other reasons and my good friends Ted Setla and Justin Schorr of the First Responders Network were kind enough to interview me about the app.

Here's how it works.

The app has 150 12-lead ECGs that were taken from actual patient encounters.

The user of the app is given a brief scenario. For example, a 95 year old female with a chief complaint of altered level of consciousness.

You can tap on the little magnifying glass to enlarge and expand the 12-lead ECG.

Once you think you know the answer you tap the ANSWER button, the card flips, and the answer text comes up along with (in most cases) an ANSWER graphic.

In this case we are dealing with a bifascicular block (right bundle branch block and left anterior fascicular block) as evidenced by the supraventricular rhythm with a QRS duration > 120 ms, the RBBB morphology in lead V1 and a left axis deviation (QRS complexes positive in lead I and negative in leads II and aVF).

The 12-Lead ECG Challenge app strongly emphasizes acute STEMI and the STEMI mimics (including benign early repolarization, left ventricular hypertrophy, paced rhythm, left bundle branch block, pericarditis, left ventricular aneurysm, hyperkalemia, hypothermia, WPW and Brugada) so it's a great study tool to help paramedics minimize false positive cardiac cath lab activations.

For example, here's an answer graphic that demonstrates the relevant findings for a patient whose 12-lead ECG was consistent with pericarditis.

The app is priced at $4.99, a bargain when you consider that online 12-lead ECG tutorials start at around $45.00. Our goal was to appeal to a world-wide market and make it affordable for everyone.

You can download it here:

(Android)  (Apple iOS)  (Web Based)

If you like the app (or even if you don't) feel free to leave a review, here or at the Android Market or Apple Store.

See also:

The Only 12-Lead ECG App You’ll Ever Need – The Social Medic

Posted by on September 23, 2011 • Filed under: ems-topics, patient-management • Tagged: , , ,

Conclusion to 88 year old male CC: Chest pain

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This is the conclusion to 88 year old male CC: Chest pain. You may wish to review the previous post for the history and clinical presentation.

Let's take another look at the 12-lead ECG.

Now with the computerized interpretation.

This 12-lead ECG shows bifascicular block and is very suspicious for acute STEMI.

The first thing that jumps out at me when I look at this 12-lead ECG is the concordant T-wave in lead V2.

With right bundle branch block (RBBB) the T-wave should be deflected opposite the terminal (last) wave of the QRS complex. Because the QRS complex ends in an R-wave the T-wave should be negative. However, in this case it is positive. This is sometimes referred to as "pseudo-normalization" of the T-wave with RBBB. You will also note that the ST-segment is slightly elevated.

Now let's take a closer look at the high lateral leads I and aVL.

Do not let your eye be fooled! I have noticed that in the setting of RBBB the S-wave is often "lifted" when ST-elevation is present. That can create the illusion that the ST-segment is isoelectric. In this case, if you look carefully you will see that the J-point is clearly elevated.

It's debatable as to whether or not 1 mm of ST-elevation is present in the high lateral leads but some ST-elevation is present. Remember, the conventional criterion of 1 mm of ST-elevation in 2 or more contiguous leads is a gross oversimplification. However, computerized interpretive algorithms obey the rules and this ECG has not triggered the ***ACUTE MI SUSPECTED*** message (yet).

When ST-elevation is present in the high lateral leads (I and aVL) we should inspect the inferior leads (II, III and aVF) for reciprocal changes. The converse is also true.

ST-depression is present in leads II, III and aVF. If you're not sure of the exact location of the J-point in leads II and III you can find the J-point in lead I and draw an imaginary line straight down to help you find your landmarks. This finding is subtle (most obvious in lead aVF) but to me this is the strongest evidence that the concordant T-wave in lead V2 and slight J-point elevation in leads I and aVL are pathological.

It can't be repeated often enough. When looking at any ECG abnormality "consider the company it keeps." We might blow off a single lead showing a concordant T-wave. We might blow off a single lead showing a slight amount of J-point elevation. We might blow off a single lead showing an inverted T-wave or ST-depression, but put them all together and a picture starts to emerge.

In this case the picture that emerges is a high-risk patient who is almost certainly experiencing an acute coronary syndrome! 

Unfortunately, this crew obtained only one 12-lead ECG and did not recognize these abnormalities. One of the best quotes I've heard about serial 12-lead ECGs came from Tim Phalen. He said, "Taking a single 12-lead ECG is like taking a single photograph of Old Faithful. Is it a geyser, or is it a hole in the ground?" 

One imagines that if this ECG were to have been repeated it would have shown changes to suggest the dynamic oxygen supply vs. demand characteristics of ACS.

On the plus side, this ECG was transmitted to the hospital and the ED physician found it to be suspicious. The 12-lead ECG was repeated in the emergency department (we do not have a copy of this ECG) and a "Code STEMI" was called. The patient was taken to the cardiac cath lab. We do not have a copy of the cath report. However, we do know that for some reason the cath was unsuccessful and the patient was sent to the OR for a 3-vessel CABG.

Diagnosis: Acute ST-elevation myocardial infarction

Posted by on September 18, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , , , ,

Syncope and sudden death in student athletes Part 2 – EMS 12-Lead podcast Episode #2

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EMS 12-Lead podcast – Episode #2 – Syncope and sudden death in student athletes Part 2

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In this episode Tom Bouthillet and David Baumrind are joined by Trudie Lobban of STARS (Syncope Trust And Reflex anoxic Seizures) — a not-for-profit organization that works together with individuals, families and medical professionals to offer support and information about unexplained loss of consciousness (syncope).

Trudie Lobban
Photo credit: http://www.atrialfibrillation-us.org

To learn more about STARS see the following links:

Syncope Trust And Reflex anoxic Seizures (STARS) – International 

Syncope Trust And Reflex anoxic Seizures (STARS) – U.S.

Syncope Trust And Reflex anoxic Seizures (STARS) – International on Facebook

Syncope Trust And Reflex anoxic Seizures (STARS) – U.S. on Facebook

Related content:

EMS 12-Lead podast – Episode #1 – Syncope and sudden death in student athletes Part 1

Posted by on September 15, 2011 • Filed under: ems-topics • Tagged: , , , , ,

88 year old male CC: Chest pain

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EMS is called to the residence of a 88 year old male patient with a chief complaint of chest pain.

On arrival the patient is found standing at the front door. He appears anxious and acutely ill.

Skin is pink and warm but diaphoretic.

The patient is led to a kitchen chair and the assessment begins.

Past medical history: Hypothyroidism, Dyslipidemia

Medications: Synthroid, Lipitor

History of present illness:

The patient states that he was cleaning the house when symptoms began.

  • Onset: Sudden and getting worse over time
  • Provoke: Nothing make the pain better or worse
  • Quality: Sharp
  • Radiate: Pain radiates to the left arm
  • Severity: 10/10
  • Time: No previous episodes

Breath sounds are clear bilaterally.

No JVD or pitting edema noted.

Vital signs are assessed.

  • RR: 20
  • Pulse: 68
  • NIBP: 145/85
  • SpO2: 96 on RA

The patient admits to nausea but has not vomited. He denies palpitations.

The cardiac monitor is attached and a 12-lead ECG is obtained.

Computerized measurements:

  • HR: 66
  • PR: 292
  • QRS: 146
  • QT/QTc: 414/434
  • P-QRS-T: 21, -50, -19

What is your interpretation of this 12-lead ECG?

What do you think is going on with this patient?

Posted by on September 7, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , , ,

ProMed Network Podcasting Schedule at EMS World Expo

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Live Video streaming by Ustream

 

ProMed Network Podcasting Schedule

Wednesday

11:30 a.m. MedicCast / EMS Garage

12:30 p.m. EMS Leadership

1:30 p.m. GenMed

2:30 p.m. EMS EduCast

3:30 p.m. EMS Newbie

4:30 p.m. CHEPcast

Thursday

11:00 a.m. EMS Garage

12:00 p.m. EMS Leadership

1:00 p.m. EMS Standing Orders

2:00 p.m. First Few Moments

3:00 p.m. MedicCast

Friday

10:00 a.m. EMS EduCast

11:00 a.m. GenMed

12:00 p.m. MedicCast / EMS Garage

* All times listed in Pacific Time Zone

Posted by on August 31, 2011 • Filed under: ems-topics, patient-management • Tagged:

Syncope and sudden death in student athletes – EMS 12-Lead podcast Episode #1

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EMS 12-Lead podcast – Episode #1 – Syncope and sudden death in student athletes.

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Tom Bouthillet, David Baumrind and Christopher Watford are joined by Dr. John Mandrola from the Dr. John M blog. We discuss sudden death in student athletes, the controversy surounding the prescreening of student athletes, the need for AEDs in the schools, abnormal ECG findings that indicate higher risk, and the EMS evaluation of syncope patients in general.

Related content from EMS 12 Lead:

13 year old female CC: Syncope

17 year old male CC: Syncope

37 year old male CC: Unconscious (syncope in an endurance athlete)

From the Pedi-U podcast:

Done Fell Out! Pediatric Syncope

From the Dr. John M blog:

CW: The ECG of the athlete

What is a normal heart rate?

Screening seemingly healthy young athletes?

The feasibility of routine ECG screening of athletes?

The mysterious athletic heart

Related media

See also:

The Ongoing Controversy Over Screening Young Athletes With ECG – The Wall Street Journal Health Blog

Experts create "cook book" for interpreting young athletes' ECGs – heartwire

Doctors frequently make mistakes when interpreting young athletes' ECGs – heartwire

Accuracy of interpretation of preparticipation screening electrocardiograms. J Pediatr 2011 Jul 9

Interpretation of the Electrocardiogram of Young Athletes. Circulation. 2011;124:746-757 (subscription)

How Important Is the Electrocardiogram in Protecting and Guiding the Athlete? Circulation. 2011;124:669-671 (subscription)

Posted by on August 25, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , ,

47 year old male CC: Crushing chest pain – Conclusion

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Here is the conclusion to 47 year old male CC: Crushing chest pain.

You may want to go back and read the original case presentation to see how we got to this point.

When we left off we had this rhythm on the monitor and surprisingly the patient was conscious and talking! 

As usual there was an excellent discussion in the comments.

I certainly agree that the first step is to check the leads. I've seen artifact mimic VF before! When I worked in the Critical Care Stepdown Unit as a cardiac monitoring technician this would sometimes happen when a patient brushed their teeth.

However, this time it was the real McCoy (hyperlinked explanation of this idiom for my international friends).

  • This has the general appearance of Torsades de Pointes.
  • It's fast, wide and polymorphic.
  • There appears to be a "streamer" effect.
  • The patient is conscious.

However, several features point away from Torsades de Pointes.

  • The ventricular rate (using the small block method) is 375
  • The QTc of the underlying rhythm is 447 ms

The rate of TdP is typically in the 150 – 300 range. A QTc of 447 while technically prolonged is still < 500 ms which is generally considered to be "safe". 

It seems to go against everything we've been taught but could this patient have been conscious with VF on the monitor?

The answer is "Yes!" There are two reasons for this.

First, the onset of VF is often course and slow (relatively speaking). A ventricular rate of 375 is a lot different from a ventricular rate of 720. We like to think of VF as if it's all the same and it usually is from a treatment standpoint. But there is quite a lot of variability as I'm sure anyone who has worked on VF detection algorithms could tell you.

The second reason is that forward blood flow continues for several minutes after the onset of cardiac arrest. That's because there is a pressure gradient between aortic pressure and central venous pressure.

This chart from a white paper on the LUCAS device helps illustrate the point.

This is a busy chart but you will note that it takes several minutes for aortic pressure and central venous pressure to merge together after the onset of VF.

Mark Glencorse over at the (retired) 999Medic.com blog presented another case of transient VF where we had the same lively debate as to whether or not we were dealing with Torsades de Pointes.

Some of you are probably thinking, "It's not VF! It's polymorphic VT!" I will simply ask, isn't VF a form of polymorphic VT? At what rate does polymorphic VT become VF?

From a treatment standpoint it doesn't matter in this case because I'd treat both rhythms exactly the same. I'd apply the combo-pads and I'd give 2 g of magnesium sulfate while I was waiting to see if the patient lost consciousness. Tim Noonan (Scallywag Medic) will be disappointed in me for saying so but you really can't hurt a patient with MgSO4 and it might help.

In this case the treating paramedic didn't carry magnesium sulfate but he did apply the combo-pads.

About a minute and a half later the patient lost consciousness.

Now I think we'll all agree that the patient is in VF and we'll also agree on the treatment! 

After another 2 cycles the patient was shocked back into a perfusing rhythm. Interestingly, the patient "woke up" several times during chest compressions.

The patient regained consciousness after return of spontaneous circulation.

Another 12-lead ECG was captured.

Now we're back where we started! (Okay, it's a little worse.)

Advanced notification was given to the receiving hospital and the cardiologist was waiting for the patient. He was taken directly to the cardiac cath lab where angiography revealed a 100% occlusion of the proximal LAD.

The lesion was successfully stented and the patient made a full recovery.

Congratulations to Phil, the Intensive Care Paramedic from Australia (and his crew) for a job well done!

Got an awesome case? Submit it to the EMS 12-Lead blog at ems12lead@gmail.com

Posted by on August 17, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , , , , , , ,

Review of the ACLS Review app by Limmer Creative

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If you've been following my fan page on Facebook you've probably already heard about the ACLS Review app by Limmer Creative.

To give you some background, Dan Limmer is a well known EMT textbook author with lots of street cred. You might recall his appearance on the EMS EduCast live from the conference floor at EMS Today 2011 in Baltimore.

His wife Stephanie (former Director of Internet Sales & Marketing for Lippincott Williams and Wilkins) brings to the table a lot of business eperience. You might call her the brains of the operation. (Kidding, Dan.) 

Together they make up "Limmer Creative" and they are the creators of the well-known EMT Review app and Paramedic Review app for iOS and Android. Now they've branched out and created review apps for ACLS and PALS.

ACLS is a paramedic's "bread and butter". While many different allied health care professionals are required to hold an ACLS certification I'm aware of no other profession that spends as much time driving home mega-code simulations.

If you've "been around the block" a few times in the EMS profession you've probably seen a few different ACLS algorithms. I became a paramedic in 1995 so I've seen the 1995, 2000, 2005 and now the 2010 updates.

Unfortunately, the older you get (it pains me to say this) the harder it is to give up cherished beliefs. We did a lot wrong in the "old days" because frankly, we didn't know any better.

  • The patient's been down for a while? Hyperventilate! He needs oxygen.
  • CPR prior to defibrillation? Fuggedaboudit.
  • C-A-B? Someone's confused! AIRWAY, AIRYWAY, AIRWAY!
  • Clearly this patient needs bretylium! 

That's one reason I like the ACLS Review app by Limmer Creative. While I pride myself on being well-versed in the literature and I've done my best to help drive best practices in my own EMS system, I find that taking practice tests based on the 2010 AHA ECC Guidelines helps to eradicate previous versions of ACLS that are still swimming around in my mind.

Must be the old age! 

I think I also like to challenge my knowledge of the guidelines. The truth is that I do very well on the tests but that's because I'm passionate about the topic.

The ACLS Review app offers 4 different tests. The way it works is you are given a test question (sometimes with a rhythm strip which I particularly enjoy) and then you are given some choices.

Take this screen shot for example:

You'll notice a little magnifying glass on top of the rhythm strip. If you like you can "tap" it and expand the rhythm strip so you can take a closer look.

For example here's a screen shot of a rhythm strip showing ventricular fibrillation.

Once you select and submit your answer you get a "check" when you're right and an "X" when you're… well… less than right.

However, my favorite thing about the ACLS Review app is that you also get a rationale.

I have found this app to be a very nice supplement to the 2010 AHA ECC guidelines. Sometimes I want to learn through trial-and-error (and not through painstakingly reading through the guidelines while my eyes glaze over).

At the end the ACLS Review app breaks down your score.

The graphical user interface is clean, the program is easy to use, and it has never "crashed" on me.

The ACLS Review app is reasonably priced at $3.99 (Apple iOS) (Android)

You can interact with Limmer Creative in the following ways:

So, now that my review is out of the way, it's time for an exciting announcement!

(Drum roll please.) 

EMS 12-Lead is partnering with Limmer Creative to put together a 12-Lead ECG Challenge app! 

I'm excited about the project and I'd like to thank Dan and Stephanie for appoaching me with this opportunity!

So keep your eyes peeled! This app will be coming soon to an Apple or Android app store near you.

See also:

ACLS Review App can help you master algorithms, prepare for ACLS Certification (iMedicalApps.com)

Posted by on August 13, 2011 • Filed under: ems-topics • Tagged: , , , , , , , ,

47 year old male CC: Crushing chest pain

28 comments

Here's an awesome case submitted by Phil, an Intensive Care Paramedic from Australia. Some minor changes have been made to ensure patient confidentiality.

EMS is called to a track and field event for a 47 year old male patient with chest pain.

On arrival the patient is found lying on the grass with a cold, wet towel on top of him. He appears pale and acutely ill. Otherwise he appears to be in excellent physical condition.

  • Onset: 30 minutes prior to EMS arrival
  • Provoke: Nothing makes the pain better or worse
  • Quality: He describes the pain as "crushing"
  • Radiate: He describes an ache to his jaw and left arm
  • Severity: 8/10
  • Time: No previous episodes

Past medical history: CAD, dyslipidemia, mild hypertension, stents x3 approximately 4 years ago

Medications: Numerous but not immediately available

Vital signs are assessed.

  • RR: 22
  • HR: 90
  • BP: 210/90
  • SpO2: 95 on RA
  • Temp: 36.9 C (98,4 F)
  • BGL: 10.8 mmol/l (194 mg/dl)

Breath sounds are clear bilaterally.

The cardiac monitor is attached.

A 12-lead ECG is captured.

A rhythm change is noted on the monitor.

The patient is still conscious.

What's going on with this patient?

What is your next move and why?

Posted by on August 11, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , , ,

17 year old male CC: Syncope – Discussion

2 comments

This is the discussion for 17 year old male CC: Syncope.

You may wish to go back and familiarize yourself with the details of the case.

Let's take another look at the 12-lead ECG.

It wasn't that long ago that I was trying to convince paramedics to perform 12-lead ECGs on chest pain patients.

I can still hear some of them saying things like:

  • "I don't need a 12-lead ECG to tell me when a patient is having a heart attack."
  • "I've never used 12-leads before and I've always given outstanding care."
  • "It's not our job to diagnose patients in the field."
  • "We're not cardiologists."
  • "It takes way too much time to acquire a 12-lead ECG."
  • "The hospital doesn't listen to EMS anyway."

Perhaps you've heard your own excuses.

Fast-forward to today and (at least in my EMS system) it's no longer debatable as to whether or not chest pain patients require a 12-lead ECG.

The new frontier is patients with syncope, general weakness, shortness of breath, etc.

In the first place patients with syncope, general weakness, or shortness of breath are sometimes experiencing acute STEMI (the anginal equivalents) and you've probably seen dozens of examples of each on this blog over the years.

On the other hand, sometimes they're experiencing complications associated with other problems that can often be identified with a 12-lead ECG if you know what to look for.

There were a lot of comments for this case that brought me back to the "old days" of hearing things like "it's not our job" or "we're not doctors." 

Paramedics are not board certified emergency physicians. That's true and I have no quarrel with that statement.

That doesn't mean we shouldn't do our due dilligence prior to allowing a patient (or guardian) sign a "no treatment, no transport" form, or an AMA form, or whatever you call it in your agency.

Any refusal must be an informed refusal. That means it's incumbent upon you to obtain a careful history, perform a physical exam, assess vital signs, and when appropriate record other diagnostic tests like a BGL, SpO2, or an electrocardiogram.

From there you should engage the patient (or the patient's guardian) in a discussion about the risks associated with refusing care, and it's extremely lazy and dishonest to tell every patient, "You may die if we don't take you to the hospital." regardless of what the complaint is.

I live in a subtropical environment that gets very hot and humid in the summer. We see 2.25 million tourists a year. They're not used to the climate and syncope is a very common complaint.

Is syncope a potential warning sign of a fatal condition? YES!

Is syncope often benign? YES!

Can a paramedic be trained to tell the difference between a high-risk patient and a low-risk patient? YES!

If the paramedic is not trained to tell the difference between a high-risk and a low-risk patient then the paramedic should be on the phone with Online Medical Control explaining the situation. Perhaps that's not a bad idea regardless.

In this case:

  • There was no family history of unexplained sudden deaths, faintings, seizures, drownings, or congenital heart diseases.
  • The patient's syncope was associated with difficulty swalling Mellow Yellow (it was not sudden or unexplained or exercise induced).
  • The patient "perked up" immediately after passing out. There was no post-ictal period and the patient was not incontinent of urine.
  • The patient's 12-lead ECG does not show arrhythmia, ischemia, prolonged QTc (446 ms is not significant), WPW or Brugada.

However, the ECG does meet the voltage critieria (for adults) in the precordial leads. However, no P-wave abnormality and no "strain pattern" is present.

Since the patient was only 17 years old and appeared to be a very athletic young man the treating paramedic felt fairly certain this was a normal ECG.

However, this is one of those occasions where the ability to transmit the 12-lead ECG to the emergency department came in very handy.

The 12-lead ECG was transmitted to the on-duty ED physician who reviewed the ECG and agreed that the patient was very low risk.

The patient (and the patient's mother) were advised that nothing life-threatening was found in the evaluation, but that EMS wasn't  giving this young man a "clean bill of health". They explained that EMS couldn't rule out all life-threatening causes of syncope in the field because we don't do blood work, we can't perform a CT scan, and that all diagnostic tests have a sensitivity and a specificity. In other words, it's entirely possible we're missing something. In addition, we're not doctors (that should please some of you).

A refusal was signed and the patient (and his mother) went back to their dinner. They were advised to call 9-1-1 again if they changed their minds or if symptoms returned.

In my opnion, this EMS crew did an outstanding job. If we're being completely honest about it we'll admit that some paramedics would have gotten on the radio and announced "false call" the moment the patient came outside and tried to cancel EMS.

How many of the rest would have been this thorough in their patient assessment?

In the last analysis the patient (or the patient's legal guardian) makes the decision as to whether or not the patient will be seen in the emergency department when the patient possesses present mental capacity. I've seen plenty of cases where paramedics have manipulated patients into refusing care out of sheer laziness or some kind of misguided attempt to spare the emergency department from seeing a patient who was a "non-emergency" in their opinion.

If find that to be appalling but that clearly wasn't the case here.

As a final thought George W. Bush experienced a similar fainting when he choked on a pretzel while watching a football game back in 2002. Remember that one? I still remember the detailed animations on the nightly news that explained how choking and coughing stimulated the vagus nerve.

Posted by on August 8, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , , , , ,

10 Questions with Jodi Doering RN – South Dakota AHA Mission: Lifeline Director

4 comments

10 Questions with Jodi Doering, RN – South Dakota AHA Mission: Lifeline Director

1.) How long have you been working with AHA Mission: Lifeline? Do you enjoy your job?

I have been with MLSD (Mission: Lifeline South Dakota) since September 16, 2010. My background prior to that is in EMS and as an RN in cardiology and Emergency Department nursing-all here in South Dakota.

I seriously with 100% truthfulness love this job. I have the opportunity to distribute an $8.4 million grant to the people of South Dakota to establish an ideal STEMI system of care in a very rural setting. I work with each of the 133 ambulances and 50 hospitals in building this system of care. We are putting at least one 12-lead monitor (Phillips, Physio-Control, or Zoll) in each of the 133 ambulances, as well as implementing Lifenet in each of the 50 hospitals. It is a little like being Santa Clause- with a catch- that you have to use the equipment and be an active participant in the system of care.

2.) How many PCI-hospitals are there in South Dakota and how are they distributed?

I have attached a map to outline.

The population of South Dakota is about 750,000. South Dakota is 76,000 square miles with 6 PCI facilities:

  • One in Rapid City (near Mt Rushmore in the SW corner) 
  • One in Aberdeen (NW corner),
  • One in Watertown (NW corner) and
  • Three in Sioux Falls (SE corner)

The 3 in Sioux Falls represent two health systems so that’s why it only looks like 2 in Sioux Falls.

The entire NW corner of the state does not have a PCI capable hospital up to as far away as almost 200 miles. In addition, South Dakota only has 4 helicopters. 1 in Rapid City, 1 in Aberdeen, and 2 in Sioux Falls. We have a large area of the state that can only be covered by fixed wing (which we have 2 of-both in Sioux Falls) or ground ALS transport.

3.) Have you found that most urban areas have prehospital 12-lead ECG programs in place and do they transport STEMI patients directly to PCI-hospitals?

When we began this process with the 133 EMS agencies of South Dakota we found the following breakdown:

  • ALS complete with 12 leads and transmitting = 8 (6%)
  • ALS with 12 leads not transmitting. = 19 (14.3%)
  • ALS with neither = 22 (16.5%)
  • BLS w/12-Lead not transmitting = 3 (2.3%)
  • BLS with neither = 81 (60.9%)

Keep in mind the agencies that are ALS are primarily a part time, volunteer ALS service and up to 80% of the time they are BLS.

The 8 agencies that had 12 leads and were transmitting prior to this process did not go directly go a PCI center. 6 did and 2 are located in very remote areas and were a part time ALS service. Bypassing their critical access hospital could have means as long as a 2 hour transport time. They were going to the nearest facility and calling for a helicopter or an ALS intercept.

4.) South Dakota has a lot of rural areas and one imagines a lot of volunteer BLS rescue squads and Critical Access Hospitals. In areas where STEMI numbers are low have you seen a reluctance to give thrombolytics (or arrange for transfer) without a cardiology consult?

YES! Note the capital letters and emphasis on YES. Part of the process of building or STEMI system of care is that we have a state wide protocol for administration of lytics in the non-PCI centers. The feedback has frequently been from the non-PCI centers:

  • "We want to talk to the cardiologist to make sure."
  • "We do different processes based on which PCI center they are going to." (lovenox, heparin, nitro, etc).
  • "I don’t want to be the one to make that call."

5.) How has AHA M:L been working to help incorporate rural areas into regional systems of care?

At our statewide Mission: Lifeline task force we have representation from all size hospitals and EMS agencies. The reality is that our PCI centers are doing a great job, our focus needs to fall not only to EMS but the hospitals that reside outside of the 30 mile radius of our PCI centers. We involve representation from Critical Access hospitals, volunteer EMS, as well as our PCI centers. We also have a quality and education subcommittee that allows a strong voice from those smaller, rural facilities.

6.) We just saw a press release that indicates every ambulance in North Dakota will be outfitted with 12-lead ECG monitors. Can you tell us anything about that? Is something similar happening in South Dakota?

The North Dakota project will be very similar to South Dakota. Lead funder is The Leona M. and Harry B. Helmsley Charitable Trust, which is providing two-thirds of the total with a grant of $4.4 million. The State of North Dakota has committed $600,000, and a combined $1.3 million will be contributed by North Dakota’s largest healthcare systems:

  • Trinity in Minot
  • Altru in Grand Forks
  • Essentia in Fargo
  • MedCenter One in Bismarck
  • Sanford Health in Fargo
  • St. Alexius-PrimeCare in Bismarck

The Dakota Medical Foundation is supporting the initiative with a $100,000 grant, and the Otto Bremer Foundation has also committed $100,000 to Mission: Lifeline. 

Minot, North Dakota already has a strong rural STEMI system with transmission of 12 leads from 12 rural EMS agencies, so while they are not putting in quite as many 12 leads as South Dakota, the models will be very similar. We face a lot of the same hurdles in regards to volunteers, miles, etc.

The grant allows for education of all EMT’s in the state in the “Learn Rapid STEMI ID” module put forth by the AHA, as well as education for all non-PCI center hospitals. In addition a statewide task force comprised of physicians, nurses, EMS, legislators, payors, administrators, etc will meet to direct this project- same as South Dakota. The ultimate goal for both of our states is simple — that we decrease time from calling EMS to reperfusion whether that is primary PCI or lytics. 

North Dakota has just hired a Mission: Lifeline director that will start next month.

7.) Change is always hard and often comes with growing pains. What are some of the most difficult challenges you've had to overcome to help shorten treatment intervals for acute STEMI in South Dakota?

For the most part our partners have been very engaged and have realized that an intervention they do in the field (12 leads) can be the difference in life or death for our STEMI patients. Quite frankly, distributing a 12 lead monitor that could cost up to $25,000 is something these EMS agencies would never have been able to afford. That part makes it an easy “sell”.

The reality is that we are about 75-80% volunteer and we are now asking them to do/learn another thing for no pay. There is a fear out there that they could hurt someone by doing a 12-lead. I frequently reference that we are not asking to turn the mailman into a cardiologist — our first step is to put the patches on and push the buttons. The monitor itself can be overwhelming for a volunteer EMT that only runs 2-4 calls/month.

We have provided education to 1600 EMTS thus far and it has all been done in their local communities by an ALS partner from a neighboring community that they are already familiar with-that has helped immensely.

8.) Has anything special been done to help educate EMS personnel with regard to 12-lead ECG interpretation? How have they embraced that education and training?

We have developed a 4 hour education program that is being deployed by 22 “super users” from across the state (21 paramedics and 1 EMT-I). This education is done in their hometowns to decrease travel time. The content does go fairly deep in the process of anatomy, physiology and looking at 12 leads- however our main basis is to get correct lead placement and to transmit to their local hospital where they are transporting the patients. This education process will repeat for each of the 3 years of the grant.

9.) Any problems with "false positive" cardiac cath lab activations? What kind of feedback is given to EMTs, paramedics, nurses and physicians who take part in regional systems of care?

Not so many problems with false activations. We of course had one right away after we went up that was given back to me as “constructive criticism” but I rebut with the fact that in South Dakota we over triage trauma patients up to 50% of the time and as long as the staff believed they were doing what was right for the patient at that time it’s ok.

Feedback loop — that is the million dollar phrase right now. Having worked most of my career in the hospital- we have not done a good job of letting EMS (especially our volunteer services) know how they are doing. Our statewide task force is working on a universal feedback loop that will go back to not only the hospitals but the EMS agencies as well.

Two of 6 PCI centers currently have a feedback loop to the transferring in hospital that they send within 24 hours-but as you know that frequently does not get to the EMS agencies. It has come through loud and clear that involving EMS in the feedback is the one key element most of us are missing.

10.) Do you have any words of wisdom for states that are just getting started?

Be Persistent. Believe in it. Utilize your resources. Make friends with your EMS partners. (I mean that-sometimes we need to put the ER, Cath Lab, and EMS in the same room with some beverages and just let them become friends…..) Find a champion. I don’t care if it is the smallest EMS agency or one of the largest PCI centers-somewhere in that agency is someone who will help you carry the torch.

I have been told that this is impossible many times. My answer becomesm, “You will have to be one of those we just have to prove wrong”. Once you get a save, you are able to put many of those skeptics to rest.

Posted by on August 5, 2011 • Filed under: ems-topics • Tagged: ,

Physio-Control to launch ReadyLink 12-Lead ECG – New device will tie rural areas into regional systems of care

21 comments

Physio-Control is on the verge of launching a new product that could be a game changer for the care of STEMI patients, especially in rural areas.

It's called ReadyLink 12-Lead ECG and it will allow BLS personnel to capture a 12-lead ECG and transmit the ECG for off-site interpretation using the LIFENET system.

This is important because right now in the United States there are a lot of rural areas that have been excluded from regional systems of care because they don't have the ability to capture 12-lead ECGs.

As a result STEMI patients are not receiving timely reperfusion, and as well all know by now, longer the time-to-reperfusion the higher the mortality! 

Last week I was given an exclusive interview with Cees Verkerk and Erik Denny from Physio-Control to talk about the device. I was also given permission to give the readers of the EMS 12-Lead blog a "sneak peak" prior to the product launch.

Here's what I found out:

  • The device looks almost like an AED but it doesn't shock. It's been designed for one thing and one thing only — to acquire a 12-lead ECG and transmit it to someone qualified to interrpet it.
  • It works with cellular technology to transmit the 12-lead ECG through the LIFENET system. If there's no cell signal it cannot transmit, so there will still be some areas where ReadyLink 12-Lead ECG will not work. 
  • On the plus side, it can roam through multiple networks and will continously look for a signal and transmit when it finds one. Or, if it loses a signal it will try again when it reacquires one.
  • There is no analog socket in the device so it cannot be used with a landline.
  • If necessary BLS personnel can call up computerized interpretive statements, so even in areas with no cell signal it would be possible to use this feature as part of the bypass or preactivation criteria.
  • The cost of the ReadyLink 12-Lead ECG has not yet been established but my sources at Physio-Control tell me the device will retail in the $7,000 – $8,000 range. More than an AED but far less than a Lifepak 15!

In the past couple of years I have been made aware of a handful of volunteer or BLS EMS agencies that have been equipped (through grants or charitable donations) with Lifepak 12s or Lifepak 15s so they can acquire and transmit 12-lead ECGs. 

While this is certainly commendable the cost can be prohibitive.

As regional systems of care for acute STEMI continue to be implemented across the country with help from organizations like the American Heart Association's Mission: Lifeline, it's easy to see how the ReadyLink 12-Lead ECG will nicely complement the LIFENET system by tying in the rural areas.

After all, they have heart attacks, too!

Posted by on August 2, 2011 • Filed under: ems-topics, patient-management • Tagged: , , ,

17 year old male CC: Syncope

53 comments

EMS is called to a local restaurant on a very hot day for a 17 year old male patient who experienced a syncopal episode.

On arrival the patient meets the ambulance in the parking lot and says, "Hey, man, I'm really sorry. We don't need the ambulance." 

Paramedics asks what happened and he says, "I just sort of… you know… took a hard swallow of Mellow Yellow… I guess…. and…. like…. I don't know if it went down wrong…. or whatever…. but like…. I sort of passed out…. but it's cool now."

The paramedics confirm that the patient is only 17 years old and inquire as to whether or not a parent or guardian is present. The patient's mother steps up and paramedics persuade her to allow them to "check her son out" in the back of the ambulance to "make sure everything is okay" on the condition that they don't receive a bill.

The patient also consents.

In the back of the ambulance the patient states that he is perfectly healthy. The only medical history is acne for which he takes a prescription medication but he forgets the name.

He appears well. The skin is pink, warm and dry.

He states that he has been drinking lots of fluids and making lots of urine.

(In response to one of the comments: he was specifically asked about his fluid status because the weather was hot and humid and EMS had been responding to many heat-related emergencies. This was not intended to convey in any way that the patient is an undiagnosed diabetic).

Both the patient and the mother deny any family history of syncope, seizures, or unexplained sudden deaths.

Vital signs are assessed.

  • RR: 16
  • Pulse: 90
  • BP: 127/84
  • SpO2: 100 on RA

Breath sounds clear bilaterally.

Neuro exam normal.

(Update: The BLG was 108.)

The cardiac monitor is attached.

A 12-lead ECG is captured.

The patient says, "So, am I going to live?"

What are your thoughts?

See also:

17 year old male CC: Syncope – Discussion

Posted by on July 30, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , , , , ,

63 year old male CC: Shortness of breath – Conclusion

7 comments

This is the conclusion to 63 year old male CC: Shortness of breath. You may wish to go back and read the original post.

Let's take another look at the 12-lead ECG.

Now with the computerized interpretation.

This ECG shows severe left ventricular hypertrophy with a "strain pattern" or secondary ST-T wave abnormality.

A "strain pattern" often shows what I sometimes refer to as "pouty-lipped" ST-depression and T-wave inversion in the lateral leads. You can see a good example of this in leads I and aVL.

The Q-wave in lead aVL looks suspicious. However, when the patient's chart was pulled at the hospital it turned out that the patient had a history of myocardial infarction.

In addition, ST-elevation is present in the right precordial leads (V1-V3). This is normal for left ventricular hypertrophy. Typically, the deeper the S-waves the more pronounced the secondary ST-T wave abnormality in the opposite direction.

In this case the most pronounced ST-elevation is in lead V2 and you will note that the S-waves are at least 35 mm in this lead (which meets the LVH voltage criteria all by itself). With a "strain pattern" like this the ST-elevation is usually, but not always, upwardly concave.

This patient was suffering from a new onset of acute pulmonary edema and clearly has a very sick heart but ruled out for acute myocardial infarction.

According to some studies LVH is the most common cause of ST-elevation in chest pain patients so this is an ECG abnormality you should learn and keep in the back of your mind! 

Interestingly, it's not easy to find an ECG that shows acute anterior STEMI and concomitant left ventricular hypertrophy in the precordial leads. Stephen Smith, M.D. from Dr. Smith's ECG Blog has a theory that acute anterior STEMI may attenuate the voltage of the S-waves in the right precordial leads (V1-V3).

You can see a possible example of this phenomenon here: 55 year old male CC: Chest pain. I have a suspicion this ECG from the Cardiphile blog shows the same thing (ignore the fact that it says inferior wall infarction).

The take-home point is that very deep S-waves in the right precordial leads should make you question the diagnosis of acute anterior STEMI.

That's not to say that the patient may not be experiencing acute myocardial infarction! That can happen (we are contantly being told) with a perfectly normal looking ECG. Rather, I am saying that it's probably not an acute STEMI, and that's the relevant point for paramedics and physicians in the emergency department who need to make a decision about activating the cardiac cath lab.

As a final point, someone pointed out a significant change between the rhythm strip and the 12-lead ECG in lead III for this case. That's true, but keep in mind that the rhythm strip was captured in "monitor mode" where the low frequency / high pass filter was set to 1 Hz! The 12-lead ECG was captured in "diagnostic mode" with the low frequency / high pass filter set to 0.05 Hz. To get accurate ST-segments you need to be in diagnostic mode.

See also:

Left ventricular hypertrophy – Part I

Left ventricular hypertrophy – Part II

Posted by on July 27, 2011 • Filed under: Uncategorized • Tagged: , , , , , , , , , , , ,

63 year old male CC: Shortness of breath

16 comments

By request I'm trying something new. The 12-lead ECG will be cropped and the computerized interpretation removed until the solution is posted. Let me know if you find this approach to be useful. This is how I used to teach 12-lead ECG interpretation but I started leaving the computerized interpretation because that's reality — you'll have access to it in the field (unless you're one of those few systems that turns the comptuerized interpretation off).

EMS is called to the residence of a 63 year old male with a chief complaint of shortness of breath.

On arrival the patient is found sitting on the edge of his bed. He appears to be in moderate respiratory distress.

Past medical history: HTN, IDDM, CHF

Medications: Numerouos (the spouse hands you a large plastic container full of medications)

On questioning the patient admits that he is also experiencing chest tightness.

  • Onset: 30 minutes prior to EMS arrival
  • Provoke: Symptoms are worse lying flat
  • Quality: "Tightness"
  • Radiate: The sensation does not radiate
  • Severity: 5/10
  • Time: Patient admits to prior episodes.

A prolonged expiratory phase is noted.

Breath sounds: basilar rales

Vital signs are assessed.

  • RR: 26
  • Pulse: 80
  • BP: 179/92
  • SpO2: 84 on RA

The cardiac monitor is attached.

A 12-lead ECG is captured.

By request here are the computerized measurements:

  • HR: 78
  • PR: 206
  • QRS: 104
  • QT/QTc: 430/490
  • P-QRS-T:  23  -39  159

What is your interpretation of these ECGs?

How would you treat this patient and why?

Posted by on July 23, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , , ,

ECG Challenge – Is it a STEMI?

41 comments

Since you all seemed to enjoy the link I posted to the ACC's ECG Challenge from 2006 I thought I'd give you another ECG Challenge.

I'm working on a special project (details to be announced soon) and I came across this interesting ECG from the archives of an old computer.

I thought it was long lost! At least the original un-cropped version.

This is one of the very first ECGs transmitted across our first LIFENET system (many years ago).

Let us assume that the patient is experiencing signs and symptoms consistent with ACS.

Does it show acute STEMI? No cheating if you've seen this before! 

(Note: Lead V4 is in the position of lead V4R.)

Posted by on July 21, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , , ,

Automated compression device war turns hardcore

22 comments

I received an email from a ZOLL rep this morning that had a file attachment called "AutoPulse Technical Report #3".

The report shows a crash test with a mannequin outfitted with either the AutoPulse or the LUCAS compression device.

Wouldn't you know it? The LUCAS device lost.

Ladies and gentlemen: the gloves are off!

Posted by on July 12, 2011 • Filed under: ems-topics, patient-management • Tagged: ,

How much should an ear ache cost?

8 comments

Photo credit: Kelly Arashin

I had a very relaxing and restorative trip up to northern Michigan last week with my family.

The weather was perfect. There was sightseeing in national forests, campfires and s'mores, good wine, good stories, and some hard work constructing a drainage system on the side of my parents' log home on Lake Huron.

However, one little aspect of my trip wasn't so nice: an earache.

I've suffered from occasional earaches since I was a little kid. For whatever reason I have small, tortuous ear canals which are susceptable to occasional infections, especially when I swim in a lake or the ocean.

Since I've been dealing with earaches for a very long time I know exactly how to treat them. I irrigate the infected ear with 50/50 water and hydrogen peroxide and I apply Cipro ear drops twice daily until the infection is resolved (which doesn't take long at all provided that I'm not out of Cipro ear drops).

Well, wouldn't you know it, I didn't bring Cipro ear drops with me on vacation. I didn't have a 10 or 20 cc syringe either. So I did what anyone else would do under the circumstances.

I toughed it out until I got home.

Unfortunately, when I got home I couldn't find any Cipro ear drops. So I either lost them or I'm out.

I did, however, irrigate my infected ear and gently applied triple antibiotic ointment with a Q-tip (I know, I know — listen, I was desperate).

To make matters worse, my regular doctor recently moved his practice a couple of hundred miles away to be closer to his aging mother. I have a new doctor who saw me recently for knee pain. Nice guy, but I don't know him well.

So here's my question to all of you. Is it reasonable that I should have to drive 30 miles, sit in the waiting room, get shuffled back into an exam room, get my vital signs taken, receive a physician exam, obtain a prescription, and get billed for a $60-$100 office visit, just to get a prescription for medical problem that I've had for my entire life?

I'm hoping that won't be necessary. I called the new doctor's office and spoke to an office clerk. I explained the situation and requested that a prescription be called into my local pharmacy. She seemed less than enthusiastic but told me that a nurse would call me back later with the doctor's reply.

Posted by on July 12, 2011 • Filed under: Uncategorized

Fun and games with response time reporting

13 comments

As I've mentioned on several different occasions, it's a huge mistake to wait until a tragedy occurs to explain the truth about response times to your community.

Response times should be measured from the patient's perspective. In other words, from the moment the dispatcher picks up the phone and says, "9-1-1 what is your emergency?" to the moment a professional rescuer arrives at the patient's side.

Any other sub-interval is smoke and mirrors (see HERE and HERE for previous posts on EMS response time reporting and other system failures).

There is no excuse for allowing our real response times to be ambiguous. It doesn't matter if some other organization does the dispatching. It's the EMS system’s responsibility to figure it out because we are ultimately responsible for the community's chain-of-survival.

In other words, if our chain-of-survival is broken (and it surely is if we have no idea how long call processing takes) then it's our responsibility to educate our citizens and our elected officials of that fact.

Remember, millions (perhaps tens or even hundreds of millions) of dollars in 9-1-1 taxes are collected each year in the United States. Where does the money go? Our inability (or unwillingness) to measure "9-1-1 call received" to "patient's side" is completely unacceptable and patients die because we pretend that our response times are better than they actually are.

Where's the accountability?

We must never allow ourselves to become acclaimated to things that would outrage members of the general pulbic once the facts become known.

Explaining why EMS wasn't there "in 4 minutes" to treat a child in cardiac arrest is not a particulary good backdrop to have this conversation with the taxpayers.

Posted by on June 30, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , , , , ,