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Why we perform serial 12-lead ECGs on patients with signs consistent with ACS

EMS1.com News

March 26, 2012


EMS 12-Lead
by Tom Bouthillet

Why we perform serial 12-lead ECGs on patients with signs consistent with ACS

As the medical professional on the scene, it's imperative that our actions are reasonable and prudent

By Tom Bouthillet

EMS is called to a grocery store for a patient complaining of chest discomfort. The patient is found sitting on the curb. He had been hoisting buckets of gravel up to the roof when symptoms began. The patient's supervisor contacted 911.

The patient denies any significant medical history and states that he takes no medications.

Paramedics assess his vital signs.

RR: 16
HR: 64
NIBP: 147/89
SpO2: 99 on RA

A 12-lead ECG is obtained.

Breath sounds are clear bilaterally.

The patient refuses any treatment or transport to the hospital. However, the paramedics (to their credit) were concerned and did their best to persuade the patient that it was in his best interest to be evaluated at the hospital.

The patient agreed to go to the hospital but stated that he would have his spouse take him.

The paramedics waited on scene while the patient contacted his spouse by cell phone. The patient's spouse asked to speak with the paramedic in charge of the call, who explained to the spouse that he was concerned that the patient could be having a cardiac problem. The spouse spoke to the patient again and convinced him to go to the hospital by ambulance.

The patient was placed on the gurney and loaded for transport. The 12-lead ECG monitor was re-attached and another ECG was obtained.

Do you see a difference?

 

Note also the changes in the right precordial leads. This patient is experiencing an acute inferior ST-elevation myocardial infarction! A "Code STEMI" was called from the field and the patient was taken directly to a PCI-hospital.

Discussion
A 12-lead ECG is a snap shot in time that may not fully reflect the dynamic myocardial oxygen supply vs. demand characteristics of ACS.

Tim Phalen compares the ECG signs of ACS to Old Faithful. "Is it a geyser or a hole in the ground?" It depends on when you snap the photo! All patients with possible ACS should receive serial 12-lead ECGs and serial cardiac biomarkers when the initial ECG is non-diagnostic.

Patients with signs and symptoms of ACS should be transported to the hospital by ambulance regardless of what the initial ECG shows. Paramedics love to say, "We can't force people to go to the hospital" and while that's mostly true, it's weak as a stand-alone statement.

Just as consent must be "informed" so, too, must a refusal be "informed," and in this context "informed" entails education because the patient may not understand the seriousness of the situation!

As the medical professional on the scene, it's imperative that our actions are reasonable and prudent. That means performing a mental status exam to make sure the patient possesses decisional capacity, explaining to the patient the risk of refusing care, ensuring that the patient can articulate that risk in his or her own words, and taking other steps to help mitigate the patient's risk.

These include encouraging the patient to go to the hospital by other means, waiting on scene while the patient calls his wife, making sure the patient is not left alone, encouraging the patient to contact 911 again if he changes his mind, and so on.

In this case by doing something other than saying "sign here," it is likely that the paramedics saved the patient's life.

Others might joke that the paramedics caused the heart attack by making the patient speak to his wife! The bottom line from both a patient care perspective and risk management perspective is that this patient was fast-tracked to the cardiac cath lab with an excellent door-to-balloon time, which is a lot better than returning to a patient in cardiac arrest!

Next month we'll discuss which patients should be screened with a prehospital 12-lead ECG.

 

About the author


Tom Bouthillet is a Fire Captain/Paramedic with Hilton Head Island Fire & Rescue, Editor of the EMS 12-Lead blog, host of the Code STEMI web series at First Responders Network, a member of the Editoral Advisory Board of EMS World Magazine, and developer of the 12-Lead ECG Challenge smartphone app. He has taught nationally in the Critical Care Transport (CCEMT-P) program out of UMBC and his writings have been referenced in the American Heart Journal, the Journal of the American College of Cardiology: Cardiovascular Interventions and the EP Lab Digest. Contact Tom at tom.bouthillet@ems1.com.
Comments
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Barbara Tate Barbara Tate Tuesday, March 27, 2012 6:06:29 PM awesome job guys. I love being a Paramedic!
Charlie McGrath Charlie McGrath Wednesday, March 28, 2012 4:32:08 AM Great read guys!
Slade Schultz Slade Schultz Wednesday, March 28, 2012 6:30:54 AM We had similar call a couple months ago, normal 12 and we encouraged transport. Repeat 12 enroute showed inferior MI. Straight to cath lab at hospital. He was really grateful when we spoke later in icu.
Kris Schott Kris Schott Wednesday, March 28, 2012 7:25:49 AM I view 12-leads as a vital sign, I repeat them every 10 minutes or so depending on patient status. An MI will evolve right before your eyes and you may miss it if you just get one. Great example, Tom. Thanks.
Ian Smith Ian Smith Wednesday, March 28, 2012 11:27:40 AM Well done, ecg's only reflect what's happening at any given time and if you inform people correctly and are persuasive enough they normally go with you.
Brooks Walsh Brooks Walsh Wednesday, March 28, 2012 12:29:49 PM Great article! I thought you would tie this in to the recent Canadian EMS study: http://informahealthcare.com/doi/abs/10.3109/10903127.2011.614045, or http://www.ncbi.nlm.nih.gov/pubmed/21954895 They found that, when they obtained repeat ECGs by protocol, they discovered significantly more STEMIs. In fact, 16% of prehospital STEMI alerts were from the second or third ECGs. http://millhillavecommand.blogspot.com/
Gary Freeman Gary Freeman Wednesday, March 28, 2012 12:39:05 PM Good job way to be proactive
Jake Stein Jake Stein Thursday, March 29, 2012 4:46:02 AM If you are telling the patient everything is coming back normal, it is easy to see their confusion as to why you want to "treat" them. For what? Very few Paramedics understand serial ECGs and the purpose. There have been lengthy discussions about this and most feel it is a waste of time and resources to stand around arguing with a person. If they are a competent adult just have them sign the release and move on.
Azliza Musthaffa Azliza Musthaffa Thursday, March 29, 2012 1:04:23 PM constantly renewing knowledge about ECG.. with this information I can share with other colleagues... this makes me more confident to identify various types of heart rhythm.
Mohd Mukhris Mohd Mukhris Thursday, March 29, 2012 1:21:50 PM Aik...
Dan White Dan White Friday, March 30, 2012 5:16:02 AM Just remember that only half of ACS patients will have ECG changes.
Jeff Mitchell Jeff Mitchell Saturday, March 31, 2012 3:27:21 PM "As the medical professional on the scene, it's imperative that our actions are reasonable and prudent. That means performing a mental status exam to make sure the patient possesses decisional capacity, explaining to the patient the risk of refusing care, ensuring that the patient can articulate that risk in his or her own words, and taking other steps to help mitigate the patient's risk. These include encouraging the patient to go to the hospital by other means, waiting on scene while the patient calls his wife, making sure the patient is not left alone, encouraging the patient to contact 911 again if he changes his mind, and so on." IMHO the moral of the story, be it cardiac or anything else!
John Gustafson John Gustafson Wednesday, April 25, 2012 12:31:17 PM Awesome job on the Medic's part!

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