EMS is called to a VA clinic for a 23 year old male who came in to get checked into the system. Somewhere in the exchange, he mentioned that he had been experiencing chest pain off & on for just over a month.
Onset: Today's pain came on gradually.
Provoke: Nothing makes the pain better or worse.
Quality: Pain described as "pressure".
Radiate: Occasionally radiates to the jaw.
Severity: "Mild" (no pain scale)
Time: Several previous episodes over the past month.
The patient denies shortness of breath. There is no nausea and the patient has not vomited.
A 12-Lead ECG is captured at the clinic.
And another.
9-1-1 was contacted.
The patient was given O2, ASA, and NTG at the clinic.
EMS arrives and performs their own assessment.
(Vital signs not available -- let us assume they are within normal limits, stable, and not otherwise helpful to the assessment).
The cardiac monitor is attached.
The paramedics capture their own 12-lead ECG.
Are you concerned about this ECG?
Why or why not?
Should a STEMI Alert be called from the field?
Why or why not?
Would you bypass the local non-PCI hospital for a STEMI receiving hospital?
Why or why not?
*** Update 03/25/2010 ***
Here are some serial ECGs captured in the field.
Does this help?
I suspect this is a healthy young man. Probably active, judging by his resting HR.
ReplyDeleteLooks like normal variant from LVH with BER.
Dr. Smith Method - Mean amplitude of v2-v4 > 5 mm.
No reciprocal changes.
i think this is angina pectoris based on ST segment elevation in ECG,n da pain comes gradually and doesnt get worst or better...and da pain is described as "pressure" and radiates to neck and jaw..
ReplyDelete? sloping saddle-shape st elevation? pericarditis
ReplyDeleteAnonymous, I doubt the ST-elevation is MI indicative. Wayne, pericarditis is just another STEMIC in my opinion, meaning whether it is pericarditis or benign early repol won't change treatment. I believe acute pericarditis usually presents with the appearance of global st-elevation due to PR depression. Like I said tho, won't change the treatment. We have figured out that we don't need to waste the cath team's precious time.
ReplyDeleteps. The serial ECGs on this patient are great. Strong work by the crew.
No reciprocal changes are notes, theoretically, they should be present. 15-18 lead would possibly, although doubtfully, help. Most likely a normal variant for this young man. With the absence of GREATER than 1mm elevation, I don't think that I would be calling a STEMI from the field, nor would I push to drive 40 miles out of the way to go to a PCI Center. Serial Markers and Serums should definitely be a priority....possibly an Echo as well...all can be conveniently found at your friendly local ER :) Strong work by the EMS crew.
ReplyDeletei think , this is not the electric profile of ACS ,so ther's no typical ST elevation and also no miror aspect .
ReplyDeleteevn i see a little abnormality in the PQ segment
and i think to pericaditis ?
You have to understand that prior to the medics arriving on the scene that the pt had 02 asa and nitro. In my experiences if the medication did what it was supposed to then you would see a noteable change from every ECG along with every treatment. BER and Pericarditis have to be present in all leads not just a few leads to call it so. No the ST elevation is not quite at the 1mm marker but it is definently a cause for concern every MI is different from the other would it hurt to call a stemi and be on the precautionary side of things. If its not a STEMI then so be it that is what the cardiologists get paid for. I would personally call a possible STEMI and let the blood work and the cath team differentiate this case. Rather be on the safe side than cause any further damage to the pt because you just didnt feel like it was a true STEMI. Always when in doubt call it what is the harm.
ReplyDeleteAnonymous,
ReplyDeleteYou are correct about not having a pre-NTG 12-lead. However there are no changes indicating STEMI and calling it a STEMI would not benefit the patient. Concave discordant ST-Elevation. There is BER in all leads, you don't necessarily need STE in all leads for it to be BER.
The problem with calling STEMI alert on patient's that aren't having a STEMI is that we will be going backwards. If we can prove it isn't a STEMI we should not be calling it. After all we want to improve our relationships with the receiving facilities and gain trust.
Looks like early repo to me too, especially with the J point notching in a few of the leads. But if he is complaining of chest pain with all the other supporting symptoms of a MI, its time to err on the side of caution and work it like the real deal. Treat your patient, not the monitor. And believe me, the cath lab team LOVES to get paged out and geared up. I don't think they would fault you for activating them on any call that had chest pain with questionable ST segment changes. On another note, I'd probably call for a helicopter to take him to a specialty center for all that ST depression in AVR. ;)
ReplyDeleteJustin H. I don't see the problem. If you have STEMI in more than one contiguous lead than you have infarct anything else is just reading to much into the situation and certainly is not erring on the side of good patient care. Now we could call it many things but in the pre hospital setting you have to ask your self what does that little piece of paper tell you about your patients situation. Time is muscle theirs no time for dilly dally
ReplyDelete