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Run of the mill
Can you interpret these ECGs?
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: 02/24/2011 - Patient Follow-Up Posted. CLICK HERE FOR THE ANSWER
EMS responds to a fitness center where an elderly female has experienced a syncopal episode.
On arrival, the staff leads a paramedic and her EMT partner to the 68-year-old female who is lying supine next to a tread mill.
She appears pale, diaphoretic, and acutely ill.
A nurse is holding a gauze pad to the patient's forehead. A look under the gauze reveals a laceration and hematoma the size of a silver dollar.
Vomit is noted on the floor next to the patient's head.
The patient is conscious but listless and oriented to person, place and time but not event.
When asked if she has any pain the patient says, "Yes" and then rolls on her side and begins throwing up.
The radial pulse is slow and barely palpable. The patient seems very weak.
She denies neck or back pain. There is no pain or tenderness on palpation of the cervical spine.
The patient is placed flat on the gurney and vital signs are assessed.
Resp: 12 and shallow
Pulse: 40 and regular
NIBP: 81/43
SpO2: 96 on RA
Breath sounds are clear bilaterally.
The cardiac monitor is attached.
A 12-lead ECG is captured.
How would you treat this patient and why? Tell us in the comments below — get it right and you could win an EMS1 T-shirt and bottle opener.
Comments
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Aaron Craig Friday, April 13, 2012 7:04:45 AM 1. Keep patient warm and comfortable in the supine position.
2. Oxygen delivered via nasal cannula - keep sats as high as possible.
3. Baby ASA
4. Fluid bolus 500mL and repeat after checking breath sounds.
5. Contact closest facility with cath lab to activate code STEMI.
6. Consider asking for orders for heparin or LWMH.
7. Consider pacing if patient becomes unstable with change in mental status, chest pain, shortness of breath, etc.
8. Transport with lights and sirens!
This patient is having an inferior MI as evidenced by ST elevation in leads II, III, aVF with additional elevation in leads V1 and possibly V2, V3. There is reciprocal changes in the lateral leads. Most likely the SA node is involved leading to her bradycardia. In addition, forward flow of blood from the right ventricle to the left ventricle has been compromised thus leading to hypotension - i.e. cardiogenic shock. This would exclude nitro and morphine in management because they would further reduce preload and worsen her systemic blood pressure. It is best to transport quickly to a hospital with cath lab capabilities as this lady's presentation carries a poor prognosis.
Thanks,
Aaron 
Brian Schlener Saturday, December 22, 2012 1:25:38 PM Obvious inferior STEMI (STE in II, III, AVF) with a high probability of right sided involvement due to the 3rd degree heart block. SA node probably got knocked out.
High flow oxygen. I'd call for a 2nd medic in case I need to do a sedation assisted intubation if the pacing doesn't improve her condition (PA protocols need 2 medics on scene).
Start pacing immediately.
Get an IV established and get some fluids running.. 250 bolus
Aspirin if she can chew.
Call a STEMI alert and high tale it to the nearest cath lab. 
Andrew Kelley Przepioski Saturday, December 22, 2012 3:32:33 PM This AVB third degree. Ventricle rate is 42, atrial rate is about 87. Some p-waves are hiding in the ST changes and T-waves.
Since she is satting well on room air (confirm that the conidition is right ie check for nail polish and the extremity is warm, considering trying another location for SpO2), respiratory rate is within normal limits, and her lung sounds are clear, I think this patient doesn't even really need supplemental oxygen, and it's no longer recommended by the AHA as long as she's 94-99%. I think a non rebreather mask could compromise her airway because she is vomiting. Because her respirations are shallow though and oxygen does have some antiemetic effect (although in high doses like FiO2 0.8 I've read), I would put her on a nasal cannula starting off at 2 liters per minute, and increase as needed.
I think her 12-lead definitely shows an inferior wall MI with right ventricular involvement. Her right coronary artery probably feeds the AV node, and that's why she's having this rhythm. I would administer 325 mg aspirin. Because of her blood pressure and right ventricular involvement, I would not give morphine or nitroglycerin.
At this point, I would start focus on trying to transport her. She's a STEMI patient, she needs to go to the cath lab.
En route, I would then try to start an IV.
I don't consider her hemodynamically stable: she's vomiting, poor skin signs, slightly altered, she had a syncope. I don't like her rhythm, but I'd treat it last since I think the STEMI is the main problem that needs a hospital and is the etiology of the rhythm. I think the IV will be useful for the receiving facility/cath lab. I would then TCP after I have an IV. If her BP doesn't raise to SBP >90, I'd consider a fluid challenge 250 mL NS. Andrew Kelley Przepioski Saturday, December 22, 2012 4:58:44 PM By the way, I saw that some of you guys were saying that it's right ventricular involvement because V1 has STE, and V2 has ST depression. The rule I learned was when STE in III > II, which is what I was going off of.
I wonder which one is more specific & sensitive. 
Ben Church Saturday, December 22, 2012 8:33:29 PM I disagree with the lack of hemodynamic compromise, a rate that low with a pressure that low is enough for me to consider hemodynamic compromise. And while I agree that an airway should be prepped I'm not sure that the use of paralytics or benzos in this case are appropriate. Given the BP and the 12 lead I am more inclined to begin TCP without the use of narcotic relief immedietly. I realize this is going to hurt but the bottom line is we need to fix her BP and mental status before even considering sedation,
In PA you need to be careful where you are about asking for that particular protocol. there are command facilities that do NOT issue etomadate to their services and will crucify you if you even think to ask for that order. I've seen it done to a least a dozen medics in Alleghany County. 
Stan Gorham Thursday, February 07, 2013 12:07:30 AM I've been out of EMS for a couple of years now, butwhy not LLB and C-Collar? 
