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77 year old female CC: Abdominal Pain

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It's a quiet Sunday afternoon when you're dispatched to a residence for a 77 year old female complaining of abdominal pain. Your dispatch notes indicates she was at the ED the day prior. Upon your arrival, you're met on the porch by the patient's son who directs you inside.

Your patient is sitting in a recliner, with mild respiratory distress, clutching her abdomen. Her skin appears a bit moist, and is warm when you touch her arm to feel for a radial pulse. When you ask her what is going on, she simply replies, "my belly won't stop hurting."

Your partner makes quick work of her vitals while you get the run down on her history.

  • Signs/symptoms: 7 of 10 abdominal pain going to her back, belching, intermittent vomiting
  • Alergies: Codeine
  • Medications: lisinopril, metoprolol, furosemide, potassium chloride, magnesium oxide, lipitor, albuterol, vitamin supplements, metformin, iron
  • PMHx: renal failure with dialysis (shunt Rt arm), hypertension, hypercholesterolemia, type II diabetes, pacemaker, asthma
  • Last ins/outs: vomiting x 3 today, did not do dialysis on Friday due to nausea/vomiting
  • Events: progressive worsening of pain and nausea

Your general impression of the patient is she just looks unwell. Your partner relays her vitals.

  • Pulse: 80 bpm, irregular
  • BP: 210/100
  • RR: 24, wheezes
  • SpO2: 94% on room air
  • T: 99.1 F (37.3 C)
  • BGL: 194 mg/dL (10.7 mmol/L)

Her son asks that you take her to the smaller, local hospital so, "she does not have to wait as long as she did at the ED yesterday." When you ask for her discharge instructions, he can only find the sheet which says Chest Pain and very generic information.

When you ask about her pain earlier, she denied any chest pain, however, to be prudent you obtain a 12-Lead:

Up and Down We Go - 12-Lead

You assist her to your stretcher, securing her with seat belts, and begin moving her to the truck.

  • What does this patient's 12-Lead ECG show?
  • What is this patient's rhythm?
  • What are your treatment priorities?
  • Can you still take this patient to a community hospital?

 

Posted by on June 11, 2013 • Filed under: ems-topics, patient-management • Tagged: , , , ,

24 year old male: “Anxiety Attack” – Conclusion

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This is the conclusion to our case 24 year old male: "Anxiety Attack". Be sure to read Part I before the conclusion!

When we left off, our providers were on scene with a young man, in custody, who was pale and had a radial pulse too fast to count. A narrow complex tachycardia was present on the monitor to which our patient helpfully pointed out, "it's SVT".

Let's find out if our patient is right!

Happens All the Time Man - Initial Rhythm Strip

The initial rhythm strip shows a regular, narrow complex tachycardia at approximately 200 bpm. Differentials include SVT (e.g. AV Nodal Reentrant Tachycardia and Orthodromic AV ReciprocatingTachycardia), atrial tachycardia, atrial flutter, and atrial fibrillation. However, given the rate, it would seem unlikely to be flutter, and given the near dead-on regularity it excludes atrial fibrillation.

Happens All the Time Man - Initial 12-Lead

The 12-Lead ECG confirms much of what we saw in the initial rhythm strip. We have a regular, narrow complex rhythm at 200 bpm. Retrograde P-waves are appreciable in leads II, III, aVF, and V1. These P-waves are often termed pseudo-S or pseudo-R' waves, and are most commonly seen in AVNRT. However, ST-elevation in aVR during SVT is a sign of orthodromic AVRT.

Regardless of mechanism, it is safe to say that our patient was right! He is currently experiencing SVT.

The treating paramedic also came to this conclusion and began treatment by lying the patient down and attempting vagal maneuvers. The patient was coached to bear down and then to blow through an empty 10 cc syringe, both without effect:

Happens All the Time Man - Vagal Attempt

An 18 gauge IV was established in the left antecubital fossa. 6 mg of adenosine was then administered rapid IV push followed by a 20 cc normal saline bolus flush. The following was captured:

Happens All the Time Man - Adenosine

This rhythm strip shows an interruption in the AV nodal reentry circuit with a conversion to a sinus tachycardia.

A repeat 12-Lead was obtained by the crew:

Happens All the Time Man - Post-conversion 12-Lead

The post-conversion 12-Lead shows a sinus rhythm without delta waves, epsilon waves, or acute ST/T-wave changes. The computerized interpretation notes a short PR interval of 98 ms, however, this author reads the PRi as normal at ~120ms. If an accessory pathway is present, conduction is concealed on the patient's baseline 12-Lead.

The patient was transported by the crew without incident and was lost to follow-up by EMS. However, this case shows that sometimes our patients will know exactly what is wrong, which underscores the importance of obtaining a good history.

  • What conditions could this patient have which caused his SVT?
  • What treatments may this patient receive if he continues to suffer from SVT?
Posted by on October 8, 2012 • Filed under: ems-topics, patient-management • Tagged: , , , , , , ,

62 year old male: Chest Discomfort – Part II

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This is part two of the three part series, 62 year old male: Chest Discomfort. As before, clinical details have been altered for educational purposes and to protect patient and provider privacy.

When we left our patient, he was experiencing the latest in what had become a series of episodes of minor chest pressure. A 12-Lead was acquired, and is given below:
 
Well Page Him Again - Initial 12-Lead
 
He looked pretty good, but as most of you noted, his ECG was at best borderline, and at worst, diagnostic of anterior STEMI. We'll hold off on our interpretation until the conclusion. So what happened next?
 
The tech who ran the ECG had the good sense to make this patient a priority and quickly got a physician to lay her eyes on the ECG. Like many of you, she was concerned about a STEMI, but not convinced. There was, however, one important thing she was sure of: even being suspicious of STEMI was cause enough to warrant expedited care.
 
The patient was immediately brought back to a room, placed on a nasal cannula at 2 L/min, and attached to the cardiac monitor while IV access was obtained and labs were drawn. The physician continued her evaluation and completed a thorough history and physical examination.
 
However, after leaving the room, she was torn. The patient had a history consistent with angina and a worrisome ECG, but during the previous activities his pain had disappeared yet again.
 
She put a page out to cardiology, but knew ahead of time that it was going to be a hard sell. It was evening and the facility where the patient presented did not have PCI capabilities on-site. Inter-facility transfer and calling in the cath-lab team would be an extra hurdle if she really wanted to push for that pathway.
 
When cardiology called back they didn't seem too anxious to come in right away. He didn't have any strong risk factors, the ECG sounded non-diagnostic over the phone, and he was now pain free. They would see the patient, but it would be on a non-urgent basis later in the evening.
 
So, worried there was more going on than stable angina, the treating physician ordered a repeat ECG. The timing was just about 30 minutes after the first, lead placement was identical, and the patient was pain free without additional intervention:
 
Well Page Him Again - Repeat 12-Lead
 
  • What does the patient's 12-Lead show now?
  • This 12-Lead was acquired while the patient was pain free, are they in the clear?
  • What are your next steps for this patient?
 
Posted by on September 30, 2012 • Filed under: ems-topics, patient-management • Tagged: , , , ,

57 year old male: Chest Discomfort – Conclusion

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This is the conclusion to 57 year old male: Chest Discomfort. We suggest you read the backstory first!

We're now in the back of the ambulance with our stubborn 57 year old male with a rapid heart rate. He looks unwell, but is otherwise hemodynamically stable. Our partner is working on a line.

Let's review the initial rhythm and 12-Lead ECG:

Round and Round He Goes - Initial Rhythm

The rhythm strip shows a narrow complex tachycardia at approximately 150 bpm. Atrial activity is not visible and may be buried in the T-waves. Our differentials include: sinus tachycardia, supraventricular tachycardia (e.g. AV Nodal Reentry Tachycardia and orthodromic AV Reciprocating Tachycardia), 2:1 atrial flutter, and junctional tachycardia.

Round and Round He Goes - Initial 12-Lead

The 12-Lead also shows a narrow complex tachycardia at approximately 150 bpm. Atrial activity is vaguely appreciable in the T-waves of V1 and III. The list of differentials remains unchanged, however, given the continued regularity sinus tachycardia seems less likely.

The paramedic who sent this case in elected to treat the patient with adenosine to convert or unmask the underlying rhythm.

Round and Round He Goes - 6mg Adenosine Bolus

The post-adenosine rhythm strip shows clear flutter activity in leads II and aVF, however, the paramedic admits they did not initially notice the F-waves. The rhythm then devolved into an irregularly irregular rhythm and a strip was printed.

Round and Round He Goes - After first Adenosine

While there is some baseline wander present, given the previous ECG, it seems very likely that this is atrial flutter with a variable response. However, the rhythm quickly accelerated to its original rate of 150 bpm.

As the treating paramedic did not appreciate atrial flutter, they administered a second dose of adenosine.

Round and Round He Goes - 12mg Adenosine Bolus

Atrial flutter is readily appreciable in Leads II and aVF, and as before the rhythm accelerated to its original rate.

Round and Round He Goes - After second Adenosine

The treating paramedic recognized atrial flutter and contacted medical control asking for orders for Cardizem.

Orders were received for 10 mg Cardizem slow IV push, which resulted in some reduction in rate but without conversion to a sinus rhythm.

Round and Round He Goes - After 10mg Cardizem Bolus

The patient was transported to a local hospital where he was placed on a Cardizem drip, resulting in conversion to a sinus rhythm after a few hours. A follow-up with a cardiologist was scheduled and the patient was discharged home without sequelae.

Any time you are faced with a regular rhythm at around 150 bpm, remember that the most common atrial rate in atrial flutter is 300 bpm and the most common conduction is 2:1.

Posted by on September 21, 2012 • Filed under: ems-topics, patient-management • Tagged: , , , , , , ,

88 year old female: Weakness – Discussion

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This is the discussion for 88 year old female: Weakness. If you've not read the backstory, we suggest you check it out!

When we last left off, our patient was in an exam room with an irregularly irregular rhythm. The ED physician had asked you if the patient had a history of atrial fibrillation.

Let's review the rhythm strip and 12-Lead ECG.

All Over the Map - Rhythm Strip

We have a narrow complex, irregularly irregular rhythm at 70-110 bpm. There is no apparent atrial activity. This is presumably atrial fibrillation.

All Over the Map - 12-Lead

The 12-Lead ECG shows a narrow complex, irregulaly irregular rhythm with no acute changes to the ST-segments. What may be atrial activity is visible in multiple leads, however the baseline is variable. A diagnosis of atrial fibrillation cannot be ruled out, however, another atrial arrhythmia should be suspected.

When in doubt over atrial activity, the Lewis Lead can help you highlight it on the surface ECG (a tip of the hat to Kelly Grayson who first introduced me to this lead). All this requires is moving the RA and LA leads into position along the sterum like so:

Lewis Lead Placement

To acquire a Lewis Lead, place the RA electrode on the manubrium and the LA electrode approximately where V3R would go and then monitor Lead I.

Once they acquired a strip from the Lewis Lead they were certain of the eventual diagnosis:

All Over the Map - Lewis Lead - Marked Up

From the Lewis Lead strip we can easily appreciate at least 5 distinct P-wave morphologies! Therefore our patient is experiencing a multifocal atrial rhythm. For completeness, multifocal atrial rhythms with a normorcardic rate is referred to as Wandering Atrial Pacemaker, while a tachycardia rate is referred to as Multifocal Atrial Tachycardia. In either case, treatment is geared towards correcting the underlying problem rather than the rhythm.

So, what are some common causes of multifocal atrial arrhythmias?

Jason Roediger did our work for us in the comments and listed the major causes:

MAT is most commonly associated with chronic obstructive pulmonary disease (COPD) in addition to associated lung disorders:  far-advanced pneumonia, chronic bronchitis, emphysema, etc.  It can also be seen in digitalis intoxication as well as other diseased states.

Other causes include electrolyte disorders such as hypomagnesemia and hypokalemia or even theophylline usage can cause MAT.

In this case our patient was found to have a chest X-ray consistent with emphysema and cardiomegaly. Her labs were notable for a low chloride, bacteria in her urine, and an elevated white count. She was admitted for urosepsis and dehydration. On admission day two she was found to have a small bowel obstruction, however, after discussing treatment options with the patient and family she refused surgery and elected for comfort care only.

If our intrepid reader had not run the Lewis Leads in this case, the patient may have received antiarrhythmics and anticoagulation therapy for a new onset of atrial fibrillation. The key takeaway here is that not all irregularly irregular rhythms are atrial fibrillation!

Posted by on September 14, 2012 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , ,

88 year old female: Weakness

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This great case was submitted by Vince DiGiulio, EMT-CC; we highly recommend you read his wonderful blog The Medial Approach to Emergency Medicine. As usual, the case has been altered to protect patient and provider privacy.

You're working triage in a busy urban ED when an 88 year old female is brought in by her family. She is in a wheelchair and appears lethargic.

When you introduce yourself she comes around and is able to answer your questions, albeit with some hesitation. Her family reports that she is independent and lively at baseline and are concerned she is having a stroke.

You move her into a triage room and grab a set of vitals. Her breathing appears unlabored with an irregularly irregular pulse at her radials. You ask an ED tech to join you to help with acquiring an ECG.

  • Pulse: 80-100, irregularly irregular
  • BP: 122/83, auto-cuff
  • Resps: 22, unlabored, clear bilaterally
  • SpO2: 92% r/a
  • GCS: 14 (E3 V5 M6)
  • LAPSS: Negative

The ED tech runs a strip from the monitor after switching to Lead I as Lead II had small complexes.

All Over the Map - Rhythm Strip

You call back to the charge nurse and ask for a bed assignment and wheel the patient back with the help of the ED tech. In the room a 12-Lead ECG is acquired while a complete history is gathered.

  • PMHx: hypertension, hypercholesterolemia, Type II diabetes
  • Meds: lisinopril, Lipitor, glipizide, ASA, and a multivitamin
  • Allergies: PCN and Sulfa
  • Last In's/Out's: normal lunch, vomiting during the afternoon
  • Events: progressive lethargy and weakness after vomiting in the afternoon

The RN hands you a copy of the 12-Lead while she updates the electronic chart.

All Over the Map - 12-Lead

Given the 12-Lead you decide that a Lewis Lead should be acquired, as it may give additional insight into the underlying rhythm:

All Over the Map - Lewis Lead

The ED physician walks into the room and asks you one question, "does she has a history of atrial fibrillation?"

  • What is this patient's rhythm?
  • What are some potential causes of our patient's rhythm?
  • Does the Lewis Lead offer any potential insights into our pateint's rhythm?
  • Would this information change your treatment decision?
Posted by on September 11, 2012 • Filed under: ems-health-safety, ems-topics, patient-management • Tagged: , , , , ,

Discussion for 51 Year Old Male: Chest Pain

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Here is the conclusion to 51 year old male: Chest Pain. You may wish to review the case.

Here is the ECG again:

 

There is a regular sinus rhythm at a rate of about 70. The QRS is narrow. The axis is normal, at about 15 degrees.

Let's take a look at the constellation of ST changes:

There is ST elevation in leads I, aVL, V2-V6. There is slight ST depression in III and aVF (and arguably in lead II) with ugly looking T wave inversions. Some of you also noted the suspicious looking Q waves in III and aVF.

Pericarditis and Early Repol were put forth as possibilities. Remember though, that neither of those will have reciprocal changes (excepting myocarditis, which may present as STEMI). Here, we have reciprocal changes inferiorly. If you were inclined to be thinking about STEMI mimics in this case, those changes should put ischemia at the top of the list.  In addition, as some of you pointed out, the ST changes do not look like Early Repol, and the amount of ST elevation here is alarming.

The crew in this case, along with the physician, decided this was STEMI. The patient was given Heparin, ASA, anti-emetics, and Morphine. His condition improved enroute, and his BP climbed to 124/75.

Upon arrival at the hospital, he was taken directly to the cath lab. There was a complete blockage of the LAD.

 

Here is the cath lab image showing the blockage:

Here is the image after revascularization:

 

I don't know about you, but I always find these images amazing. Fortunately, our patient was discharged from the hospital to cardiac rehab a few days later. He was expected to recover nicely. 

Enjoy the holiday!

 

 

 

 

Posted by on July 4, 2012 • Filed under: ems-health-safety, ems-topics, patient-management, Training, training-development • Tagged: , , , , , ,

65 year old male CC: Fall with injury – Conclusion

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This is the conclusion to 65 year old male CC: Fall with injury. You may wish to review the history and clinical presentation.

When we left off the patient was in severe heart failure with the following 12-lead ECG.

As we have mentioned before on several occasions, the most important thing when treating a patient with a tachycardia is to decide whether or not the tachycardia is causing the symptoms or the symptoms are causing the tachycardia.

In other words, you should try to rule out the possibility that it's a compensatory tachycardia. As this case clearly demonstrates, this can be very difficult! 

The crew felt that the differential diagnosis for this wide complex tachycardia (from most likely to least likely) was VT, 2:1 atrial flutter with LBBB, sinus tachycardia with LBBB, or some other SVT with aberrancy.

Due to the patient's instability, the treating paramedic felt there was little to lose and much to gain by attempting synchronized cardioversion. If the rhythm was VT or 2:1 flutter the patient's condition might improve dramatically. If it turned out to be sinus tachycardia with LBBB he'd be in the exact same position.

Attempt #1

Attempt #2

There appeared to be no change in the heart rhythm.

A report was given to online medical control and the patient was transported emergently to the hospital.

On arrival the patient was placed on BiPAP and started on a NTG drip.

Here was the 12-lead ECG on arrival.

The patient was given lopressor 5 mg slow IV push.

The conversion rhythm shows sinus rhythm at 92 bpm with left bundle branch block.

So, we now know that the patient probably had LBBB at baseline. However, without a heart rate histogram it's difficult to say whether or not this was 2:1 flutter that converted sinus rhythm or sinus tachycardia that was slowed down with the lopressor.

This is often overlooked in the emergency setting but in the inhospital setting it's very important to document the onset or termination of an arrhythmia for this very reason.

The patient's SpO2 came up above 90% and the patient became more alert and was attempting to communicate by the time EMS was done writing their report. No further information is available.

Posted by on July 2, 2012 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , , , ,

65 year old male CC: Fall with injury

57 comments

Here's a very interesting case submitted by a faithful reader who wishes to remain anonymous. Some changes have been made to preserve patient confidentiality.

EMS is called to a local breakfast restaurant for a 65 year old male who fell in the parking lot. He was reported to have suffered a head injury.

On arrival the patient is found sitting in his car. He appears critically ill. Skin is pale and diaphoretic. Nail beds are blue. The patient's level of consciousness is significantly diminished. His shirt and pants are wet and it's not clear if he was incontinent of urine or spilled a drink on himself. He has audible expiratory rales without the need for a stethescope. 

The patient states that he tripped and fell. His wife states that he was "fine" prior to falling but she does not impress EMS as a good historian. When asked about his history she says, "heart." 

The head appears atraumatic with the exception of some abrasions to the face. He admits to head pain "all over" and keeps muttering "please take me to the hospital."

Due to the patient's diminished level of consciousness it is not possible to clear the cervical spine with any established criteria. However, the paramedics conclude that the patient cannot be laid flat and elect to defer spinal immobilization. The patient is placed on the gurney with the head elevated and vital signs are assessed.

  • RR: 30
  • HR: 148
  • NIBP: 150/77
  • SpO2: 58 on room air

The patient is placed on a NRB mask @ 15 LPM. The chest is exposed and no chest trauma is apparent. Breath sounds: rhonchi and rales bilaterally

The patient is given a dose of SL NTG and loaded in the back of the ambulance. At this point the patient appears peri-arrest.

The cardiac monitor is attached.

A 12-lead ECG is obtained.

What would you do next?

See also:

65 year old male CC: Fall with injury – Conclusion

Posted by on June 27, 2012 • Filed under: ems-topics, patient-management, Training • Tagged: , , , , , ,

“What Happened?”–Discussion

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This is the discussion to "What Happened?" You may wish to review the case here.

Ok, let's review the initial 12 Lead:

Just about everyone picked up on the infero-posterior STEMI.

Where it got interesting for me, was determining what the rhythm was! At first glance, the rhythm was for the most part regular (note the computer interpretation of Atrial Fibrillation with RVR!) and narrow, with a rate just a touch faster than 100. I did not see P waves before most of the QRS complexes, and I initially thought it was a junctional tachycardia.

As the STEMI was most likely due to an RCA occlusion, it is not surprising to have conduction disturbances. The pause, followed by an apparent sinus beat (circled in red above), had me wondering if this was indeed junctional with a sinus "escape" after the pause, or some kind of sinus rhythm with AV block.

In keeping with our spirit of "Peer Sourcing", I ran this strip by electrophysiologist Dr. Nick Tullo, of the ECG Academy.com. A review done by Life in the Fast Lane of Dr. Tullo's excellent academy can be found here. This is the conversation I had with Dr. Nick about this rhythm:

Me: Thanks for the help Dr. Nick. Now, what the heck is this?? Junctional, or sinus/AV block?

Dr. Nick: I would call it "Atypical Wenckebach" –essentially 13:12. You can see a sinus P following the fourth beat, and then a similar pause just before the end of the tracing. The pause is less than two times the previous R-R, and the PR of the second beat following the pause is longer than the PR that interrupts the pause (what you are calling accelerated juntional is really sinus rhythm with a first degree AV block, but you can't see the P easily because it's buried in the previous T). In the setting of acute IWMI it's due to the same high-vagal-tone mechanism that would cause the usual 3:2 or 4:3 Wencheback (or even complete heart block in some patients) but the AV node is mostly keeping up.

Me: Wow… OK!  But, how do we know it's not a junctional rhythm with a sinus beat escaping from the pause?

Dr Nick: You have to look hard for the P waves. If it was a junctional rhythm you'd see consistent P's at the end of the QRS or maybe in the very early part of the ST segment. If I'm right, the P wave will be on the T-wave somewhere and not always in the same spot (since it's not directly connected to the previous QRS). Granted, the ST elevation makes it hard to see the Ps. But I see the answer clearly:

Look at V5…see how the first beat has a concave upslope of the T wave while the second beat looks like it has a bump on it? That bump is the P wave. Assuming that the R-R interval midway through the "junctional rhythm" is equal to the atrial rate (since the PR doesn't change midway through an Atypical Wencheback cycle) measure back from the visible P preceeding the third beat in V5…doesn't it land right at the bump? The reason the T looked concave the beat before that is because that P wave is on the peak of the T.

I've put together some graphics to help illustrate the important points. 

First is Lead V5, which Dr. Nick referenced, blown up. I've done the same with lead II. Note the subtle morphology changes in the two T waves. This is the last P wave  of the cycle, which does not conduct. the P wave following the pause is the first of the cycle, and has the shortest PR interval:

I know, you're thinking, "Really? Do those little blips/bumps really measure out?" Don't take my word for it. I've got one more illustration to show you. I took a mid cycle R-R interval (1), as Dr. Nick suggested, and used that to measure back and see where the P wave should be in leads II and V5 (2,3):

As you can see, right on cue, those blimps/bumps are right where the P wave should be. And there we have it: 13:12 Atypical Wenckebach, with a PVC at the very end of the strip.

My sincere thanks to Dr. Nick Tullo for his help with this case, and kudos to Jason, who expertly picked up on this in the comments section.

Now for the second 12 Lead:

The patient was treated with thrombolytics (TNK), and as many of you commented the resulting rhythm was an accelerated idioventricular rhythm (AIVR).  AIVR appears similar to VT, but slower (slower than 120). In the thrombolytics era, this transient rhythm was noted to be a marker of reperfusion, although not all patients with a reopened coronary artery have AIVR. When it appears it rarely causes hemodynamic instability, and usually requires no treatment. For more information about AIVR, see here.

Of course, you will notice that I have circled several leads in the 12 lead above. In keeping with this case, in which nothing seems to be typical, you will notice that in fact the ST segments have not resolved during the AIVR. The inferior ST elevations remain, as do the ST depressions in V1-V4, and aVL. 

When asked about this, Dr. Smith, of Dr. Smith's ECG Blog had this to say: "This is one of the few cases of AIVR I've seen that was not associated with reperfusion."

In this case, our patient failed thrombolytics. He was immediately sent for rescue PCI. Unfortunately, we don't have any additional information.

There was a lot of information in this discussion. I sure learned a lot! 

I look forward to your comments, and as always, thanks for reading!

Posted by on June 2, 2012 • Filed under: ems-health-safety, ems-topics, patient-management, Training, training-development • Tagged: , , , , , , , , ,

Snapshot: 32 year old male–chest discomfort

46 comments

Here's a new snapshot case straight from the UK… We have a 32 year old male, normally fit with no history whatsoever. He has had a stressful week (personal issues), and decided maybe a 4 mile run might help. It didn't. When he returned home, he developed sudden onset of chest discomfort, and decided to lie down for bit. After a couple of hours, he wasn't feeling better and called 911.

While he is alert and oriented, he is also anxious and diaphoretic. Lungs are clear bilaterally, but the RR is elevated at about 30. Pulse is too fast to count, but the BP is 126/70. He describes the chest discomfort this way: "I feel like someone is punching me in the chest!" It is substernal, non-radiating, and rated a 5/10. His only other complaint is a touch of lightheadedness.

Here is the rhythm strip and 12 lead:

Your mission, should you choose to accept it, involves coming up with a differential diagnosis for our patient, and stating which factors favor one diagnosis over another. Oh, just one more thing… How do we treat him?

We look forward to your excellent responses!

Posted by on April 30, 2012 • Filed under: ems-health-safety, ems-topics, patient-management, training-development • Tagged: , , , ,

69 year old female CC: Shortness of breath, weakness

14 comments

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.

  • Past medical history: Healthy
  • Medications: None

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?

Posted by on April 14, 2012 • Filed under: ems-topics, patient-management • Tagged: , , , , , ,

63 Year Old Male: “Dental Pain”

34 comments

Here is an interesting case submitted by Adam Frederick, NREMT-Intermediate.  As usual, some details have been changed to protect patient confidentiality.

EMS is called to the local Urgent Care for a 63 year old male complaining of upper jaw pain related to "dental work". He had made two trips to the dentist this past week for pain related to "work done on a crown". Both times the dental work was in order, and the dentist could not find a reason for the  jaw pain. Today, while walking on the treadmill at the local fitness center, the jaw pain returned. He drove to urgent care because the dental office was closed. 

While at urgent care, he reported to the nurse that the pain began about 45 minutes ago, and seemed to worsen when he did strenuous activity. He thought it odd that today he had some chest discomfort as well, but felt it was probably due to his anxiety.

EMS arrives to find the patient in exam room 2. He looks pale, and his skin is cool and moist. He reports jaw pain of 8/10, and substernal chest pain of 4/10. History is significant for hypertension and anxiety. He takes Lipitor, ASA, and Metoprolol daily. He has no known allergies. His vitals are as follows:

  • HR: 90 and regular
  • BP: 180/114
  • RR: 16
  • Skin: cool/moist/pale
  • Lungs: clear bilaterally
  • Spo2: 98% on supplemental oxygen

You apply your cardiac monitor and acquire the following rhythm strip and 12 lead ECG:

 

Prior to EMS arrival, the patient was given 4 baby aspirin, but now refuses nitro and the IV. He states he "doesn't know what all the fuss is about", and that he "just wants to go home", and you get the feeling that he just might refuse transport.

  • What do you tell your patient?
  • Are you concerned about the ECG? If so, why?
  • How would you treat this patient, and where would you like to take him?
Posted by on April 10, 2012 • Filed under: ems-health-safety, ems-topics, patient-management, training-development • Tagged: , , , , , ,

Team EMS 12-Lead brings home Judges’ Choice for 2012 EMS Blog of the Year

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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:

  • Calibre of posts relating to the Fire and/or EMS fields
  • Frequency of posting Professionalism towards our service(s)
  • Quality of content
  • Longevity as a blogger

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:

  • Use of other online channels to promote their content
  • Blog design
  • Blogger creativity
  • Reader engagement"

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.

Posted by on March 26, 2012 • Filed under: ems-topics • Tagged: , , , , , ,

88 year old male CC: Chest pain – Conclusion

12 comments

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

  • CKMB 2.14
  • CPK 58
  • Trop < 0.01
  • K+ 2.8 (low)
  • Na 142 
  • Calcium 5.8 mg/dL (critical) – non-ionized
  • Renal profile WNL

@ 0535

  • CPK 254
  • CKMB 30.03
  • Trop 0.341

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!

Posted by on March 25, 2012 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , , , , , , , ,

88 year old male CC: Chest pain

33 comments

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.

  • Past medical history: "Cardiac", pacemaker, hypertension, dyslipidemia
  • Medications: Numerous, unavailable at the time of EMS evaluation

Paramedics lead the man to a chair and the assessment begins.

  • Onset: 30 minutes prior to EMS arrival
  • Provoke: Nothing makes the pain better or worse
  • Quality: Poorly localized pressure
  • Radiate: Does not radiate
  • Severity: 7/10
  • Time: Admits to previous episodes but unable to give details

Vital signs are assessed.

  • RR: 18
  • Pulse: 70
  • NIBP: 140/92
  • SpO2: 90 on RA

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?

See also:

88 year old male CC: Chest pain – Conclusion

Posted by on March 19, 2012 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , , , ,

90 year old male CC: “Possible stroke” – Conclusion

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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! 

Posted by on December 6, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , , ,

90 year old male CC: “Possible stroke”

32 comments

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.

  • RR: 16
  • Pulse: 116
  • NIBP: 115/53
  • SpO2: 96 on RA

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:

90 year old male CC: "Possible stroke" – Conclusion

Posted by on November 29, 2011 • Filed under: ems-health-safety • Tagged: , , , , , , , ,

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

7 comments

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: , , , , , , , , , , ,

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: , , , , , , , , , ,

88 year old male CC: Chest pain

20 comments

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: , , , , , , , , ,

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.

Play

Podcast: Play in new window | Download

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

13 comments

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: , , , , , , , , , , , , ,

47 year old male CC: Crushing chest pain

29 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: , , , , , , ,