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EMS 12-Lead
by Tom Bouthillet

ECG Challenge: Just a little depression

EMS is called to a 66 year old male complaining of chest pain. On arrival the patient is found sitting in a chair outside his residence. He had apparently been gardening when he became acutely ill.

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: 07/12/2011 - Patient Follow-Up Posted. CLICK HERE FOR THE ANSWER

This month we're trying something a little different and withholding the computerized interpretation until the solution is posted.

EMS is called to a 66-year-old male complaining of chest pain.

On arrival the patient is found sitting in a chair outside his residence. He had apparently been gardening when he became acutely ill.

Onset: 30 minutes prior to EMS arrival
Provoke: Nothing makes the pain better or worse
Quality: "Crushing pressure"
Radiate: The pain does not radiate
Severity: 10/10
Time: He admits to having an episode of chest pain 1 week ago "but not like this"

Past medical history: HTN, high cholesterol, cholecystitis
Medications: ASA, lisinopril, rosuvastatin

Skin is cool, pale and diaphoretic.

Breath sounds are clear bilaterally.

The patient denies shortness of breath but admits to nausea. He has not vomited.

Vital signs are assessed.

RR: 12
Pulse: 68
BP: 98/54
Temp: 98.0
SpO2: 98 on RA

BGL: 108

The patient is placed on the cardiac monitor.

A 12-lead ECG is captured with the following computer measurements.

HR: 66
PR: 170
QRS: 116
QT/QTc: 440/461
P-QRS-T: 37 -49 177

What do you think of this 12-lead ECG?

Would you call a STEMI Alert based on this 12-lead ECG? Why or why not?

How would you treat this patient?

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.
Ron Graham Ron Graham Sunday, March 16, 2014 6:08:52 AM How some right-sided leads to exclude/confirm posterior wall injury? These are not "just a little depression."
Greg Soto Greg Soto Sunday, March 16, 2014 6:31:14 AM Smartphones are not the best for reviewing these cases. :-)
Justin Waring Justin Waring Sunday, March 16, 2014 6:41:09 AM Widespread Depression With St Elevation In aVR Most Likely LMCA occlusion, Proximal LAD, Or Severe 3VD should Also Be In The Defferential. Pt Needs The Cath Lab.
Toby Bisso Toby Bisso Sunday, March 16, 2014 6:41:31 AM NSTEMI...O2, aspirin nitroglycerin, (watching that BP) and morphine (if needed for pain) to ER
Shaikh Sohail Nadeem Shaikh Sohail Nadeem Sunday, March 16, 2014 12:24:28 PM st elevation in AVR means severe underlying coronary disease left main disease i m quite agree with justin
Ray Ivan Pitch Ray Ivan Pitch Sunday, March 16, 2014 10:50:12 PM ST depression in I II & aVL, ST elevation in aVR and V1 - i'd like to see V4-V6 nonetheless lets go STEMI alert, and get V7-9 if we can to see what's going on posteriorly given V1 depression, get Pt on Morphine to bring the pain & stress down, IV fluids and Pads on just in case. I'd suggest LCMA with possible posterior involvement
Adam Lomax Smith Adam Lomax Smith Tuesday, March 25, 2014 12:31:33 PM LBBB, Diagnostic sgarbossa criteria in lead 2 with inappropriate concordant ST depression. Stemi alert please!
Akif Mufti Akif Mufti Wednesday, March 26, 2014 2:53:45 AM Keeping history in mind, aortic dissection Does not look like acute MI, st elevation in avr could be due to dissection extension towards left coronary system Last but not the least left anterior hemiblock
Lubna Ahmed Lubna Ahmed Wednesday, March 26, 2014 2:22:14 PM good
Zoltán Husti Zoltán Husti Friday, August 08, 2014 8:08:19 AM I think this is the correct answer.
Ioannis Papadopoulos Ioannis Papadopoulos Friday, August 08, 2014 8:44:25 AM LM or LAD proximal and three vesels disease...
Gary Huntress Gary Huntress Friday, August 08, 2014 9:12:36 AM I'm disappointed in myself for missing that in lead 2. I was specifically looking for Sgarbossa but I overly focused on the precordial leads :( Tunnel vision is bad!!
Costas Bar Costas Bar Friday, August 08, 2014 12:27:54 PM ?xcept aVR ST elevation, this ECG shows an LBBB (QRS is 116 but in the ER I would not be able to tell the difference), possibly not pre-existing and this patient is in haemodynamic risk (low BP) , pale and diaphoretic, so the clinical presentation is compatible with an acute coronary syndrome... If he is treated conservatively he is in risk of cardiogenic shock or acute pulmonary oidema in a while, which means that he will enter the cath lab anyway but with a much worse prognosis for a beneficial outcome and we also have to mention the recent onset of symptoms which means that he will have much to gain from a PCI if a total occlusion is to be found. I would treat him with a novel anticoagulant (he is already on ASA), unfractioned heparin i.v and alert the cath lab for emergency coronry angiography and possible primary PCI.
Joseph Jones Joseph Jones Friday, August 08, 2014 1:16:22 PM Left main. Fluid and txt to an interventional facility,
Dr. Smith's ECG Blog Dr. Smith's ECG Blog Sunday, August 10, 2014 5:46:02 AM LBBB with concordant ST depression in lead III and excessively discordant ST depression in V5 in a pattern of subendocardial ischemia. No occlusion, but very dangerous. LM insufficiency vs. 3 vessel vs. LAD, but arteries open. Nevertheless, hemodynamic instability (low BP) is always an indication for cath. Activate.

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