Activated HEMS for LBBB: Made the right call?

[MSDeltaFlt]

Vitals p89, BP 128/78, sp02 94%, lungs clear, didn't get heart sounds, no cough, no edema. Cp felt like pressure and he stated he felt it was hard to catch his breath. He stated nothing made his pain better or worse. He stated it stayed constant from onset throughout. Skin was pale and diaphoretic.

In my limited experience I felt it was cardiac before I saw a 12 lead. I guess I was looking for is what would a more experienced provider do given the same situation.

Anyways one of the flight medics is going to call me tomorrow and let me know what happened, so when I find out I will let you guys know.

Okie doke. Just checking.

 

[medicsb]

The question isn't so much cardiac or not, but STEMI (or, say, Sgarbossa equivalent) because that is where time might really matter. NSTEMI, unstable angina, etc. do not need immediate PCI, so ground transport would be wholly appropriate. For STEMI, it could, depending on the EMS/STEMI system be fine to go by ground if transport time is <60 minutes (assuming cath lab activation from the field). It takes time for the team to get to the hospital and to set up to receive the patient. Usually they have a 30 minute time frame to arrive at the hospital, and then it will take a certain amount of time to get everything set-up for the procedure. During off hours, it could take over an hour for the team to be ready, so any gain from helicopter transport will likely not translate to any real gain in time saved since they'll be sitting in the ED. Even during day hours, if there is a patient on the table, the STEMI will probably have to wait some time.

 

[Christopher]

Vitals p89, BP 128/78, sp02 94%, lungs clear, didn't get heart sounds, no cough, no edema. Cp felt like pressure and he stated he felt it was hard to catch his breath. He stated nothing made his pain better or worse. He stated it stayed constant from onset throughout. Skin was pale and diaphoretic.

In my limited experience I felt it was cardiac before I saw a 12 lead. I guess I was looking for is what would a more experienced provider do given the same situation.

Anyways one of the flight medics is going to call me tomorrow and let me know what happened, so when I find out I will let you guys know.

I'm a biased against helicopters when you've got the means to drive a patient somewhere...so ignore me if that is an issue

1). With an equivocal 12-Lead, even with s/s of ongoing ACS, it would be best to go via ground. An echo or labs is going to rule this patient in/out most likely.

2). Flying somebody for "suspected new LBBB" is a bit like flying somebody for mechanism of injury alone.

I don't fault your decision, LBBB produces some damn impressive ECG changes, and we (EMS educators) haven't done the best job of properly informing new and old medics alike why "suspected new LBBB" isn't actually a big deal.

I certainly drove silly fast to the hospital with one too many patients when I was starting out :wacko: I wish I could go back and talk myself out of a lot of those decisions...

I look at helo usage like anything else, it has benefits and risks. The benefits from a helo are so unbelievably small in most cases that it does not really serve your patient. As long as you find yourself using this intervention as the exception rather than the rule, you're doing Ok!

 

[TomB]

Anyways one of the flight medics is going to call me tomorrow and let me know what happened, so when I find out I will let you guys know.

Can you post the ECG?

 

[snarff]

Ok talked to a medic from the helicopter that my friend knew. She was not on the crew that picked the guy up, but she did ask the other crew about it. Apparently the guy was having an MI "High lateral". They said the 12 lead from the helicopter never showed anything different than the one I ran. LBBB with st depression in III and aVF with 1mm of elevation in aVL. She didn't know what % of occlusion.

Sounds like the guy is going to have a good outcome. This definitely puts me at ease. I certainly don't want to cost some guy thousands of dollars for nothing. So hopefully we both are happy lol.

 

[DrankTheKoolaid]

re

There ya go. A brand new Medic and you have already learned the lesson of Paramedic intuition. Learn to listen to it.

 

[Handsome Robb]

Ok talked to a medic from the helicopter that my friend knew. She was not on the crew that picked the guy up, but she did ask the other crew about it. Apparently the guy was having an MI "High lateral". They said the 12 lead from the helicopter never showed anything different than the one I ran. LBBB with st depression in III and aVF with 1mm of elevation in aVL. She didn't know what % of occlusion.

Sounds like the guy is going to have a good outcome. This definitely puts me at ease. I certainly don't want to cost some guy thousands of dollars for nothing. So hopefully we both are happy lol.

I suck at deciding on using HEMS or not mostly because its rare that they're faster than us. All the times I've called for them they've launched when we were dispatched and the patient needed an airway and I can't RSI.

I think you made the right call. You took the patients presentation and your qualitative and quantitative assessment tools/findings and came up with a solid working differential and then got the patient where he needed to be in the quickest fashion. One of the few cases that time does matter. Seconds? No minutes? I'd say so.

Pretty sure someone already said it but you can't fake skin signs.

I'd be really interested to see the ECG. I'm not nearly as good as some of these guys are but I'd be interested to see whether it met the Sgarbossa Criteria. LBBBs always make me wonder... If I remember correctly you only had one ECG? Or didn't have dynamic changes after interventions? People always say "they're paced no bother doing a 12" but if you're watching the morphology change in serial ECGs I'd be worried...

 

[VFlutter]

People always say "they're paced no bother doing a 12"

Please :censored::censored::censored::censored::censored: slap anyone who says that, thanks.

 

[grub]

Good Job

First of all, good job on doing the 12 lead! I'm a 12 lead instructor and believe in them highly. An ST depression in II & III with an ST elevation in AVL and a ??new?? LBBB tells me you may have had a NEW MI on the left ventricle? PAced Pts. still need 12 leads ALWAYS>> Being a Diabetic throws all the cards out the window and really makes it more urgent. Second.... The fact that your even thinking about the helicopter being abused tells me you followed the right path. There is a lot of abuse in calling a helicopter I have seen it many times. Your pt. had an obvious MI and you did your best to get him reperfused at the correct facility! read up on Sgarbossa’s criteria.... it will help you with paced,LBBB (imposters) and give you a prospective on IDing the real rhythm........ GOOD JOB


Sgarbossa's criteria:

Here is the criteria. A patient is presumed to be experiencing an evolving AMI if any of the following are present.
1.ST segment elevation = or > 1 mm that is concordant with the QRS complex.
2.ST segment depression = or > 1 mm in leads V1, V2, or V3.
3.ST segment elevation = or > 5 mm that is discordant with the QRS complex.

 

[grub]

Please :censored::censored::censored::censored::censored: slap anyone who says that, thanks.

YES!!! You are so correct!

 

[Brandon O]

Just to point out another way of looking at this, calling somebody a STEMI and mobilizing the cavalry BECAUSE they show an isolated LBBB is probably wrong. However, if they give a clinical impression of STEMI, and the ECG shows a LBBB, and you're thinking, "I'm just not comfortable ruling a STEMI in or out in the presence of LBBB, because it makes interpretation difficult (heck, I'll keep learning, maybe one day!), so I'm basically going to pretend I never even acquired this, and treat based on signs and symptoms"... it may be quite sensible to handle it as a STEMI.

The Bayesian way of looking at this: the pre-test probability was high, and the ECG was equivocal and changed nothing, so the post-test probability remained high.

The "is this okay?" way of looking at this: as an empirical approach this is supported by the AHA and is widely practiced by many EDs and interventionalists.

The "punt" way of looking at this: although you should strive to always be able to glean useful data from the ECG, if you honestly can't (and although possible, it is tricky in LBBB!), "treat the patient, not the monitor" is a somewhat defensible approach.

Just recognize that no matter how you approach it, this is NOT the same as assuming all "new" LBBBs are STEMIs. Not by a long shot.

 

[Christopher]

Just to point out another way of looking at this, calling somebody a STEMI and mobilizing the cavalry BECAUSE they show an isolated LBBB is probably wrong. However, if they give a clinical impression of STEMI, and the ECG shows a LBBB, and you're thinking, "I'm just not comfortable ruling a STEMI in or out in the presence of LBBB, because it makes interpretation difficult (heck, I'll keep learning, maybe one day!), so I'm basically going to pretend I never even acquired this, and treat based on signs and symptoms"... it may be quite sensible to handle it as a STEMI.

Considering the NNC (number needed to cath, I just made that up) in order to get a "new or suspected new LBBB" with an actual occlusion is big...way big, even with clinical signs supporting it; I think in the absence of primary ST-changes you should not make this call.

 

[Brandon O]

Considering the NNC (number needed to cath, I just made that up) in order to get a "new or suspected new LBBB" with an actual occlusion is big...way big, even with clinical signs supporting it; I think in the absence of primary ST-changes you should not make this call.

As a global recommendation, I would agree, but there are probably constellations of clinical findings and other circumstances where it would be beneficial (or at least reasonable).

Trying to find that threshold could be tricky, of course. It really comes down to the point where a skilled provider would, after obtaining the H&P, say "I don't need to rule this patient in -- I need to rule him out. And it'll have to be pretty friggin' convincing."

 

[Christopher]

As a global recommendation, I would agree, but there are probably constellations of clinical findings and other circumstances where it would be beneficial (or at least reasonable).

Trying to find that threshold could be tricky, of course. It really comes down to the point where a skilled provider would, after obtaining the H&P, say "I don't need to rule this patient in -- I need to rule him out. And it'll have to be pretty friggin' convincing."

We get a number of "convincing" LBBB chest pains that we see during QA. At my department we've done a pretty good job of educating our providers when you need to activate (e.g. clear benefit) vs when you should not (e.g. no clear benefit).

However, every now and then we get a "new or suspected new LBBB" inappropriately activated.

For the topic here, I find it all moot without an actual ECG to look at. STEMI criteria should be solidly based on findings in the ECG which correlate to clinical findings. LBBB is not a finding in the ECG which suggests STEMI.

 

[Brandon O]

You know I'm with you for the most part. The problem is that many providers take this same tack, but have a far-too-low threshold for it (and their ability to interpret is weak enough that they have to punt on a regular basis).

But no matter how good you are, sometimes you don't know, and I think there is room for a decision that acknowledges one's own inability to interpret the ECG and makes a reasonable call on empiric grounds.

You walk in the room, think "dang, he looks like he's about to code," throw him on the monitor, and the bloomin' thing doesn't turn on. Now what?

You always consider risk/benefit, of course. Maybe you don't call the bird or activate the cath lab, but you divert ten minutes farther. Weigh what you know (not what you wish you knew) and do your best.

The fact that you should strive to minimize your "fallback" decision-making doesn't mean that you shouldn't have those mental protocols in place. When you don't know what to do, you've still gotta do something...

 

[grub]

I agree

Brandon, you hit it on the head...! This guy had a very high probability of an MI. ST elevation in 2 or more contiguous leads with reciprocal changes, is what we need to fit the criteria for STEMI. he only gave us 1 lead with ST elevation but we had the inferior reciprocal changes in II&III we needed the whole 12 lead to see to make a good DX.
Treating the Pt. is always the best path to follow. Symptoms and ECG's get twisted by the diabetic pt. anyway. In this situation, I'm glad he felt the pt. was in a serious situation. The Pt.s symptoms were pretty convincing of a cardiac emergency. I do however, feel that the big STEMI imposters like BBB,LVH,paced.....ect can leave you feeling dumb and blank with the only thing left to treat being the Patient. I've had many 12 leads show normal with none or minimal symptoms and then get pos cardiac enzymes and a pos MI dx. at the ER. I DON'T PLAY WITH DIABETICS, THEY WILL FOOL YOU...! We have to do the best with what we have and right now, the average medic in the field hasn't mastered the 12 lead because it takes training and lots of practice. We do treat the Pt. different by what we see on the 12 lead and we do save lives by being able to read a 12 lead appropriatly. We are the Doctor,nurse,respiratory therapist,xray and psychologist, all in one. To be good at what we do, takes training and lots of it. We can carry our profession on our sleeve or in our hearts, it our choice. Good post Brandon

 

[Christopher]

But no matter how good you are, sometimes you don't know, and I think there is room for a decision that acknowledges one's own inability to interpret the ECG and makes a reasonable call on empiric grounds.

I don't doubt the likelihood of ACS, I doubt the need for activation of a STEMI without changes (or with LBBB alone). You still make for the appropriate facility and run it up the ACS ladder.

Brandon, you hit it on the head...! This guy had a very high probability of an MI. ST elevation in 2 or more contiguous leads with reciprocal changes, is what we need to fit the criteria for STEMI. he only gave us 1 lead with ST elevation but we had the inferior reciprocal changes in II&III we needed the whole 12 lead to see to make a good DX.

The traditional criteria of elevation in 2 or more contiguous leads only applies to non-LBBB ECGs. (don't read too much into this statement, I'm by far the least 'criteria based' person around)

Regardless, as you note without an ECG to view it is hard to determine if the activation is appropriate, since an ECG is required to make an activation

 

[grub]

If you want to see an ER doc get excited, show him your 12 lead that you did before to started treatment 45 mins. ago with ST elevations and obvious sign's of MI... right after he just read the nurses 12 lead she did 2 minutes ago that was normal after all your fine treatment that reversed all the sign's and symptoms ; ) He'll thank you for it with a look of serious interest!


Another 12 lead point:
If I get a Pt. (especially females and diabetics) that are 50 or older and c/o flu like symptoms, they get a 12 lead. diabetics and silent MI's fall into this catagory. Diabetics have neuropathy and loose pain sensation where non-diabetics will have complants. Silent MI's are just that, SILENT! The only way you will know what you have, is a 12 lead to confirm it. It's real embarrasing to bring in a flu pt. and then see them get rushed to the cath lab:sad:

 

[Benjamin]

I am just a basic, but I think you made the right choice for your patient in this situation. You have the right to be proactive. Thank you for all you do. God bless and be confident in your assessment.

 

[Carlos Danger]

Just to point out another way of looking at this, calling somebody a STEMI and mobilizing the cavalry BECAUSE they show an isolated LBBB is probably wrong. However, if they give a clinical impression of STEMI, and the ECG shows a LBBB, and you're thinking, "I'm just not comfortable ruling a STEMI in or out in the presence of LBBB, because it makes interpretation difficult (heck, I'll keep learning, maybe one day!), so I'm basically going to pretend I never even acquired this, and treat based on signs and symptoms"... it may be quite sensible to handle it as a STEMI.

The Bayesian way of looking at this: the pre-test probability was high, and the ECG was equivocal and changed nothing, so the post-test probability remained high.

This is exactly how I see it. ^^^^

You were perfectly correct to assume an AMI and get this guy to a cath lab ASAP, given the clinical presentation and the non-reassuring EKG finding. A presumably new LBBB in the presence of convincing clinical s/s of an MI, is always an AMI until proven otherwise.

As for calling the helicopter? Well that's really a separate issue. Using HEMS was the right thing to do IF they could get the patient to the cath table significantly quicker than you (I'd say 20 minutes quicker; others may argue slightly shorter or slightly longer), or if they have the ability to do some important intervention that you don't (probably not applicable to this specific case, but in general).

On the whole, I'd say you did right.