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ECG Challenge: The missed match News

August 16, 2012

EMS 12-Lead
by Tom Bouthillet

ECG Challenge: The missed match

EMS is called to residence of 67-year-old male complaining of shortness of breath; what's happening with this patient?

By Tom Bouthillet

EMS is called to the residence of a 67-year-old male complaining of shortness of breath.

At the time of EMS arrival, the patient walks out of the bedroom into the living room and slumps over onto the gurney in obvious distress.

Past medical history: Hypertension, prostate CA
Medications: Lisinopril, Norvasc
Breath sounds: Diminished bilaterally

The patient appears anxious. His skin is dusky and diaphoretic.

He states that he was short of breath "on and off" all night and had planned on playing tennis in the morning but "felt way too bad."

Vital signs are assessed.

  • RR: 40
  • HR: 74
  • NIBP: 154/89
  • SpO2: 93

The patient states that he became "much worse" after ambulating from the bedroom to the living room. As he calms down, his respiratory rate comes down to about 28.

The patient is placed on oxygen via NRB mask at 15 LPM as the cardiac monitor is attached.

A 12-lead ECG is obtained.

The electrodes were not sticking well to the patient's skin, so lead V3 was held down manually, and another 12-lead ECG was taken.

Upon questioning, the patient admits to some chest discomfort. The treating paramedic decided to assess leads V4R, V8 and V9 (sometimes referred to as a "15-lead ECG").

The patient states that he recently got back from a business trip to the West Coast.

What do you think is happening with 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
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Dave Scruggs Dave Scruggs Thursday, August 16, 2012 7:27:50 PM Pulmonary embolus
Margaret Thiel Margaret Thiel Thursday, August 16, 2012 8:30:57 PM I am a new paramedic, so don't laugh as I am trying to learn. (thanks) PE is my first thought. But, is the dusky skin color an indication of PE? Another thought I am thinking about is toxicity? Maybe diet related (grapefruit, etc) or overdose or liver issue concerning the Norvasc? MI is kinda my last thought, but for sure a thought of mine. Gotta say the dusky skin color has me thrown as to PE or toxicity/od, but sounds more like MI sign. Appreciate any and all education I get from you terrific folks. You teach me something everytime I read this page. Kudos to all of you in EMS and love ya all! My verdict.... PE. Am I right?
Margaret Thiel Margaret Thiel Thursday, August 16, 2012 8:34:19 PM PS.... toxic liver levels will cause SOB, diaphoretic, chest pain, etc. I know cuz I had all the classic heart attack signs and symptoms, but my liver was the problem. My heart is perfect. OK, now you can laugh at me.
Shilon Sechrest Shilon Sechrest Friday, August 17, 2012 3:27:57 AM PE
Eric Graham Chase Eric Graham Chase Friday, August 17, 2012 4:32:09 AM PE
Kev Hitchens Kev Hitchens Friday, August 17, 2012 4:59:11 AM PE would be mine without actually being there....
Suhail Hassan Suhail Hassan Friday, August 17, 2012 5:21:21 AM q..wave lead3...twave inversion...lead3, avl, avf, v1, the last twave inversion leadv4.
Suhail Hassan Suhail Hassan Friday, August 17, 2012 5:22:03 AM please answer?
Maciej Walczak Maciej Walczak Friday, August 17, 2012 5:25:06 AM HPI and ecg..... for me this is PE
Frank Ay Frank Ay Friday, August 17, 2012 5:45:34 AM The EKG's shown suggest inferior ischemia, perhaps with right sided extension. Wondering if the T wave inversions in V1-V3 might be due to posterior problems. PE sounds good with SOB and dusky but PE would not cause dimminished lung sounds as the air is going in and out perfectly fine; only the pulmonary blood flow is restricted. Would really expect tachycardia though with a PE unless his norvasc (ca channel blocker) is keeping his rate under control. It should be considered though given recent travel from CA (although we don't know what state he is coming from!). Any signs of DVT in his legs? Since he was travelling, might wonder if he was scuba diving on this trip the day before the flight(?) home as his symptoms might fit decompression sickness.
Frank Ay Frank Ay Friday, August 17, 2012 5:56:08 AM never mind about posterior. I just looked at V8/V9 now :-)
Sarah Bye Sarah Bye Friday, August 17, 2012 7:15:42 AM 1st degree AVB, STTW changes in III, V1-V3 and possible V4R (hard to tell if that's baseline artifact or actual changes). Since he has been traveling, PE is in the DDx. STTW changes could be ischemic and secondary to lack of blood flow to left side of the heart from a PE. O2 and secondary support with transport to hospital for d-dimer, troponin, x-ray, and CT Pulmonary Angiogram for starters.
Benjamin Terry Benjamin Terry Friday, August 17, 2012 7:42:38 AM S1, QT3 (slurred s-wave in lead 1, q-wave and inverted t-wave in lead 3) are fairly good indicators for a PE when present with symptomatic PT.
Jacob Miheve Jacob Miheve Friday, August 17, 2012 11:31:33 AM ECG is negative for STEMI, and neither STEMI nor PE would account for the diminished lung sounds. Specifying that his trip was to the "west coast" makes me think he flew, so the significant and rapid altitude changes, chest discomfort, DIB, and diminished lung sounds would make me consider the possibility of a slowly developing spontaneous tension pneumothorax. Continue high-flow O2 and monitoring, monitor EtCO2, establish an IV, and I would transmit those 12-leads to medical control and consult with the Doc before going on with my chest pain protocols (ASA, NTG, morphine). If I couldn't get hold of med-control, I would go with the CP protocol, but with careful monitoring.
Randy Fugate Randy Fugate Friday, August 17, 2012 2:02:41 PM Although not the largest S wave, given the history and presentation, I believe the patient meets the S1-Q3-T3 criteria for a PE. Of course I could be wrong..........
Andy Tiernan Andy Tiernan Friday, August 17, 2012 2:09:26 PM Recent trip and what almost sounds like an "air hunger" point to poss PE but the diminished breath sounds with the decreased SaO2 point to a poss pulmonary edema versus embolism. Not all AMIs are STEMIs, I see the 1st Degree AVB and wouldn't normally give it a second look except if I see the possibility of a LPHB like the axis is starting to move towards. Again, that wouldn't bother me except for the PT has chest pain! Looking at the Q in III is not too conclusive since it doesn't reflect in II or aVF. The T inversion looks to be Inferior and Septal. It's tough but not all horses look like zebras and sometimes ducks don't quack. Hmmmm... something about S1Q3T3 rings a bell, RAD, T inversion in the right precordial leads (V4R), 1st degree AVB - All EKG changes published as being associated with Pulmonary Embolism. I would probably still treat as ACS but report my field impression to the ED MD and also adjust my transport decision given the fact that our local ED can do nothing for either ACS or PE.
Billy Harris Billy Harris Saturday, August 18, 2012 12:03:52 PM P.E.
Heather Costa Heather Costa Saturday, August 18, 2012 12:10:04 PM He is normally active (going to play tennis in the morning). With some minor issues and recent travel I would say PE.
Douglas Souris Douglas Souris Saturday, August 18, 2012 12:19:02 PM I have not been out of the Ambulance for a few years and I am coming back. From what I do remember and undertand from the hx it sounds like a PE. As for the 1st degree heart block, it appears to be something I may also make note of but not be concerned about. The recording is very blurry to me so I can not reallly see it all that well.
Mike Stephenson Mike Stephenson Saturday, August 18, 2012 12:26:07 PM Pulmonary Embolism
Danielle Connell Danielle Connell Saturday, August 18, 2012 2:19:43 PM pulmonary embolism....he has a 1st degree HB. also, did the pt also complain about an ache under either of his armpits and did he have a wheeze to go along with the SOB?
Mike Berry Mike Berry Saturday, August 18, 2012 2:20:15 PM would of like to see capnograthy on this pt to rule in a PE,
Jane A. Merrill Jane A. Merrill Saturday, August 18, 2012 2:49:48 PM Sounds like it may be a good call on your part???!! Sounds like too that your EMS job is almost as tough as a doctors!! Good luck to you!! :)
Ken Grauer Ken Grauer Saturday, August 18, 2012 3:01:26 PM I agree with Maciej - Hx & ECG = Pulmonary Embolus. There is a classic S1Q3T3 in association with persistent precordial S waves and anterior symmetric T wave inversion (which reflects "RV strain"). The overall pattern does not look like ACS.
Angela Washington Angela Washington Saturday, August 18, 2012 6:36:54 PM Oops
Heidi M Fischer Heidi M Fischer Saturday, August 18, 2012 6:38:45 PM I'm also very new at this but I'll have a guess: S1Q3T3 (S-wave in lead I, Q-wave in lead III, inverted T-wave in lead III)? Points towards PE?
Jose Ortiz Jose Ortiz Saturday, August 18, 2012 8:09:22 PM Work up your
Jose Ortiz Jose Ortiz Saturday, August 18, 2012 8:12:16 PM Work up your diff/dx P.E. c.h.f. Etc. P.E. sounds like
James Nolan James Nolan Saturday, August 18, 2012 8:28:06 PM The 12 lead appears to be a Lateral MI with depressions on lead III and aVR...It could be a PE as well, but I would lean more on the MI side of things just to be safe since he has a history of HTN and walking from the bedroom to the living room made things more difficult. Plus, it appears that damage to the heart has already been done since BP isn't as high as it could be in a HTN patient. The BP is more than likely affected by the beta block he has been taking. Please let me know since I am still a paramedic student.
Annette Webb Annette Webb Saturday, August 18, 2012 8:50:11 PM Talk English, boy! Lol
Fiona Mcguire Fiona Mcguire Saturday, August 18, 2012 11:36:10 PM how about just call the dr?
Reno Daly Reno Daly Sunday, August 19, 2012 7:48:01 AM Having watched what an ER team, equipped with a nearby blood lab (for D-dimer test), a CT machine (pulmonary CT), etc, and all the other equipment at their disposal in a controlled environment, try to diagnose essentially the same problem, I have a newfound respect for EMT's. That you can do this in the field with limited gear available to you is just truly amazing! Good work.
Lars Olsen Lars Olsen Sunday, August 19, 2012 4:16:45 PM PE for the win, dyspnea on exertion and the 1st deg are the clues.
Lars Olsen Lars Olsen Sunday, August 19, 2012 4:17:49 PM dusky skin color is a sign of poor perfusion. When you see "dusky skin color" think cyanosis.
Janine Freeman Wood Janine Freeman Wood Sunday, August 19, 2012 6:33:07 PM Was that the right answer? If so, then we rock!!!!
Heidi M Fischer Heidi M Fischer Tuesday, August 21, 2012 5:38:37 PM Ha ha Fi, now you're telling me! That could have saved me hours of work on our PE assignment from hell (fond memories - lol).
Joey Bianco Joey Bianco Tuesday, August 21, 2012 6:46:34 PM No
James Nolan James Nolan Tuesday, August 21, 2012 9:59:01 PM Thanks Joey, lol
Dominik Schreiber Dominik Schreiber Tuesday, August 28, 2012 2:08:23 PM Endlich gefunden! Hope, all of you are doing well! Ich bin seit genau 2 Tagen online und suche die Welt nach FreundInnen ab. Got you! :-)
Joshua Davis Joshua Davis Monday, September 10, 2012 4:02:35 PM History and ECG suggest PE.
Janie Miller Davis Janie Miller Davis Monday, September 10, 2012 9:20:22 PM Boy, I tried to read the story and keep up...too many words, charts, stuff for me! Glad and grateful you do what you do!
Andrew Kelley Przepioski Andrew Kelley Przepioski Monday, April 08, 2013 2:30:29 PM I agree with pulmonary embolism. The rate is 68. I think tachycardia is the #1 finding in pulmonary embolism so this is a negative finding. The rhythm is normal sinus rhythm with first degree AV block cause the rate is within normal limits, it's regularly regular, and there is an obvious p-wave in V1 associated with each complex and non changing, but the PRi is >0.20 (bigger than 1 big box). The machine says 0.25s. The QRS is kinda wide, like 0.10s (looking at the anterior leads), the machine says 0.106s. I don't NSR with AVB 1 has anything to do with pulmonary embolism. Looking at the frontal axis, I can see that I is biphasic both R and S wave about equal in size so it's either going almost perfectly up or down, and II and III are positive if you use the I, II, III trick, or aVF is positive if you use I and aVF, which means it's going down. The machine says 91 degree. I cannot tell the Z axis, they are all biphasic, no progression after V2. When the R/S >1, I consider right bundle branch block (RBBB), posterior wall MI, and right ventricular hypertrophy (RVH). No second R-wave in V1 (although sometimes RBBB present itself with qR), there are S-waves in I and V6 though. V6 is like a pseudo posterior lead, and doesn't have ST elevation (STE). Lead V8 and V9 are posterior leads and have no STE. I think this is RVH, which I believe I read is common in shortness of breath. Like I said, I believe there is RVH. S1Q3T3 is actually a right ventricular strain pattern I believe. I don't see any other ventricular strain pattern (ie STE in anteroseptal leads or discordant T-waves), and voltage criteria not met for LVH. I don't any signs of atrial enlargement either. The T-waves in the lateral leads are very symmetrical. Retrograde T-wave in the anteroseptal T-waves (seen in pulmonary embolism too). Already mentioned S1Q3T3. Short of breath and recent trip, low SpO2, retrograde T-wave in at least V1 and V2, RVH, and S1Q3T3, I think pulmonary embolism is a very reasonable working diagnosis. Other things that would have supported pulmonary embolism, but wasn't present, was pseudo RBBB pattern in V1, tachycardia, ST depression in anteroseptal or inferior leads.
Aaron Rubio Aaron Rubio Saturday, April 27, 2013 4:13:33 PM I'd agree with you but then we'd both be wrong.
John Donovan John Donovan Thursday, May 23, 2013 4:38:05 AM PE
JamesandRachelle Bethea JamesandRachelle Bethea Thursday, May 23, 2013 5:03:53 AM I agree with the comment below, recent travel, normally active without issue and the huge indicator is S1Q3T3 (S wave in lead I, Q wave in lead III, and inverted T wave in lead III - hallmark sign of PE. Can also be caused by right heart strain, but the pt has no respiratory hx) Combined with SOB, dyspnea, chest pain and low 02 sat = PE.
Bruce Goldthwaite Bruce Goldthwaite Thursday, May 23, 2013 6:05:50 AM PE, dyspnea with exertion that is relieved with rest and an other wise negative exam and 12 lead EKG.
Mark Smikahl Mark Smikahl Thursday, May 23, 2013 10:08:32 AM PE...S1Q3T3 Phenomena adds some probability as well. MI would most likely result in pulmonary edema, and any bronchospasm would be simple to detect-plus no history of such. I would wonder if he has had any recent medical/dental procedures, travel, new medications, trauma, etc....
Alexander Labak Alexander Labak Tuesday, April 29, 2014 8:01:23 AM PE, S1Q3T3 ...
Joseph Jones Joseph Jones Saturday, September 06, 2014 4:15:04 AM PE
Valeri Behr Valeri Behr Saturday, September 06, 2014 4:15:28 AM S1 T3 Q3=PE
Sascha Steingrobe Sascha Steingrobe Saturday, September 06, 2014 4:48:31 AM PE as he shows SIQIII, T wave inversion in III and septal. Hx if business trip will match this. Wellens syndrome as DDx but the anterior inversion is not significant.
Chris Perham Chris Perham Saturday, September 06, 2014 9:12:59 AM S1Q3T3...curious if he would desat with ambulation and the tachycardia would develop
Barry D'Alive Barry D'Alive Saturday, September 06, 2014 12:45:51 PM You mean as a PARASYMPATHETIC response?

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