Thursday, 14 January 2010

Can you see ST-Elevation???

This ECG was captured from a patient, I have found out since this patient was c/o chest pain, p/t had a AMI, about 2 years ago... This was given to me by a good friend and colleague... Who stated the doctor in the Emergency Dept.. Give my colleague a telling off for not recognizing ST ELEVATION

DO YOU SEE ANY ST SEGMENT ELEVATION ???

Please discuss the ECG and the features... Sorry about the not having no history on this patient!!!
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6 comments:

  1. Flat T-waves in several leads but beyond that no ST-elevation. I would classify this ECG as nondiagnostic. The doctor must have had this ECG confused with another!

    Tom

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  2. Does the patient really in this case has ST elevation ?? May be you mean a history of STEMI well in this case we can consider the deep Q wave in lead aVF as a part of STEMI in inferior leads(the ECG here doesnot show the 12 leads ).
    The QRS interval is normal which exclude acute infarction in the setting of new or presumabely new bundle branch block !! The only place where i can find minimal ST elevation by looking so carefully is in leads V1 and V2, is it acute septal infarction !!!!

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  3. Dr. Hillis -

    1 mm of ST-elevation in lead V2 is a normal finding in most male patients (the so-called male pattern). I see nothing in this ECG to suggest acute injury.

    Tom

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  4. I do agree with Tom B.
    V2-Elevations, esp with this pattern, are often found in young male individuals, also described in the setting of early repolarization.
    There is no red flag indicating acute injury, even without history.

    Thanks.
    Mike.

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  5. It looks a little messy. Was it crumpled up by your colleague and thrown at the medic? There is 'high takeoff' ST elevation following the deep S waves in the chest leads and widespread non-specific ST-T wave changes.

    I wonder if there is LVH.

    The ECG looks a little weird and probably the chest leads (and maybe even the limb leads) were not placed correctly. I'd probably repeat it myself and check that the leads were correct before making any firm decisions on it. (Obviously taking the history and examination into account bla bla ...)

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  6. Thanks Dr Jenkins... I respectfully disagree and say VERY messy ECG...:) and knowing my colleague, it would not surprise me at all if she had crumpled the ECG up and thrown it at the medic...lol, but I believed on this occasion the medic got off lightly and the ECG was just crumpled in her pocket.

    I fully agree about the non-specific ST-T wave changes, and following the some of the Sokolow-Lyon voltage criteria for LVH, S wave in lead V1 + R wave in lead V5 or V6 >3.50mV, there is evidence of LVH in this ECG, also evidence of old inferior infarction. You quite rightly mentioned, the Limb & precordial leads are incorrectly placed... this is a pet hate of mine with paramedics and education should be given to the importance of correct lead placement, and how important this is when comparing the pre-hospital ECG to a 12-lead ECG captured in the Emergency Department... the pre-hospital ECG... may can be misdiagnosed by inexperienced medics... Don't know the solution to this one, apart from more intensive ECG interpretation skills for paramedics, which I have been fighting for a long time, but with the uneducated attitude of if I can't treat it, then I am not interested, this having a impact on poor patient management, incorrect hand over to hospital staff, and quite possibility the patient not getting the correct treatment right away.

    Thanks Dean

    PS: Please let me know when the 3rd edition of "ECG's BY EXAMPLE" will be in the shops.

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