Make this page my home page
  1. Drag the home icon in this panel and drop it onto the "house icon" in the tool bar for the browser

  2. Select "Yes" from the popup window and you're done!

ECG Challenge: The court's verdict? News

March 14, 2013

EMS 12-Lead
by Tom Bouthillet

ECG Challenge: The court's verdict?

How would you treat this patient and why?

By Tom Bouthillet

Editor's note: Check out this month's ECG case study and submit your treatment plan in the comments below. If Tom selects your plan as the best, you could win an EMS1 T-shirt and bottle opener. Good luck!

EMS is called to a local tennis court for a 63-year-old male complaining of chest pain.

At the time of EMS arrival, the patient is found sitting on a bench.

Past medical history: Cataract, erectile dysfunction

Medications: Cialis (tadalifil)

The patient appears acutely ill. He is pale, warm, and diaphoretic.

Vital signs are assessed.

  • RR: 18
  • HR: 74
  • NIBP: 127/65
  • SpO2: 97 on RA

Breath sounds: clear bilaterally

The patient is placed on oxygen via NC mask @ 4 LPM as the cardiac monitor is attached.


A 12-lead ECG is obtained.

What do you think of the 12-lead ECG?

Is the local community hospital appropriate or should the patient be transported straight to a PCI-capable facility?

How would you treat this patient?

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
The comments below are member-generated and do not necessarily reflect the opinions of or its staff. If you cannot see comments, try disabling privacy and ad blocking plugins in your browser. All comments must comply with our Member Commenting Policy.
Andrew Kelley Przepioski Andrew Kelley Przepioski Thursday, March 14, 2013 3:33:04 PM Ha, this is a tough one for me. Rhythm strip The first four complexes make me suspicious of sinus brady with ventricular bigeminy that becomes normal sinus rhythm. 12-lead Rate: 68 Rhythm: regularly regular, p-waves present, P waves are associated with the QRS complexes, PR is within normal limits, QRS are narrow. Normal Sinus Rhythm. Axis: Left axis deviation based on I being positive, aVF being negative. V3 doesn't seem appropriate for the R-wave progression, it has a very small R-wave. V4-V6 barely changes from each other. Enlargement: None, R/S < 1 in V1 so no right ventricular enlargement, voltage criteria for left ventricular hypertrophy not met in the precordial leads, I, aVL, or aVF. Unremarkable p-waves in II and V1. ST/T changes, Q-waves: Retrograde T-wave in III, T-wave is very flat in aVF, and the T-waves in a couple of leads look symmetrical and hyperacute to me, especially I, and V3-V6. About 2 mm in V4 alone. I've read that reciprocal changes are sometimes the first changes before ST elevation occurs on ems12lead and Dr. Smith's blog (, and reading Garcia's book, The Art of Interpretation: 12-lead ECG, I feel like the ST segment and T-waves are under appreciated compared to ST elevation. Since there is a dramatic rhythm change in the rhythm strip, it makes me think ischemia. Although there is only ST elevation in one lead, V4, I am very suspicious that this patient is having an MI so I would personally go to the PCI capable facility. I would treat him for suspect cardiac ischemia. If his SpO2 is >94%, heart rate is 78, respiratory rate is 18, and although his skin signs aren't great, if there isn't anything else eg altered mental status, I don't think supplemental oxygen is indicated. I'd like to give him aspirin (in my county, we give 324 mg PO). After I've given aspirin, I'd like to start an IV. If he has taken cialis within the past 36 hours, I would withhold nitroglycerin, and I would go straight morphine sulfate and make sure his blood pressure remains >100 systolic. If he hasn't taken cialis within the past 36 hours and I have an IV, I'll administer nitroglycerin 0.4 mg (spray translingual/tablet sublingual) every 5 minutes, and if that doesn't relieve pain, then I'd go to morphine sulfate (2 mg or more IV). Serial 12-lead is a must. I suspect that treating it might mask a STEMI, but I think that's fine as long as he is ends up at the PCI capable facility where they can use other methods like an echocardiogram and labs to determine if he is having an MI.
Alfredo Lozornio Alfredo Lozornio Thursday, March 14, 2013 3:54:53 PM AMI posterior inferior do not give nitrates give a saline bolus
Qantu Curio Qantu Curio Thursday, March 14, 2013 4:28:11 PM I would ask about sob if none no oxygen as his Sa02 is 97 because too much free oxygen can cause more harm than good per new aha. Give aspirin, IV, ask about last cialis use and give nitro accordingly, morphine if long enough with the pt and no relief from nitro. Transport to pci facility. Serial 12 leads during transport after each nitro or morphine. Looks like an early stage anteroseptal AMI.
Ernesto Franco Ernesto Franco Thursday, March 14, 2013 7:29:49 PM I would preffer to transport it to a PCI facility, the patient is hemodinamically stable, but he could be suffering from a side effect of Cialis like an impaired coronary perfusion, the truth is that at first we have a ST elevation on DII, DIII and AVF reflecting and inferior MI, but when they get the 12 lead EKG we don't have any continues leads reflecting a STEMI or NON-STEMI, this patient needs to get an IV TKO, Oxygen, and draw blood samples to see if he is suffering from hyperkalemia due to peaked "t" waves V2, V3 and V5.
Danny Nail Danny Nail Friday, March 15, 2013 6:39:50 AM I think that the patient may have taken some of his Ed medication recently and the increase in exertion has caused an increase in oxygen demand. He is in sinus rhythm with pvc's which also is another indicator of oxygen deprivation. I think he should be placed on a nasal canula at 4 lpm to start, IV with a normal saline bolus of 250 cc, remained on the cardiac monitor and transported to a pci facility. More needs to be asked of his medical history and recent medications that he has taken. If the patient has not taken his Ed medication in 24 hours we can administer Asa 324 mg po followed by 0.4 mg Nitro SL. The 12 lead looks ok, but little indicators to me are that he may have the beginnings of LBBB, and he also has physiological left axis deviation which could be due to either age or if he was once obese.
Teresa Sluss Teresa Sluss Friday, March 15, 2013 1:34:28 PM Well, to tell you bout where I live the closest cath lab is an hour away, if it good weather flight them out, if not take them to the closest hospital as for as I see it, yea we can track the hour away, but the damage that is happening to this patient maybe the local hospital can help with it and they will get the patient trasported quicker then we could.
Michael Willis Michael Willis Friday, March 15, 2013 1:57:55 PM Routine cardic care. When did he last take Cialis? I'm with Syed in that the V2-V4 hyperacute T's make me suspicious of early Antero-septal infarct. 324mg ASA...Nitro unless contraindicated as above. Max 3 if applicable and pressure tolerates then progress to MS or Fentanyl. Serial 12 leads to watch for evolution. 2 IV sites. Fluids kvo. Lead II on 12 lead almost looks like it has a delta wave as do some of the others. (viewing on a cell phone) That or a BBB that just isn't obvious yet and the computer isn't seeing it. Gut says stemi. PCI asap. Monitor patient closely.
Nathan Stanaway Nathan Stanaway Friday, March 15, 2013 4:42:20 PM I'm nowhere near an ecg guru, but based on only the 6 second strip and the 12lead, I see irritation most likely from cardiac hypoxia until proven otherwise. Based on the description of the patient, I would prefer transport to PCI facility. If it was a lot further than the tertiary facility maybe not... Again, NOT an ecg guru....
Jameson McIntosh Jameson McIntosh Friday, March 15, 2013 6:57:33 PM Here's my answers, in order. I see a sinus rhythm with multifocal premature complexes (likely junctional/ventricular in origin, based on width+discordance). Flipped T's and depression in lead III and what I think looks like subtle depression in aVF. Knowing that ischemia doesn't localize well on a 12-lead, I'm suspicious of these being early reciprical changes. I like to use the PAILS pneumonic when looking for reciprical changes, which que's me to look at the anterior leads for signs of injury. I see low voltage QRS with poor R-wave progression, POSSIBLY a fragmented QRS (or possibly just artifact) in v2, and hyper-acute T-waves in v2, v3, and v4 (comparing S-wave depth to T-wave amplitude). These ECG changes, combined with the Hx and presenting symptoms, seem highly suggestive of ACS. I think this is the early signs of a significant LAD occlusion, warranting a look at the posterior leads and serial 12-leads so we can watch for STEMI evolution. He doesn't meet criteria yet to bypass where I work, but that wouldn't stop me from transmitting this ECG to our Vital Heart Response doctors for consultation. I think this is going to become a STEMI, and considering we're 90 minutes from a cath lab here, I'd like to get him moving there sooner than later. My treatment decisions will depend on if my patient has taken his Cialis in the last 48 hours. If so, I'm withholding the nitrospray. Treat as per ACS protocols and keep doing 12-leads!
Lieh Elleirbag Lieh Elleirbag Saturday, March 16, 2013 6:22:43 PM Oxygen deprivation would make sense. I had this rhythm a few years ago when I was in too much of a hurry getting to the station in the AM and just drank some fruit juice. Then had the bright idea to go search and rescue training all day before drill. Needless to say about halfway through search and rescue training at drill I still had not eaten and went into Respiratory distress. I was taken to the ambulance and placed on O2 via non-rebreather, over about 30 minutes symptoms resided, breathing was no longer labored and I went back to the station. The chief insisted the paramedics at the station check me out on ECG and this is what is showed. My blood sugar was never tested with vitals and the problem has never reoccurred. I rechecked my ECG strip since I keep it all these years and it matches this one near pefect except that my QRS complex was slightly more higher than the above.
William Hammond William Hammond Saturday, March 16, 2013 6:36:59 PM I would start IV bolus 250CC keep on monitor and O2 Pt looks to have flipped T wave sign of possible electrolytes out of balance due to heat exhaustion from playing tennis and or other activities. Pt needs temp checked and possible cooled. Check blood sugar, treat if needed. Transport in position of comfort to our local. Monitor thur out transport.
Alison Duncan Alison Duncan Sunday, March 17, 2013 5:06:15 PM Lead 3 is flipped, poor R wave prog. and slight ST elev. laterally. Do right and posterior leads and troponin, STAT and transport to a PCI facility if the Trops or 15 lead are positive for AMI.
Mike S. Dumond Sr Mike S. Dumond Sr Monday, March 18, 2013 7:08:09 AM PCI here is 3 1/2 hours away. ASA, O2, IV NS KVO, Labs drawn will be more diagnostic. NTG-SL depending on last time he took Cialis, Fentanyl if NTG is not an option.
Erik Testerman Erik Testerman Monday, March 18, 2013 8:04:13 PM Thus why the need for serial ECG's is imperative!!
Nancy K. Boyle Nancy K. Boyle Tuesday, March 19, 2013 9:05:30 AM "Patient looks acutely ill." I'd treat the patient, not the monitor. It looks like a duck. PCI-facility for sure.
Nancy K. Boyle Nancy K. Boyle Tuesday, March 19, 2013 9:19:13 AM Hyperacute T waves often precede STEMI - looks like anterior STEMI in progress.
John Thomson John Thomson Saturday, March 30, 2013 4:37:47 PM Rhythm strip shows PVC's which converts to NSR. 12 Lead shows left axis deviation and some t-wave inversion which may be due to ischemic changes. I would want to ask the patient about their cardiac history as there appears to be subtle Delta waves in Lead II, V5 & V6 which would suggest WPW. It could explain the Lt axis deviation, the T-wave changes and possibly the PVC's if he was converting from a tachy rhythm back to NSR prior to the 3 lead. I would also want to keep in mind that those peaked T's could be a sign of hyperkalemia which could also explain some of the ECG findings and PVC's and patients symptoms. Regardless, although the patients vitals are stable he is still complaining of chest pain and therefore unstable in my books. The patient would get chewable ASA, and I would do blood glucose level and a 15 lead prior to administering nitro (depending on last use of Ciialis) and/or morphine in case he is having a posterior MI. I would transport this patient to the PCI capable hospital for sure. Regardless of what the ECG reads he will need serial ECG's and a full cardiac panel based on his symptoms and age. That way if he progresses to a STEMI it's a quick trip to the cath lab.
Glenda McDonald Lunceford Glenda McDonald Lunceford Thursday, May 23, 2013 12:44:51 AM Danny ..... Roger and I have tried everything to reach you and Jennifer to ask for our appliance Dollie and our ladder to be RETURNED to us. Jennifer blocked me when I tried to send her a message to ask politely for them back... So I know she is aware that we need both back. The dollie alone cost us quite a bit and we have some friends staying with us from out of town that are moving to a new place and we really need it to use immediately. It's our property and we loaned it to you in good faith and I don't understand why you won't return it to us. Roger has tried many times to message you so please do the right thing and return our property. We will be happy to drive out to caddo to pick them up anytime . Please return them I really don't want to have to report them stolen but I will if I have to. Thanks

Today's Top Stories

Monday, March 2, 2015

Line-Of-Duty Deaths

Submit information on fallen EMS providers in your area.

Featured Columnist

Chris Cebollero

Elements of Leadership

As the crisis unfolded Christian Hospital EMS personnel knew who they were, what to do, and how to get it...

    Featured Product Categories