Run of the mill: Patient follow-up

Did you pick the right treatment plan based off the patient's ECGs?

Editor’s Note:

Editor's note: We asked columnist Tom Bouthillet to pick a winner to this month's contest, and he wrote: "Once again I was amazed at the number of thoughtful responses to the "Run of the Mill" case. It was very difficult to pick one as the most correct, especially since reasonable people can disagree as to whether or not the physical exam was reliable enough to clear the spine in the field.

As a matter of fact, I made it difficult to see how everyone would respond. I always enjoy reading
the comments because I get to learn new things and someone always brings up points I hadn't considered. But, after careful consideration I picked gnmcinc whose answer can be seen towards the bottom of the comment block. It was a very well thought out response that correctly interpreted the ECG, recommended a logical treatment plan, and considered total time to definitive treatment.

-->  Haven't read the initial case presentation? Read: Run of the mill

Let's take another look at the rhythm strip.

This ECG shows 3rd degree AV block with a junctional escape rhythm at 40 beats/min.

Let's march out the P-waves.

When a bradycardia presents with more P-waves than QRS complexes, we know there is a block of some kind.

Because the PR-interval is variable we know this is either 2nd degree AV block type I (Wenckebach) or 3rd degree AV block.

So which one?

With 2nd degree AV block type I there will be clustering of QRS complexes because of the "dropped" P-waves.

This ECG shows a constant R-R interval.Therefore, it is reasonable to assume it is 3rd degree AV block.

So, is the escape rhythm junctional or ventricular?

The QRS complex is "narrow" at 92 ms (0.092 s) according to the computerized measurement.

Hence, it is junctional and not ventricular.

Now let's look at the 12-lead ECG.

This 12-lead ECG shows acute inferior ST-elevation myocardial infarction (STEMI).

Note the ST-elevation in lead II, III and aVF and reciprocal ST-depression in leads I and aVL.

(Note: The precordial leads aren't pretty either. There is subtle ST-depression in lead V2 and R-wave progression is absent in the right precordial leads (V1-V3). The ST-segments and T-waves are flat in leads V5 and V6.)

This 12-lead ECG is also very suspicious for right ventricular infarction because the ST-elevation in lead III is greater than the ST-elevation in lead II.

Regardless, the patient's blood pressure is 80/40 so nitroglycerin is contraindicated.

The patient needs fluid. Lots of fluid!

You might argue that the patient should receive atropine or transcutaneous pacing (TCP).

That might prove to be therapeutic, but it's important to remember that the most important determinant of myocardial oxygen demand is heart rate.

Correcting the heart rate could reverse shock and improve coronary perfusion. Or it could increase myocardial demand to the point where it worsens ischemia/injury.

To me it makes more sense to try fluid first.

The other important thing, of course, is to call a "STEMI Alert" and get this patient to a cardiac cath lab or fibrinolytic therapy depending on transport time!

Remember, time is therapy for STEMI patients!

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

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