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51 year old female CC: Near Syncopal Episode – Conclusion

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This is the conclusion to a 51 year old female CC: Near Syncopal Episode. If you haven't read the first part we highly recommend it!

When we left off, our crew was attending to a 51 year old female who had almost passed out in a stadium tunnel during a college football game. We received a few questions as to the type of football, which could be important to the diagnosis, so we will clarify that this was an American Football game.

Our crew had found her to be hypotensive, first bradycardic and then tachycardic, with concerning changes on the 12-Lead.  A nasal cannula at 4 L/min was initiated and they established bilateral IV's and were rapidly infusing nomal saline to restore perfusion.

Let's take a look at the initial rhythm strip:

Wouldn't Want to Miss the Big Game - Initial Rhythm

The initial rhythm strip shows a narrow complex tachycardia at ~130 bpm, without clear P-waves. Retrograde P-waves can be seen in numerous complexes T-waves, leading to a presumptive diagnosis of a junctional tachycardia.

Wouldn't Want to Miss the Big Game - Long Rhythm Strip

The longer rhythm strip shows sinus complexes followed by runs of junctional tachycardia. Astute readers will note Wenckebach conduction of the retrograde P-waves!

This finding alone would be highly concerning given our patient's present condition and history, however, when we move onto the 12-Lead her diagnosis is clinched:

Wouldn't Want to Miss the Big Game - Initial 12-Lead

The initial 12-Lead ECG again shows a junctional tachycardia, with markedly hyperacute T-waves and ST-elevation in the anterior precordials with downsloping ST-depression in the inferior leads. The degree of which the T-waves tower over the R-waves in V4 is truely impressive!

The crew immediately recognized the extensive anterior wall infarct with cardiogenic shock, and given the concurrent finding of a junctional tachycardia presumed there to be gross insult to the AV nodal tissue. They placed defibrillation pads on the patient and helped the arriving crew package the patient. The patient was able to follow commands and 324 mg aspirin was given PO. After 1 liter of fluid the patient remained hypotensive and another bolus was started. Oxygen was titrated to maintain an SpO2 of >96%.

Eventually the patient stated she had some dull pressure in her chest, but otherwise denied pain or shortness of breath. An early STEMI notification was given and while enroute to a STEMI receiving center the crew ran multiple 12-Leads, capturing the evolution of the myocardial infarction.

Wouldn't Want to Miss the Big Game - Subsequent 12-Lead 1

In this 12-Lead we can clearly see periods of alternating tachycardia and bradycardia, an ominous sign given the evolving MI. V5 and V6 were removed and adjusted closer to V4 and V7 so that defibrillation pads could be placed.

Wouldn't Want to Miss the Big Game - Subsequent 12-Lead 2

Wouldn't Want to Miss the Big Game - Subsequent 12-Lead 3

Wouldn't Want to Miss the Big Game - Subsequent 12-Lead 4

The patient was taken directly to a cath lab suite and found to have a 100% occlusion of the LAD and after the placement of a stent the patient's ECG normalized and her hypotension resolved.

This case illustrates the amazing evolution of an extensive anterior myocardial infarction and highlights the role the LAD can play in AV nodal function. We hope you enjoyed these ECG's as much as we did!

Posted by on November 18, 2012 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , , ,

62 year old male: Chest Discomfort – Conclusion

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This is the conclusion to our three part case series, 62 year old male: Chest Discomfort. Before reading the conclusion, we suggest you check out Part I and Part II. Thanks again to Vince DiGiulio, EMT-CC for this wonderful case!

When we last left off, our patient had experienced a resolution of his chest pain accompanied by changes on his 12-Lead ECG. The ED physician had called cardiology, but they were unimpressed. Are we comfortable with this?

Let's review our patients'  first 12-Lead.

Well Page Him Again - Initial 12-Lead

We have a narrow complex, regular rhythm at 90 bpm consistent with a normal sinus rhythm. Flat or downsloping ST segments are visible in leads III and aVF. Additionally, ST-Elevation is present in leads V1 through V4. As some readers pointed out, this is diagnostic for an Anterior Wall Myocardial Infarction. There are also some subtle hints that this is not a normal variant:

  • Dr. Smith included in the comments that the R-wave amplitude of V2-V4 is only 10 mm. In cases of AWMI, a loss of precordial R-wave amplitude is often noted.
  • If you compare the T-waves in V1 and V6, you'll note that they are much larger in V1 than in V6. Dr. Henry J. L. Marriott describes this finding as a "loss of precordial T-wave balance." Dr. Mattu covers this in depth in his excellent video New Tall T-Waves in V1.

The most important point is that there is no other explanation for our patient's ST-Elevation. There is no LVH or BBB present and Early Repolarization is a diagnosis of exclusion in a 62 year old patient.

Regardless, any patient with chest pain should be evaluated with serial ECG's. During our patient's second 12-Lead, he happened to be pain free:

Well Page Him Again - Repeat 12-Lead

Our repeat 12-Lead shows a normal sinus rhythm, with the development of terminal T-wave inversions in leads V1-V4. Several of our readers correctly pointed out that these are the hallmarks of the eponymous Wellens' Syndrome (or Wellens' Warning). Interestingly enough, the computer's interpretation now displays *** ACUTE MI ***.

Well Page Him Again - Wellens Syndrome

So what is the importance of this finding?

In 1982, Hein JJ Wellens identified two types of abnormal T-waves associated with critical, proximal LAD stenosis. The first type, not seen in our case, features deeply inverted, symmetric T-waves in the anterior precordial leads. The second type, featured above, are characterized by biphasic T-waves. In his seminal study, Wellens found that these electrocardiographic patterns were most often seen during pain free periods. Subsequent studies showed that nearly every patient with Wellens' Syndrome had blockage in the LAD, ranging from 50-100%!

So what happened with our patient?

Our patient continued to experience transient episodes of chest pain. His troponin-I levels returned at 1.09 ng/mL 20 minutes after the pain-free ECG. Recognizing Wellens' Syndrome, the ED physician had the patient transferred directly to the cath lab for immediate PCI.

Key points highlighted by this case:

  • Obtain Serial ECG's!
  • A single ECG diagnostic for STEMI is indication for cath lab activation.
  • Resolution of chest pain is not a reason to withold aspirin.
  • Wellens' Sydrome strongly suggests an advanced degree of LAD stenosis and requires urgent evaluation.

References

  • Dr. Smith's ECG Blog – Wellens' Syndrome
  • de Zwann C, Bar FW, Wellens HJJ. Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction. Am Heart J 1982; 103:730-736. [PubMed]
  • Parikh KS, Agarwal R, Mehrota AK, Swamy RS. Wellens syndrome: a life-saving diagnosis. Am J Emerg Med 2012; 30:255e3-255e5. [PubMed]
  • Rhinehardt J, Brady WJ, Perron AD, Mattu A. Electrocardiographic manifestations of Wellens' syndrome. Am J Emerg Med 2002; 20(7):638-43. [PubMed]
Posted by on October 5, 2012 • Filed under: ems-topics, patient-management • Tagged: , , , , , , ,

58 year old female CC: Chest pain – Conclusion

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This is the conclusion to 58 year old female CC: Chest pain.

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

Remember, ST-elevation needs to be explained, and if the etiology involves myocardial infarction, urgent time-sensitive decisions need to be made.

In this case, we have ST-elevation in leads V1-V5, which suggests the possibility of acute LAD occlusion.

This finding is all-the-more concerning when we consider that R-wave progression is poor (absent) and the QTc is prolonged at 481 ms. Both of these findings point away from benign early repolarzation.

It's all too easy to dismiss a patient like this as having a mere anxiety attack. We need to keep an open mind and careful not to stimatize our patient.

How else might we explain the ST-elevation in the precordial leads?

We can consider the possibility that the ST-elevation is "old" or from a previous MI (the ECG finding we sometimes refer to as left ventricular aneurysm).

However, when we measure the T/QRS ratio we see that the T-waves are far more acute-looking than we would expect with left ventricular aneurysm.

The T/QRS ratio is 0.45 in lead V2 which is way above our threshold of 0.36.

Another possibility that some of you very astutely pointed out in the comments is Tako-Tsubo (or Takotsubo) Cardiomyopathy. I found that suggestion particularly interesting because it does seem to tie together all of the elements of this case.

In this case, the treating paramedic wasn't sure what to make of the ST-elevation in the precordial leads so he transmitted it over the LIFENET to the receiving hospital.

The two ED physicians weren't sure what to make of it either, but to be on the safe side they called a "Code STEMI".

The following 12-lead ECG was captured en route to the hospital.

The differences between this ECG and the previous ECG are not dramatic, but if you scrutinize the two you will see that there are differences in QRS, ST and T wave morphology.

By the time the patient arrived in the emergency department her chest pain was completely gone.

After a discussion with the cardiologist she consented to cardiac catheterization.

There was an acute 99% occlusion of the LAD which was successfully stented.

Diagnosis: Acute ST-elevation myocardial infarction.

See also:

81 year old male CC: Palpitations

76 year old female CC: Chest pain

Posted by on May 9, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , , , , , , , ,

71 year old male CC: Chest pain – Conclusion

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This is the conclusion to 71 year old male CC: Chest pain.

Thanks for all the great comments!

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

This 12-lead ECG shows acute anterior ST-elevation myocardial infarction.

Significant ST-elevation is present in leads V2-V5, I and aVL with reciprocal ST-depression in leads III and aVF.

A “STEMI Alert” was called from the field and the ECG was transmitted to the emergency department.

The patient was treated with MONA and the following 12-lead ECGs were recorded en route to the hospital.

The T-waves remain hyperacute but there is significant regression of ST-elevation. Remember, hyperacute T-waves are the best indicator of viable myocardium at risk!

When the paramedics (and their patient) arrived at the hospital the cath team was waiting.

Angiography revealed a 99% occlusion of the LAD. The lesion was crossed with a wire, the balloon inflated, and a stent was successfully placed with TIMI 3 flow restored (successful reperfusion).

After a short stay at the hospital the patient was discharged home.

Discharge diagnosis: ST-elevation myocardial infarction

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

Found on the Lifenet Receiving Station

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Here’s an interesting set of ECGs I found on the Lifenet Receiving Station. They were transmitted to the emergency department by a neighboring EMS system. I have no details of the history or clinical presentation.

ECG #1


ECG #2


What do you think?

Posted by on September 1, 2009 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , ,

76 yom CC: Shortness of breath while walking

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Here is the story.

Patient is a 76 year old male. No known medical history, no meds, excellent physical condition, walks every day.

Two days prior the patient experienced some shortness of breath while walking, but the sensation went away with rest. Approximately 30 minutes prior to EMS arrival, patient walked outside to get the newspaper, bent down, and experienced some mild chest discomfort. The patient walked back inside and felt like someone was "standing on his chest." At this time the patient's spouse called 9-1-1.

At the time of EMS arrival, the patient appears acutely ill. He is slightly diaphoretic but not overly anxious. He admits to 8/10 chest pain and mild dyspnea. He denies nausea, vomiting, or palpitations. No JVD. Breath sounds are clear bilaterally.

Vital signs are assessed:

RR: 18
Pulse: 58
BP: 155/90
SpO2: 98 on RA

The cardiac monitor is attached.

A 12 lead ECG is captured.

What now?

Let us assume for the sake of discussion that you live in a rural community.

You are 25 minutes away from your local receiving hospital (no cath lab) and 55 minutes away from a hospital in the next county over that is capable of primary PCI.

Do you bypass the local community hospital?

Should the cardiac cath lab be activated prior to your arrival?

Who makes the decision?

Posted by on February 20, 2009 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , , , , , ,