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!

Home > Topics > Cardiac Care
February 14, 2012
All Articles

EMS 12-Lead
by Tom Bouthillet

Why we capture a 12-lead ECG with the first set of vital signs

Too often, paramedics think of the 12-lead ECG as just one of the things to check off the list

By Tom Bouthillet

EMS is called to the residence of a 66-year-old female complaining of chest discomfort. The patient is found sitting in a kitchen chair. She is alert and oriented but highly anxious and diaphoretic. She appears acutely ill.

Paramedics assess her vital signs.

  • RR: 18
  • Pulse: 74
  • NIBP: 102/63
  • SpO2: 95

A 12-lead ECG is obtained.

Although this ECG meets the voltage criteria for left ventricular hypertrophy in the limb leads, it shows acute inferior STEMI.

ST-elevation is present in leads II, III and aVF along with reciprocal ST-depression in leads I and aVL. Remember that left ventricular hypertrophy is usually an anterior STEMI mimic.

A "Code STEMI" was called from the field. The patient was given four baby aspirin, a sublingual nitroglycerin spray and oxygen.

Less than 4 minutes later, the patient was in the back of the ambulance and another 12-lead ECG was captured.

As you can see, the ECG is now nondiagnostic for acute STEMI! This patient's reperfusion could have been seriously delayed. But, because the paramedics obtained a 12-lead ECG with the first set of vital signs, the patient was taken rapidly to the cardiac catheterization lab, where an acute 99 percent occlusion of the right coronary artery (RCA) was identified and stented.

The door-to-balloon time was less than 60 minutes.

Too often, paramedics think of the 12-lead ECG as just one of the things to check off the list. "I need to place the patient on oxygen, I need to start an IV, I need to give baby aspirin, I need to give nitroglycerin, I need to get a 12-lead ECG…"

In reality, early acquisition of a 12-lead ECG for all patients with signs and symptoms of ACS is critically important to the success of a prehospital 12-lead ECG program.

Why? Because the same drugs we give to restore balance between myocardial oxygen supply and demand can "clean up" or erase ischemic changes on the 12-lead ECG!

Sometimes the prehospital 12-lead ECG is the only evidence that a patient's chest pain was cardiac in origin! Imagine if this patient never received a prehospital 12-lead ECG and the cardiac biomarkers came back negative.

A patient with a high-risk lesion might have been discharged home. It's unlikely, but it could happen. What would you want for your mother or father?

Next month we'll talk about why we perform serial ECGs!

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
The comments below are member-generated and do not necessarily reflect the opinions of EMS1.com 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.
Bruce Wayne Washburn Bruce Wayne Washburn Wednesday, May 28, 2014 7:14:28 PM Good example of getting that 12 or 15 lead early
Christopher Roy Christopher Roy Wednesday, May 28, 2014 8:19:58 PM Was a right sided 12-Lead obtained prior to the NTG?
Kevin Faile Kevin Faile Thursday, May 29, 2014 2:04:50 PM Lead 2,3 and AVF would indeed require 12 and 15 LEAD EKG to rule out right side involvement prior to NTG use. I primarily use my first 3 LEAD EKG as LEAD 2,3 and AVF, then 12 LEAD and if needed 15 LEAD.
Chris Starkey Chris Starkey Wednesday, October 01, 2014 6:26:11 PM WV IT IS PROTOCOL FOR EMT-b'S TO OBTAIN A 12 LEAD AND COMMUNICATE IT TO THE FACILITY RECEIVING IF WE HAVE IT ON BOARD. LET THEM DETERMINE THE 12 LEAD AND ADJUST ORDERS. WE CAN NOT YET INTERPRETATIVE THEM, BUT I HOPE THATS NEXT
Michael S Murphy Michael S Murphy Wednesday, October 01, 2014 10:45:32 PM Not sure how I would feel giving nitro with her systolic bp 102 kinda a close call...I would at least want dual lines with boluses ready
Scott Brown Scott Brown Thursday, October 02, 2014 8:17:31 AM ...provided you work in a system where you can call a CODE STEMI and they cat the pt based on your strip as opposed to running one when you get there.

EMS1 Offers

We Recommend...

Connect with EMS1

Mobile Apps Facebook Twitter Google+

Get the #1 EMS eNewsletter

Fire Newsletter Sign up for our FREE email roundup of the top news, tips, columns, videos and more, sent 3 times weekly
Enter Email
See Sample

Online Campus Both

Cardiac Care Videos