Prehospital 12 Lead ECG – What Are the Indications?

The primary purpose of the prehospital 12 lead ECG is to detect acute coronary ischemia or injury in the prehospital setting.

That's not to say it's the only purpose for a prehospital 12 lead ECG, but it's the main reason we carry 12 lead monitors on the ambulance!

Ideally, the early identification of STEMI patients will:

  1. Ensure delivery of STEMI patients to facilities capable of performing prompt, expertly performed primary PCI (regional systems of care).
  2. Shorten door-to-balloon (D2B) times by enabling parallel processing, or early activation of the cardiac cath lab, especially during off-hours (nights, holidays, weekends) or anytime the cath lab isn't staffed 24 hours/day.

So which patients should receive a prehospital 12 lead ECG, and why? What are the indications?

I'll start with my top 10, and open it up for discussion.

1.) Chest pain or discomfort – In my opinion, any unusual sensation, nose to navel, front or back, qualifies. This will ensure that you cast a wide net and pick up on lots of atypical presentations.

2.) Shortness of breath – I ask all chest pain patients about shortness of breath (many admit to mild dyspnea even with normal respiratory rates and clear breath sounds), and I ask all shortness of breath patients about chest pain. Both get a 12 lead ECG regardless. Be especially mindful of new exertional dyspnea, particularly in the elderly patient, and acute pulmonary edema.

3.) Syncope or near syncope – Let's face it, a lot of our syncope patients end up refusing transport to the hospital, but a small subset are at high risk for sudden death! Capture a 12 lead ECG and review it for ACS, arrhythmias, a prolonged QT/QTc, signs of hypertrophic cardiomyopathy, or Brugada's Syndrome.

4.) Diaphoresis unexplained by ambient temperature, unexplained general weakness, or unexplained nausea and vomiting. Be especially suspecious if your patient is a diabetic.

5.) Suspected diabetic ketoacidosis (which may be an atypical presentation of ACS).

6.) A feeling of impending doom – Often a patient just knows something is frightfully wrong! Usually accompanied by diaphoresis unexplained by ambient temperature.

7.) Any suspected drug overdose or metabolic derangement. Be especially alert for dialysis patients who present with general weakness and/or shortness of breath!

8.) An unconscious patient (excluding cardiac arrest). On the other hand, it's one of the first things you want to accomplish when your patient experiences ROSC.

9.) Palpitations – Defined as any uncomfortable awareness of your own heart beat. Includes "skipped" beats and "racing" heart.

10.) Any heart rate less than 50 or greater than 150.


  • SoCal Medic says:

    I cant argue any of that honestly. Personally that is what I attempt to achieve with my patients.

  • RJ Stine says:

    I do them on general illness calls without any outward symptoms and sometimes upper abdominal pain as well. I do everything I can on the sick calls, not only is it good practice for when the real time comes, I sometimes come across things that make me go “hmmmm”

  • Patrick says:

    Did you include “because we can bill for it?”

  • Tom B says:

    Must have slipped my mind!

  • Shaggy says:

    I remember around 2002 or so reading the press releases regarding the “atypical” s/s of MIs in women. That week I got a call for an older woman with c/o N/V and generalize weakness. I remember she had no CP or SOB but her BP and pulse were a little on the low side. It was a too long ago to remember. I decided to do a 12 lead in the house while my partner complained she should go BLS. The 12 lead showed ST elevation in leads II, III and avf. I remember calling it in and the command MD was reluctant to believe it was an MI but reluctantly let me give the ASA. She was wisked off to the cath lab while we were shoving off. So older women, especially with diabetes, get 12 leads for a C/O N/V and/or generalized weakness.

  • Dave B says:

    It is a thorough and comprehensive list… i know it is a subset of number one, but i believe complaints of “acid reflux” should receive special mention. i have had more than one patient whose only complaint was “acid reflex” end up in the middle of an MI.. One of these went so far as to “assure” me it was acid reflux, even though they had never had acid reflux before! But more importantly, discharging missed MI’s due to GERD complaints is a leading cause of malpractice suits against ER docs.

  • Dave B says:

    Your list does bring up a question for me… where do we stand on the administration of ASA for pt’s having atypical presentations? If we suspect atypical presentation of MI is a possibility, do we routinely give ASA? I know in my system that is not done. We all know the benefits of ASA, reducing mortality by 25%… we also know that 50% of patients having an MI may not have ECG changes. So, at least in my system, there is a very large “Aspirin Gap”, where many patients who “could” get it, don’t. Do we give it to patients who are fatigued? for syncopal episodes? Short of breath? Should we? this is a question i’ve wondered about. with a high safety profile, and high benefits for MI patients, what is the downside of this “one time” administration for patients who may not end up having an MI? is it worth it for those who “may” be having one?

  • one guy i remember had only left triceps pain and mild diaphoresis.

  • joanie says:

    I would also add while patient is monitored on telemetryt, any ECG changes is an indicator for a 12 lead.

  • DEE@HLWD says:

    I also wonder why medics even ask if the pain is worse on movement or inspiration.??? I have had several code hearts with the patient complaining that the pain is worse on movemnt, palpation and inspiration. Some medics think that it's automatically muscular pain.

  • Earl (The Pearl) Bookheimer says:

    Ok not sure it posted..I do 12 leads on all ALS calls.  I also added that any Female 50 or greater gets 1.  It only takes a minute and they have symptoms that are Atypical and have caught stemi's..  Been doing it for awhile..30 years and have seen when we first tried to do 12 leads to now and I love the short time it takes to do one and transmit it..

  • Earl (The Pearl) Bookheimer says:

    I saw a reply about a ASA to be given.  It does not hurt the patient and the benefits outweigh the risks unless they are Allergic to ASA.   I give it all the time for typical and atypical and the docs in the areas i work 3 Counties have no problems with it.

  • Alan says:

    One to add to the list is post arresst with ROSC.  In addition I personally do a 12 lead on anyone I consider putting on telemetry.

  • Alan says:

    Sorry didn't notice the ROSC thing in number 8!  hehe

  • Nilsoe says:

    What about stroke patients?

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