Found on the Lifenet Receiving Station

Here’s an interesting set of ECGs I found on the Lifenet Receiving Station. They were transmitted to the emergency department by a neighboring EMS system. I have no details of the history or clinical presentation.

ECG #1


ECG #2


What do you think?

7 Comments

  • SoCal Medic says:

    St Segment Depression in the Inferior Leads with changes in T Wave morphology between the two (looks to be over 5 min). aVR in 12 Lead a has a inverted T Wave without Deviation and in B has ST sgement Elevation with the bi-phasic T Wave morphology. Minimal Elevation in V1 increases into the second 12 Lead along with ST Segment changes/depresssion along with change in T Wave Morphology in V6. My guess is, being that V6 would be reciprocal for V6R, V1 looks at the right part of the Septum, the Inferior Wall could be supplied by the Circumflex, and aVR is positive for elevation (Lead II being hte recirpcoal confirming infarct at that point), I would call it a RVI and see if I can get an activation (based soley on the 12 Lead, either way I would have to really sell it. Am I close??

  • SoCal Medic says:

    Also it is hard to tell if the ST segment elevation observed in V2-V4 stays constant, but I don't like how the ST segment looks or the changes in the overall T Wave between A and B.

  • Tom B says:

    Christopher – Don't over-think it! In the first ECG, the T waves in the right precordial leads are abnormal. But could it be explained by benign early repolarization or the male pattern? The reciprocal changes in the inferior leads are the give-away! I was surprised that the GE-Marquette 12SL interpretive algorithm called ECG #1 a normal ECG.Regardless, ECG #2 tells the tale because there are, as you say, changes between the first and second ECG.Most striking (to me) are the changes in leads II and aVF, but as you say, there are also changes visible in lead aVR.In addition, there are changes in QRS morphology. For example, loss of R wave amplitude in leads V2 and V3.See also:From Dr. Smith's ECG blog, ST depression limited to inferior leads is reciprocal to high lateral wall and represents STEMI.Tom

  • SoCal Medic says:

    Doh. I hate it when I do that. Funny how when you revisit something the picture is easier to grasp. The nice thing about the blog is it allows the opportunity for discussion. Thanks again.

  • Tom B says:

    Christopher – That's exactly what makes Web 2.0 a better medium for learning than a book! I like the feedback. It's helps me learn, too.Tom

  • Simon G. says:

    St elevation in aVR and V1 is indicative of left main occlusion (J Am Coll Cardiol, 2001; 38:1355-1356)..this would explain the lateral supplied by circ and anterior supplied by LAD

  • MM says:

    Working on ANT wall Mi recip. changes Inf/Lat leads. MI

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EMS 12-Lead

Cardiac Rhythm Analysis, 12-Lead ECG Interpretation, Resuscitation
Comments
Bryan Laviolette
“Bad heartburn” – 82 y.o. female without chest pain.
In addition to the above treatment consensus (ASA, Plavix, judicious NTG, fentanyl, fluid bolus, right sided leads), I would absolutely transport this patient to a PCI centre. Culprit artery is the RCA (STE lead III > II) leading to AV nodal ischemia and junctional bradycardia. In addition to the above treatment I would give 0.5…
2014-08-22 13:14:35
Jared
“Bad heartburn” – 82 y.o. female without chest pain.
Not much to add but my 2 cents...I'd definitely be careful with the nitro, not saying withhold it completely but absolutely use some common sense. I'd have to say probably RCA occlusion, and catch team needs to be activated for a stemi alert immediately. Treat it like a stemi until proven otherwise. If it walks…
2014-08-22 08:49:36
Brooks Walsh MD
“Bad heartburn” – 82 y.o. female without chest pain.
The option was indeed turned on! As for non-CP presentations of ACS, I absolutely believe that these warrant the same level of urgency as the "typical" presentations. Both men and women, young and old, all commonly present without classic chest pain. Besides, how much difference is there between "burning in the epigastrium," and "pain in…
2014-08-21 17:10:37
Austin
“Bad heartburn” – 82 y.o. female without chest pain.
You took the words right off of my keyboard, Jason! A little bit of critical thinking works wonders when faced with "protocol versus best interests of the patient" type decisions. Not to encourage deviation from protocols and such, but it is a much less severe trespass if you bend the rules a bit as long…
2014-08-21 16:33:27
Brooks Walsh MD
“Bad heartburn” – 82 y.o. female without chest pain.
My uninformed opinion? I pretty much agree with AHA - if they aren't hypoxic, no need. I'm not sure how terrible superoxia really is, short-term, but why bother if it doesn't help?
2014-08-21 16:31:05

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