Name The Rhythm

[firemedic0227]

83 Year old Male C/C Weakness, just not feeling all that great. The Patient says he has not been feeling well over the past few days but this morning he has become really weak. He is pale in complexion a little sweaty. PMH of Cardiac Related problems.

HR 83
BP Not able to obtain
Radial Pulse: N/A
Sugar: 226
SPo2: 96 Room Air

Hook the patient up to the monitor, it shows that there is depression in leads 2. Do a 12 lead and this is what it shows.

Attempted IV's in both AC's unsuccessful, Patient doesn't complain of any chest pain. Patient was then drilled with the IO given a small bolus of Saline BP was then Systolic of 100. Patient taken Code 3 with a STEMI alert declared.

Any thoughts to why the heart has so much ischemia going on, on the 12 lead?

 

[throcktharock]

Probably has something to do with the Septal infarct with reciprocal depression.

 

[Brandon O]

Oh gosh. Gorgeous strip.

Partial left main occlusion or three-vessel disease. Note the near-global ischemia and the colossal aVR elevation.

Usually they present worse than this.

 

[firemedic0227]

After coming back to the hospital after another call, the Cardiologist said that he had nearly a 100% blockage of an artery (don't remember which one) and also had a bleed some place but wasn't exactly sure where at that time leading to being hypovolemic which is causing the ischemia in his heart. The patient wasn't well enough to do open heart surgery to do a bypass because of his low BGL which was only 6. Didn't sound like it was going to be a good outcome for the patient.

 

[Scott33]

.Partial left main occlusion or three-vessel disease. Note the near-global ischemia and the colossal aVR elevation.

^^^This^^^

 

[STXmedic]

After coming back to the hospital after another call, the Cardiologist said that he had nearly a 100% blockage of an artery (don't remember which one) and also had a bleed some place but wasn't exactly sure where at that time leading to being hypovolemic which is causing the ischemia in his heart. The patient wasn't well enough to do open heart surgery to do a bypass because of his low BGL which was only 6. Didn't sound like it was going to be a good outcome for the patient.

He had a BGL of 6? And it was hypovolemia that was causing the ischemia, not the 100% occlusion?...

 

[MSDeltaFlt]

83 Year old Male C/C Weakness, just not feeling all that great. The Patient says he has not been feeling well over the past few days but this morning he has become really weak. He is pale in complexion a little sweaty. PMH of Cardiac Related problems.

HR 83
BP Not able to obtain
Radial Pulse: N/A
Sugar: 226
SPo2: 96 Room Air

Hook the patient up to the monitor, it shows that there is depression in leads 2. Do a 12 lead and this is what it shows.

Attempted IV's in both AC's unsuccessful, Patient doesn't complain of any chest pain. Patient was then drilled with the IO given a small bolus of Saline BP was then Systolic of 100. Patient taken Code 3 with a STEMI alert declared.

Any thoughts to why the heart has so much ischemia going on, on the 12 lead?

Not ever RCA feeds the inferior portion of myocardium. Judging from ST depression and VS I'd say the 100% occlusion was RCA giving this poor fellow a Right side AMI.

 

[Handsome Robb]

Is it junctional? AJR specifically. I don't see any P-waves but I'm also on my phone.

Septal infarct with global ischemia. Potentially RVI/Posterior involvement, but I'm no where near the caliber these guys are at reading 12-leads so take my thoughts with a grain of salt. I agree with Oto, gorgeous 12-lead.

Did an EJ ever cross your mind before drilling a live, awake and talking patient? Feet, legs and biceps are cool too....just a thought.

Wait, you said his BGL was 226 in your original post then 6 in a later post...what was it? hypoglycemia isn't a reason to keep someone from a life saving surgery...it's easily correctable.

 

[firemedic0227]

Sorry I didn't mean BGL of 6, I meant Hemoglobin of 6. I also wasn't in the back, I was driving. I am just a basic with a little extra knowlege I guess.

 

[Handsome Robb]

Sorry I didn't mean BGL of 6, I meant Hemoglobin of 6. I also wasn't in the back, I was driving. I am just a basic with a little extra knowlege I guess.

Yea that's a touch on the low side...

Still haven't taken the test dude? Only gonna get more and more difficult the longer you wait.

 

[Christopher]

http://img20.imageshack.us/img20/862/83yomale.jpg[/IMG]
Any thoughts to why the heart has so much ischemia going on, on the 12 lead?

Rate: v-rate 80 bpm, a-rate maybe 80 bpm (tough to see)
Regular: regular w/o ectopy
P-waves: perhaps P-waves seen on the tail end of the T-waves in V1. Difficult to know if this is a long PRi or a long RP; no help from the limb leads.
PRi: either a prolonged PRi, a long RP, or non-existent
QRSd: ~110 ms

Rhythm: normal sinus or accelerated junctional depending on the P-waves (academic endeavor)

Axis: normal frontal, poor R-wave progression
QTi/QTc: normal
ST/T-wave changes: profound ST-depression with ST-elevation in V1; biphasic T-waves in multiple leads

DDx: LMCA occlusion, severe 3-vessel disease complicated by hypovolemia, proximal LAD occlusion complicated by hypovolemia

 

[firemedic0227]

I have taken it 3 times (embarassed) so I am taking a refresher through my Fire Department starting this weekend and spread over the next 2 months. So hopefully by the end of March I will have taken it again. I have been keeping up, I read my books a lot and I get lots of direction from a lot of great medics on my department. Thanks for all the replies, I am not the greatest at 12 leads and this makes me think things over. Once again thanks guys!

 

[boerbull]

A colleague of mine had a call to a 60 yo male with severe SOB and occasional chest pains for two day's. Upon arrival the pt had a ECG quit similar to this one. My colleague suspected a main stem stenosis or a pulmonary embolism. Pt went into VFIB before any treatment except for O2. Got ROSC after 2 defibs. Transported to closest hospital because he could't get him intubated cause of trismus. After intubation the anesthesiologist wanted a CT-scan before transport to a level 1 hospital.
Turns out to be a massive cerebral haemorrhage.

 

[Handsome Robb]

I have taken it 3 times (embarassed) so I am taking a refresher through my Fire Department starting this weekend and spread over the next 2 months. So hopefully by the end of March I will have taken it again. I have been keeping up, I read my books a lot and I get lots of direction from a lot of great medics on my department. Thanks for all the replies, I am not the greatest at 12 leads and this makes me think things over. Once again thanks guys!

Good luck dude!

PM me if you need help studying or pointers for the test. I know we graduated around the same time. Just gotta pass the test and you're home free!

 

[Aprz]

I am not the greatest at 12 leads and this makes me think things over. Once again thanks guys!

If it makes you feel any better, I don't recall reading about this in any 12-lead book I have read. I would have missed this too if it weren't for things like ems12lead, Dr. Smith's blog, Amal Mattu's blog, lifeinthefastlane, etc. They've mentioned lead aVR being a lead that's ignored (I think that was key in this 12-lead, lead aVR) and how it can be useful.

 

[Merck]

While the majority of STEMIs/ischemia/changes are due to occlusion seeing global changes should prompt evaluation of other DDx. No question that some of the mentioned things like triple vessel disease, left main occlusion are at the top of the list there should also be consideration of other things. Aneurysm and valve insufficiency should be considered, as should infection.

This strip doesn't scream STEMI to me but certainly does make sense with a low Hgb. Even with the 100% occlusion it's likely the pt has developed decent collateral flow (or he'd be dead). There may not be an actual plaque rupture and thrombus - important considerations since this patient likely should not recieve TNK if it came to that without due consideration.

 

[KellyBracket]

I had a similar patient, with a similar ECG recently. She showed a classic aVR STE with profound ST depression in at least 7 leads. She adamantly denied any chest/back/belly complaints, and had good v.s.

I got cardiology on-board pronto, but the Hgb came back before they got in. Hgb was 5, and the ECG findings disappeared after multiple transfusions.

 

[Brandon O]

I had a similar patient, with a similar ECG recently. She showed a classic aVR STE with profound ST depression in at least 7 leads. She adamantly denied any chest/back/belly complaints, and had good v.s.

I got cardiology on-board pronto, but the Hgb came back before they got in. Hgb was 5, and the ECG findings disappeared after multiple transfusions.

Interesting stuff. I think most of us have found that the LMCA/proximal LAD/three-vessel pattern popularized by Amal Mattu is less specific for MI than it is a general indication of global ischemia or hypoxia. Clinical correlation is pretty important; all of the legit cases I've seen have presented with cardiogenic shock and seemed to be truly dying.

I don't think I've seen any other examples caused by anemia; if you can blog that case I think people would be interested.

 

[KellyBracket]

That would be good - I just have to wade though my pile of properly de-identified ECGS... I don't really have a system for organizing them.

 

[Vince D]

That would be good - I just have to wade though my pile of properly de-identified ECGS... I don't really have a system for organizing them.

I might suggest anal-retentively scanning in every ECG you deem worth saving, editing out the patient info in photoshop, numbering each case so that it can be cross-referenced to the original in a stack of binders, and then tagging each TIFF file with pertinent findings for easy searching and retrieval.

Actually I might not, because it's a harrowing experience now that I think about it...