Tell me a time a 12-lead actually mattered for you....

[rhan101277]

Hospitals and Doctors finally realizing that paramedics can interpret these fairly accurately and get the cath team ready saves lots of time.

 

[reaper]

In that specific case, yes. But, I believe my response was to a scenario that involved chest pain, not a 'silent MI'. Valliant effort, though.

With that said, the common "silent MI" is often accompanied with some, and/or all of the following: difficulty breathing, nausea, vomiting, diaphoresis, and anxiousness. These symptoms, combined with the risk factors associated with diabetics, elderly, and/or females (as mentioned before) will automatically raise my suspicion of an occurring infarction. At that point, of course, I would use the tools available to not only help confirm my suspicion, but also to justify my treatment.

Generally speaking, I don't blindly apply a 12 lead to every patient with an upset tummy or bucket full of puke. As in the case above, I would treat the signs and symptoms of the patient, not the monitor.

Try not to read into my quote too literally. It's simply a phrase one can remember in order to not fall into tunnel vision, which many new EMTs do. Remember, there should be more tools in your box than the latest and greatest piece of electronics; those tools lie within your head. God forbid, your basic forgets to charge the batteries, right?

Semantics.

That is the major problem. Most Silent MI's will have none of the symptoms you described. You may have the nice old lady that has just been feeling off, with no other signs or symptoms, that is having a silent MI.

One I remember, from working in ED. Pt was a 78 yo F, CC of toothach. Pt walked into triage and was telling me that she had a toothach. Had been going on all day. Pt had went to her dentist earlier that day and he found nothing wrong with her teeth. This threw a big red flag for me. I placed her in a wheelchair and took her to a room. Preformed a 12 lead, which showed 2.5mm of elevation in v3,v4, and v5. This sweet little old lady was in middle of major STEMI and had no classic signs. She had denied any chestpain,SOB, aches or N&V. Just a toothach that was bothering her all day.

So yes, those simple pt's do require 12 leads! Follow your assessment and your gut feeling on the simple calls.

 

[redcrossemt]

So yes, those simple pt's do require 12 leads! Follow your assessment and your gut feeling on the simple calls.

Absolutely agree...

Any patient that needs a "3-lead" needs a 15-lead as far as I'm concerned. Weakness, dizziness, not feeling right, mental status changes/confusion, SOB/DIB, ABD pain, obviously CP, and pretty much any other problem "nose to navel" gets one from me.

Note that you can not diagnose V-Tach v. SVT w/aberrancy without a diagnostic ECG, which your 3-leads are not. Also can't see ST changes, not always seeing T/U waves or how big they really are, etc.

Also, with thanks to Bob Page, I now monitor in V1/MCL1. A much better lead than II to have on the home screen of your monitor.

 

[redcrossemt]

Oh and my recent personal story...

Ran on a middle-aged gentleman for SOB. He was acutely dyspneic with labored breathing, accessory muscle use, history of COPD, so I was getting out a nebulizer while my partner gets vitals. Turns out his pulse was 26 (carotid and 3-lead) and his BP was not so great (maybe 70 systolic). So, anyway, tried atropine with no result, and started pacing...

Well, I was obviously not on my game that day, and forgot to get a 12-lead while we were doing the IV and atropine... so whatever, doesn't matter, right?

We get to the hospital, the guy stops breathing, he's tubed and they acquire a 12-lead (which we had to stop pacing for)... Turns out this guy is hyperkalemic with HUGE t-waves! He missed a few dialysis treatments and forgot to tell us. After bicarb, calcium, D50, and insulin; the guy was able to come off the pacer and was extubated later that day.

This is one of the only cases I've ever had a regret about. If I had done a 12-lead, we could've starting treating this guy enroute, and probably would have been able to stop pacing by the time we arrived at the hospital. He wouldn't of needed the ETT (most likely), etc.

 

[ExpatMedic]

Oh and my recent personal story...

Ran on a middle-aged gentleman for SOB. He was acutely dyspneic with labored breathing, accessory muscle use, history of COPD, so I was getting out a nebulizer while my partner gets vitals. Turns out his pulse was 26 (carotid and 3-lead) and his BP was not so great (maybe 70 systolic). So, anyway, tried atropine with no result, and started pacing...

Well, I was obviously not on my game that day, and forgot to get a 12-lead while we were doing the IV and atropine... so whatever, doesn't matter, right?

We get to the hospital, the guy stops breathing, he's tubed and they acquire a 12-lead (which we had to stop pacing for)... Turns out this guy is hyperkalemic with HUGE t-waves! He missed a few dialysis treatments and forgot to tell us. After bicarb, calcium, D50, and insulin; the guy was able to come off the pacer and was extubated later that day.

This is one of the only cases I've ever had a regret about. If I had done a 12-lead, we could've starting treating this guy enroute, and probably would have been able to stop pacing by the time we arrived at the hospital. He wouldn't of needed the ETT (most likely), etc.

Which leads were required or used to notice those T waves?

 

[mycrofft]

I had the opposite, a 12 lead NOT to use in care.

Pt c/o CP/dysp, pulse rapid and not of uniform amplitude to palp, shirt off, leads on...normal sinus rythm. Says so right here on the interp.
Oh, wait. Radial pulse doesn't match QRS on EKG, whole different rate.

The machine (W.A. AT-2 Plus) was repeatedly replaying AND interpreting an EKG in memory. Pt went to hospital, AT-2 Plus went to biomedical repair.

 

[Akulahawk]

Absolutely agree...

Any patient that needs a "3-lead" needs a 15-lead as far as I'm concerned. Weakness, dizziness, not feeling right, mental status changes/confusion, SOB/DIB, ABD pain, obviously CP, and pretty much any other problem "nose to navel" gets one from me.

Note that you can not diagnose V-Tach v. SVT w/aberrancy without a diagnostic ECG, which your 3-leads are not. Also can't see ST changes, not always seeing T/U waves or how big they really are, etc.

Also, with thanks to Bob Page, I now monitor in V1/MCL1. A much better lead than II to have on the home screen of your monitor.

The 3-lead monitors I used DID have diagnostic quality... but you had to tell it to do it... and it'd print you the strip. You'd never see diagnostic quality tracings on the screen... I'm also a fan of V1/MCL1. I used to put the 3-lead in the normal config... cycle through Leads I-III, then reconfigure for MCL1. One of the monitors we had was a 5-lead. That one was usually set to show V1.

 

[TomB]

If you're talking about using QRS morphology (Wellens or Brugadas criteria) to differentiate between VT and SVT with aberrancy, I don't think it really matters whether or not the low frequency / high pass filter is set to 1 or 0.05 Hz. On the other hand, I think it's crazy to classify a wide complex tachycardia as SVT with aberrancy based on QRS morphology regardless of what mode you're in. "Ruling in" VT is fine, because that should be your default diagnosis anyway. But failure to "rule in" VT does not "rule out" VT! I personally think these criteria do more harm than good. "Wide and fast" is VT until proven otherwise, and QRS morphology is not proof, because VT can mimic the typical BBB and bifascicular patterns!

Tom

 

[redcrossemt]

If you're talking about using QRS morphology (Wellens or Brugadas criteria) to differentiate between VT and SVT with aberrancy, I don't think it really matters whether or not the low frequency / high pass filter is set to 1 or 0.05 Hz. On the other hand, I think it's crazy to classify a wide complex tachycardia as SVT with aberrancy based on QRS morphology regardless of what mode you're in. "Ruling in" VT is fine, because that should be your default diagnosis anyway. But failure to "rule in" VT does not "rule out" VT! I personally think these criteria do more harm than good. "Wide and fast" is VT until proven otherwise, and QRS morphology is not proof, because VT can mimic the typical BBB and bifascicular patterns!

Tom

Ahh, but with a 12-lead you can also look at the overall axis, the direction in V1 and V6 tells a lot, and there is the often characteristic downward slur when V1 is negative. I agree that QRS morphology is not proof, but with the other things mentioned above, you can be pretty certain of V-Tach v. SVT.

 

[redcrossemt]

Which leads were required or used to notice those T waves?

Don't remember... but it was not obvious on lead II, either on the screen or the paper.

 

[redcrossemt]

The 3-lead monitors I used DID have diagnostic quality... but you had to tell it to do it... and it'd print you the strip. You'd never see diagnostic quality tracings on the screen... I'm also a fan of V1/MCL1. I used to put the 3-lead in the normal config... cycle through Leads I-III, then reconfigure for MCL1. One of the monitors we had was a 5-lead. That one was usually set to show V1.

Cool... Poor man's 12-lead right there! Just a lot of moving stickers and acquiring to do...

 

[TomB]

Ahh, but with a 12-lead you can also look at the overall axis, the direction in V1 and V6 tells a lot, and there is the often characteristic downward slur when V1 is negative. I agree that QRS morphology is not proof, but with the other things mentioned above, you can be pretty certain of V-Tach v. SVT.

Yes, you can look at the axis, and a right superior axis is strongly suggestive of VT. You can look at lead V1 and if you have RBBB morphology and the "left bunny ear" is taller than the "right bunny ear" it's strongly suggestive of VT. If you have LBBB morphology and there is a Q-wave in lead V6, it's strongly suggestive of VT.

Like I said, when morphological criteria are used to "rule in" VT, it's not a problem. It's when you take the next step and decide that failure to "rule in" VT effectively "rules out" VT that you can make a fatal error. There is no algorithm that can safety classify a wide complex tachycardia as SVT with aberrancy.

Tom

 

[redcrossemt]

There is no algorithm that can safety classify a wide complex tachycardia as SVT with aberrancy.

Agreed.

 

[dave3189]

A little off the subject

I was wondering if I can pick the brains of some of you experienced folks out there with a question I have been researching but can't seem to find. I am a recently certified Basic and I dont recall this being addressed in my course. Question is, when you are able to get someone back to a rythem from cardiac arrest (VT/VF) with CPR & defib, what is the typical presentation? I'm guessing the LOC doesn't change much initially but vitals do? Any help with this is much appreciated! Thanks all!

 

[fma08]

Yes, you can look at the axis, and a right superior axis is strongly suggestive of VT. You can look at lead V1 and if you have RBBB morphology and the "left bunny ear" is taller than the "right bunny ear" it's strongly suggestive of VT. If you have LBBB morphology and there is a Q-wave in lead V6, it's strongly suggestive of VT.

Like I said, when morphological criteria are used to "rule in" VT, it's not a problem. It's when you take the next step and decide that failure to "rule in" VT effectively "rules out" VT that you can make a fatal error. There is no algorithm that can safety classify a wide complex tachycardia as SVT with aberrancy.

Tom

I thought we were done looking for bunny ears...

 

[redcrossemt]

I was wondering if I can pick the brains of some of you experienced folks out there with a question I have been researching but can't seem to find. I am a recently certified Basic and I dont recall this being addressed in my course. Question is, when you are able to get someone back to a rythem from cardiac arrest (VT/VF) with CPR & defib, what is the typical presentation? I'm guessing the LOC doesn't change much initially but vitals do? Any help with this is much appreciated! Thanks all!

Start a new thread for *really* off-topic things, please and thanks!

 

[Medic744]

Yesterday, caught a possible MI.

 

[dave3189]

Does that mean I'm not getting my question answered?

 

[kittaypie]

Does that mean I'm not getting my question answered?

start a new thread.

 

[Akulahawk]

Cool... Poor man's 12-lead right there! Just a lot of moving stickers and acquiring to do...

More like 9-lead because you won't get AVR/AVL/AVF leads. 12-3=9

But yeah, lots of stickers and acquiring... and the MCL's only approximate the V leads.