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Early bird gets the worm News

November 21, 2010

EMS 12-Lead
by Tom Bouthillet

Early bird gets the worm

Can you interpret these ECGs?

By Tom Bouthillet

--> UPDATED: 12/07/2010 - Patient Follow-Up Posted.  CLICK HERE FOR THE ANSWER


EMS is called a "Wellness Center" (it would prove to be a chiropractor's office) for a 20-year-old male with a near syncopal episode.

On arrival the patient is found sitting in a chair with his head between his legs. He is pale and diaphoretic and appears acutely ill.

The patient's chiropractor states that he was adjusting the patient's spine when the patient complained that he didn't feel well.

The chiropractor sat the patient down on the end of the exam table and the patient suddenly "went limp."

The chiropractor caught the patient and laid him down flat. The patient recovered, sat up, insisted on standing, promptly "went limp" again and was placed in a chair.

The chiropractor contacted 911.

Past medical history: "Back problems"

Medications: Vicodin, Skelaxin, Flexeril

Vital signs are assessed.
RR: 18
Pulse: 56
BP: 92/48
SpO2: 99 on RA
BGL: 118

The patient denies chest discomfort. He admits to nausea but has not vomited.

Breath sounds are clear bilaterally.

A 12-lead ECG is captured.

And another.

You are 15-minutes from the local non-PCI hospital and 45-minutes from a STEMI Receiving Center.

How would you treat this patient and why?


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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Mohamad Abdelmaguid Mahmoud Mohamad Abdelmaguid Mahmoud Monday, March 05, 2012 12:52:13 PM I will treat this patient with NSAID , I think ECG shows Diffuse ST elevation with PR elevation in aVR with PR depression in Lead II which coiencieds with acute pericarditis..
Dawn Altman Dawn Altman Monday, March 05, 2012 2:00:49 PM Although he has the ST segments to support acute pericarditis, he should not be fainting as a result. He also does not have PR segment depression, although he does have PR elevation in aVR. Do not know if he is febrile. Due to the fact that he has a relatively low BP, takes pain meds and a muscle relaxant, has no chest discomfort, appears poorly perfused, and loses consciousness upon sitting and standing, I vote for postural hypotension. I would try fluid replacement first, and followup at the closest hospital.
Kim Elkins Kim Elkins Tuesday, December 18, 2012 4:18:17 AM Could he have chronic STE?..and/or a vagus nerve reaction?
Séan Johnston Séan Johnston Tuesday, December 18, 2012 5:11:13 AM Possibility of osborn waves in v4, v5, b2b Could be indicative of a subarachnoid bleed.
Séan Johnston Séan Johnston Tuesday, December 18, 2012 5:13:00 AM Whoops, v6, not b2b.
David Schott David Schott Tuesday, December 18, 2012 6:51:52 AM Torn vertebral artery that is what I'm going to diagnose from my arm chair
Alexander Robinson Alexander Robinson Tuesday, December 18, 2012 7:40:54 AM How about a history of injury? Is his reason for visiting the chiro recent? If so, I'd be concerned about the possibility of a brain bleed because of the Osborn Waves.. TBI would explain the brady, but someone would have to clarify to me why his other vitals aren't conforming to Cushing's Triad.
Alexander Robinson Alexander Robinson Tuesday, December 18, 2012 7:46:44 AM Although I'd also like to know this pt's physical condition... is he athletic or not. Wouldn't hurt to check orthostatics on this guy for sure.
Jaber Ibrahim Almajbry Jaber Ibrahim Almajbry Wednesday, December 19, 2012 10:35:31 AM Dx is J wave syndrome which include hypothermia , STEMI , ERS & Brugada syndrome , check temperature to exclude hypothermia, serial troponin to exclude STEMI( pt has no chest pain) if +ve give aspirin & clopedogril & send him for PCI according to contact to balloon time , if STEMI is excluded treat as Brugada or type 2 ERS (inferolateral type which has intermidiate risk of SCD) give Quinidine or Isoprenaline or pacing according to the pt condition & send him to EPS lab for ptovocative test & study.
Brian Hiestand Brian Hiestand Monday, November 18, 2013 5:45:17 AM The differential for a young, apparently healthy individual abruptly passing out mostly lives in the "not sick" realm - dehydration, orthostasis, vagal response due to the sickening sensation of one's spine being forceably relocated, but there are a couple of landmines. HOCM, long QT, WPW, and Brugada are the relatively rare, but potentially really dangerous, actors here. The cardiac exam is not provided, so I can't speak to the presence of an outflow tract murmur. I will say that the p-waves are not normal in appearance, possibility of atrial enlargement. The QTc is fine, and there are neither delta waves nor a short PR interval to make me think of WPW. This *may* be indicative of a Brugada type III ECG, with the saddle back ST elevation that is most prominent in V2. The ST elevation is diffuse, with notched j points - more consistent with repol variant. I am not particularly concerned with STEMI here, especially in the absence of chest pain in someone I would not suspect of being at high risk for atypical angina (elderly, female, diabetics). Bottom line - nearest hospital, not PCI center. Fluids, monitor en route. Make sure he can still wiggle his toes after getting his spine cracked - we did not discuss spinal shock on the differential ;-)
John Hileman John Hileman Monday, November 18, 2013 6:50:14 AM I would definitely consider this a "treat the PT, not the monitor" case. I wouldn't immediately scream STEMI, but would take repeated 12-leads. Not enough reciprocal depression for one thing. Osborne wave indicates possible hypothermia, so I would also monitor for sepsis. I agree with the stage-1 pericarditis. But I'm still pretty inexperienced, so even I don't really listen to what I say! :-)
Athanasia Avramidou Athanasia Avramidou Monday, November 18, 2013 7:23:28 AM ACS (biphasic T anterior wall).local non pci hospital for evaluation and treatment because its closer
Chris Morrison Chris Morrison Monday, November 18, 2013 9:09:00 AM Brugada vs possible Wellings Syndrome though less likely due to his low risk factors. No inverted t waves to suggest CNS ischemia. Don't activate but he needs to go to a facility with interventional cardiology under lights.
Abu Saif Altamimy Abu Saif Altamimy Monday, November 18, 2013 11:17:56 AM biphasic t waves in v2 and v3 so its wellens syndrome urgent pci is recommended
Will Roberts Will Roberts Monday, November 18, 2013 11:55:14 AM What I would like to see is what is his EKG when the patient is symptomatic. But like others have said? what is his core temp? My preliminary impression is Sinus w/ possible early repol. Not completely sold on those notches being Osborne waves (could be still). Brugada is still not too far off my list of possibilities.
Erind Gjermeni Erind Gjermeni Monday, November 18, 2013 11:57:59 AM unlikely STEMI (no Depr, and diff STE) but i would send him for a coro anyways. V3 looks prety bad.
Patrick Friel Patrick Friel Tuesday, February 11, 2014 9:00:59 AM I would treat pt with fluid repeat ECG while enroute to PCI. I think the second ECG looks worse than the first. Young people have heart problems as well. I would rather treat on the safe side. Being young I would rather not want the non PCI center to sit on pt to do additional test. Let PCI determine if that want to cath pt.
John Rourke John Rourke Tuesday, February 11, 2014 9:06:08 AM On the assumption that the STEMI receiving centre will have cardiac experts and this is by no means a typical or easy to interpret ECG I would take the extra half hour drive. I would do repeat ECGs with more obs (Including temperature and cap refill) en route and feet up to help with BP.
Peter Faulds Peter Faulds Tuesday, February 11, 2014 9:39:52 AM theres st elevation in nearly every lead pericarditis but the elevation is altered in some leads rsr in I interesting ecg any more on his condition
Guka Machitidze Guka Machitidze Tuesday, February 11, 2014 9:51:45 AM Substernal or left precordial pleuritic chest pain with radiation to the trapezius ridge (the bottom portion of scapula on the back), which is relieved by sitting up and bending forward and worsened by lying down (recumbent or supine position) or inspiration (taking a breath in), is the characteristic pain of PERICARDITIS - That explains, why the patient visited chiropractor's office for "back problems"
Guka Machitidze Guka Machitidze Tuesday, February 11, 2014 9:51:59 AM Plus diffuse ST elevations & ST depression in aVR lead in conjunction with subtle PR depression in limb leads & PR elevation in aVR lead
Gordon-the Medic Gordon-the Medic Tuesday, February 11, 2014 10:08:33 AM Micheal Noone
Larry Moore Larry Moore Tuesday, February 11, 2014 11:00:31 PM I'd tend to follow the pericarditis theory here. There is a taller STE in lead 2 than in lead 3 & I don't see any reciprocals anywhere. The STEs look mainly concave rather than convex or flat, though V3 gave me some pause, I think it's an inflated version of V2. That being said, I'd feel better if there were more of a Spodock's sign here. More history would be nice, but his meds makes me think this has been building a little while and his bradycardia & hypotension may be vagal induced. His short QTc and Osborne waves would make me consider hypercalcemia, too.
Dawn Reyes Dawn Reyes Tuesday, February 11, 2014 11:11:24 PM EKG nut!! lol.. interesting though :)
Brandon Kahiau Rickard Brandon Kahiau Rickard Wednesday, February 12, 2014 12:27:16 AM Exactly what I thought Larry! Lol
Cindy Esveld Cindy Esveld Wednesday, February 12, 2014 2:37:28 AM Wow... my last nursing instructor would have loved you! ;)
Larry Moore Larry Moore Wednesday, February 12, 2014 2:57:45 AM Don't be too impressed. I may have had some good points, but I was wrong. It's early repolarization, which has always been a tough read for me.
Vinod Kumar Vinod Kumar Wednesday, February 12, 2014 9:36:13 AM This ECG does not favour STEMI, Differential diagnosis will be the following: 1.ARVD should be excluded due to the presence of epsilon wave. 2.Brugada syndrome should be excluded as the st segment in anterior leads are in favour of it. Above mentioned disease can cause syncope. Additional findings are ? Early repolarisation
Christopher Nicosia Christopher Nicosia Thursday, July 03, 2014 1:53:50 PM I would like to see a posterior ECG. Inferior ST elevations, some in precordials and look at aVR. Prosthetics with nausea, something else going on.
Christopher Nicosia Christopher Nicosia Thursday, July 03, 2014 1:54:38 PM *orthostatic changes...Love auto correct
Adam Thompson Adam Thompson Friday, July 04, 2014 6:11:12 AM Young males would generally present with "classic" symptoms of a cardiac event. I'm assuming that the patient is hypotense due to another cause. 12-Lead Findings: - Almost global concave up STE without reciprocal changes - "Notched J-points" - Intact precordial R-wave progression - Short QT/QTc - No dynamic changes Differential Dx: Early Repol vs. Pericarditis - No chest pain - No Spodick's Sign Appears to be classic early repolarization (not that the title gave anything away). - Assess for opiate overdose - Assess for orthostatic changes - Determine cause of potential exaggerated vagal response (perhaps it's the quacks fault) Phenomenal case presentation as always Tom. Thank you.
Ruud Valkenborg Ruud Valkenborg Thursday, October 23, 2014 3:52:32 AM there is a early ST-T segment. No stemi at all
Kieran Potts Kieran Potts Thursday, October 23, 2014 4:00:18 AM Interesting tracings. Looks very pericarditis-ish to me. With the STE being greater in v3 than v2. And more or less global STE. Although I am viewing on a small iPhone screen! The lack of any chest pain and symptoms typical of MI would exclude him from our local PPCI guidelines. But I'd contact the lab and express concerns. They'd more than likely accept and angio/echo him before deciding what to do, if not for PPCI they'd keep him for monitoring on the CCU I think. given his age I know pericarditis is an easy 'cop out' though... Treatment here would be pre alert, maintain BP at 90 systolic, blue light transport. I'd probably cannulate prior to transporting. Could argue whether we'd go down the aspirin and Gtn route - he's pain free so gtn wouldn't be indicated for us, but due to the presentation aspirin is indicated for 'clinical or ecg evidence of ischemia'.
Kieran Potts Kieran Potts Thursday, October 23, 2014 4:02:17 AM And as mentioned below lead II is greater than III.
Paul Dirkes Paul Dirkes Thursday, October 23, 2014 5:36:37 AM Early repolarisation. No stemi. Collaps could be vasovagal. No pta depression so no pericarditis
Sean Morrison Sean Morrison Thursday, October 23, 2014 7:11:21 AM Benign early Repolarizaton
Terra Long Ciurro Terra Long Ciurro Thursday, October 23, 2014 7:23:26 AM Med-related?
Audrie Michelle Audrie Michelle Thursday, October 23, 2014 8:54:41 AM Why do you say that? Because of his age? The morphology of the T waves in V2 and V3 is convex, and the T wave in AVL is biphasic. Lead 1 has a little bit of elevation. He's definitely symptomatic. I wouldn't rule out STEMI in this case.
Rory Groessl Rory Groessl Thursday, October 23, 2014 5:39:48 PM Benign early repolarization.. notching/slurring at the terminal QRS with upward concave ST Elevation
Hakim Aldahesh Hakim Aldahesh Thursday, October 23, 2014 5:50:42 PM repolarization disorders
Sean Morrison Sean Morrison Friday, October 24, 2014 1:28:10 PM Audrie Michelle Just learned it! Did u see the conclusion? Maybe the chiropractor vagaled him out.

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