12 Lead Automatic when 3 Lead Applied

[Medic2409]

A medic at another local service just told me that their Med Control is ordering an automatic 12 lead to be done anytime the 3 lead is applied.

His reasoning is that you can't diagnose with a 3 lead.

Hmmm....

It is true that 3 leads have a filter built in to try to cut down on artifact. This filter may either show or mask ST elevation that a 12 lead would not. Also true, the 12 lead looks at many more aspects of the heart than a 3 lead.

My thinking is the doctor is a bit off. Arrythmias, blocks, asystole, etc. are easily found with a 3 lead. At present, we don't monitor a 12 lead, we print one, and continue monitoring the patient with the 3 lead. Further, I feel that this may potentially set the medics up for issues should they do an intervention on someone who does not need one.

For instance, my practice is that for most of the medications I give, I will put the patient on a 3 lead, just for monitoring purposes. An 18 year old buxom chic with, say, nausea who I'm giving zofran to doesn't need a twelve lead.

Thoughts?

 

[JPINFV]

As with every procedure, the big question is what are you looking for, what are your concerns, how invasive the test is, how acceptable to the population the test is (giving a rectal exam to everyone looking for occult blood has a different level of acceptability than a 12 lead), and the cost.

As such, the cost vs benefit threshold for cardiac monitoring and 12 leads are extremely low given that the overall cost of both (given financial cost and social acceptability) are rather small. My question is what are you looking for on a 3 lead that can't be obtained better than on a 12 lead? Is there value in having a pre-treatment 12 lead to compare to in case something happens? Is the 3 lead being used for anything else besides an alarm box, and if not how much value does that alarm box really bring to the table considering that the patient is never really alone?

 

[jwk]

A medic at another local service just told me that their Med Control is ordering an automatic 12 lead to be done anytime the 3 lead is applied.

His reasoning is that you can't diagnose with a 3 lead.

Hmmm....

It is true that 3 leads have a filter built in to try to cut down on artifact. This filter may either show or mask ST elevation that a 12 lead would not. Also true, the 12 lead looks at many more aspects of the heart than a 3 lead.

My thinking is the doctor is a bit off. Arrythmias, blocks, asystole, etc. are easily found with a 3 lead. At present, we don't monitor a 12 lead, we print one, and continue monitoring the patient with the 3 lead. Further, I feel that this may potentially set the medics up for issues should they do an intervention on someone who does not need one.

For instance, my practice is that for most of the medications I give, I will put the patient on a 3 lead, just for monitoring purposes. An 18 year old buxom chic with, say, nausea who I'm giving zofran to doesn't need a twelve lead.

Thoughts?

For ANY medication you give, you monitor an EKG? Why?

 

[DrParasite]

A medic at another local service just told me that their Med Control is ordering an automatic 12 lead to be done anytime the 3 lead is applied.

His reasoning is that you can't diagnose with a 3 lead.

Hmmm....

so if you can't diagnose anything with a 3 lead, do do them at all? wouldn't it not make more sense just to put everyone on a a 12 lead and leave them on a 12 lead until you drop them off at the hospital?

 

[the_negro_puppy]

His reasoning is that you can't diagnose with a 3 lead.

Thoughts?

 

[NYMedic828]

Hmmm, i think this is v-fib, and they have no signs of life, but let me get a 12 to be certain.

 

[JPINFV]

Yes, you can Dx basic rhythms. Want to get a better picture, then you need a 12 lead, least anyone want me to go find a thread on here where someone is claiming they can Dx a STEMI on a 12 lead. Besides, 12 leads are useful for things besides STEMIs

 

[Firemedic1989]

Its all situational, based on how your patient is presenting and what their complaining of. Treat your patient not the monitor! Also, any past cardiac Hx, and they are complaining of chest pain or any other sypmtom that might lead you to believe that it can be cardiac in origin, do a 12 lead. In all reality a 3 lead takes 15 seconds to apply, why not take the extra minuet and 45 cents that it cost for the electrodes and throw them on, which will give you such a greater picture. also take it a step further, if you have a patient complaining of CP and no finding of ST elevation, DO A 15 lead. IN LEAD 11 YOU HAVE NO CLUE! If anyone gets a chance to sit through one of Bob Pages 12 lead ECG seminars I highly suggest you attend. What you think you know and what he will show you that you dont know is just amazing

 

[JPINFV]

Treat your patient not the monitor!

...but what if the monitors correct and your evaluation of the situation wrong?

 

[bstone]

Maybe start using a 5 lead instead?

 

[JPINFV]

Maybe start using a 5 lead instead?

Unless you have it set to use a 12 lead filter (diagnostic mode), it's going to have the same issue. Then there's still the fact that you're missing a bunch of precordial leads.

 

[Medic2409]

For ANY medication you give, you monitor an EKG? Why?

Protocols at a previous service required a 3 lead for any medication given, with the exception of Glucose (D50, oral, etc.) I got into the habit there, and it has carried over. It may not be necessary, but for me, one reason is that it is a tool to help keep an eye out for potential adverse changes.

 

[Medic2409]

@ the_negro_puppy...my thoughts exactly!



Chest pain that is cardiac in nature, pressure, pale, cool, clammy, diaphoretic, all that good stuff most definitely should get a 12 lead, followed by Right sided or even Posterior views if indicated.

 

[TomB]

Rules like this are made when too many medics in a given EMS system 'get a quick 3-lead' and then either wait until the patient is loaded in the back of the ambulance to get a 12-lead or neglect to get one at all. If you do QI for a STEMI system you run into this problem a lot and paramedics can be very stubborn when it comes to changing their practice. You're right, there are times it seems logical to monitor a patient's heart rhythm even though you're not worried about ischemia/injury. But I'll bet their Medical Director got tired of talking to crews about why they didn't do a 12-lead ECG on a STEMI patient.

 

[KellyBracket]

...
Chest pain that is cardiac in nature, pressure, pale, cool, clammy, diaphoretic, all that good stuff most definitely should get a 12 lead ...

Well, that's the rub, isn't it? Not all STEMI patients seem to be "cardiac" at first glance, and a 12-lead is essential in picking up the AMIs that don't look like the illustration in Netter's.

In fact, in order to pick up most STEMIs, you need to do a lot of 12-leads. A recent study developed a decision rule for when to acquire a full ECG. It boiled down to something like:

* Anybody over 30 y.o. with chest pain,
* Anybody over 50 y.o with chest, head, and upper extremity complaints,
* Anybody over 80 y.o. with any torso complaints (except maybe isolated diarrhea...).

Even then, they only captured 92% of the STEMIs with this rule.

You can read a longer review of this paper at When should you get an ECG? , but the basic point remains - you're going to miss a lot of STEMIs if you only get them on the "obvious" cases!