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EMS 12-Lead
by Tom Bouthillet

ECG Challenge: What in the wide, wide world of sports?

EMS is called to a nursing home for a 71 year old female with shortness of breath.

By Tom Bouthillet

Editor's note: Check out this month's ECG case study and submit your treatment plan in the comments below. Get it right and you could win an EMS1 T-shirt and bottle opener. Good luck!

--> UPDATED: 06/07/2011 - Patient Follow-Up Posted. CLICK HERE FOR THE ANSWER

This case was submitted by a faithful reader who wishes to remain anonymous.

EMS is called to a nursing home for a 71 year old female with shortness of breath.

On arrival the patient is found lying in bed with her head partially elevated.

She appears acutely ill.

Skin is pasty but warm and moist.

The patient denies chest discomfort but admits to shortness of breath.

Breath sounds: rales are auscultated bilaterally, most prominent in the lung bases

Past medical history: Epilepsy, hypertension, atrial fibrillation, CHF

Medications: Aspirin, simvistatin (Zocor), carbamazepine (Tegretol), atenolol (Tenormin), spironolactone (Aldactone)

Vital signs are assessed.

RR: 40
Pulse: 60
NIBP: 118/84
Temp: 96.8

SpO2: 98 on RA

BGL: 218

The patient is placed on the cardiac monitor.

A 12-lead ECG is captured.

What is your interpretation of these ECGs?

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-in-Chief of the, Chief Content Architect of, 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.
Jason Buc Jason Buc Saturday, March 08, 2014 8:03:02 AM Alright- This EKG tells me the pt is hyperkalemic. The qrs is VERY wide. 0.242s per the computer. Anything over 1 big box (0.20s) is suggestive of a metabolic abnormality. The p-wave is gone; another trait of hyperkalemia. Pacer has been considered but no pacer spikes and overly wide. Idioventricular doesn't match my pt and the qrs is overly wide for that. History and med's point towards hyperkalemia as well. While there is no renal failure in her history yet she has HTN to a degree that it has caused her CHF. That same HTN has been affecting her renal function and may now have led to renal failure. Spironolacatone is a K+ sparing diuretic. That means the urine output has been flowing but leaving the K+ behind. Everything points in that direction. Where I work I have to consult for Ca+ 1g and Sodium BiCarb 1meq/Kg for treatment. I need to consider fluid because believe the pt to be dehydrated (see above diuretic). But I'm likely going to hold off on fluid given lung sounds. Final treatment consideration is nebulized albuterol 20mg. We are going to initiate this treatment. Albuterol cause a K+ shift from extracellular (floating around in the blood stream, doing bad things to the heart) to intracellular (tuicked away inside the cell membrane no longer messing with the heart). Additionally the bronchial dilation may help with the rales. Yes there will be an increased workload on the heart but I'm comfortable with that given her current set of complaints and v/s
Finn Larsen Finn Larsen Saturday, March 08, 2014 8:36:18 AM Z pattern. Hyperkaliæmi.
Erik Testerman Erik Testerman Saturday, March 08, 2014 11:46:26 AM Agree with Jason .. Hyperkalemia and I as well would have to call for orders for Calcium and Bicarb... However, if she was in cardiac arrest, it'd be standing orders...Albuterol, D50, Insulin, Kayexalate, Lasix, and of course--the life saving Foley.
Kavi Priya Kavi Priya Saturday, March 08, 2014 12:20:04 PM wide qrs complex,tall t waves
Elizabeth Matson Elizabeth Matson Saturday, March 08, 2014 12:42:47 PM What's her K level?
Craig 'stacky' Stack Craig 'stacky' Stack Wednesday, August 13, 2014 5:35:50 AM just curious, what is the normal BSL reading the reading you gave there, the ones we use the normal range is 4.0mmol-8.0 mmol/L
Amr Hassanien Alnowihy Amr Hassanien Alnowihy Wednesday, August 13, 2014 6:20:21 AM very great comment, but I wonder if this patient have AF, where are the p-waves
Ray Saviciunas Ray Saviciunas Wednesday, August 13, 2014 7:49:12 AM Wide QRS tall peaky Ts, Spiro on Rx list & hyperglycemic (steroid), smells like hyperkalemia. Transmit ekg and talk to med control about calcium chloride. Second 12 lead afterward.
Cody Boylen Cody Boylen Wednesday, August 13, 2014 4:14:36 PM If I were to guess I would say she overdosed on her Tegretol which is a member of the tricyclic antidepressants family

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